BRINGING SCIENCE TO TREATMENT

Post concussive disorder: early intervention and long-term management

Concussion is currently a very topical issue for athletes, coaches and sports medicine professionals around the world. With that in mind, Kay Robinson discusses the different sub types of post-concussive disorders, how to recognise and address them early, and recommendations for their long-term management

2017 Wakefield Trinity’s Matty Ashworth in action with Hull FC’s Albert Kelly and subsequently suffered a concussion Credit: Action Images / Lee Smith Livepic

Following many high profile cases, legal battles and the publication of the Berlin Consensus Guidelines 2016(1), concussion is making headlines and is at the forefront of the minds of athletes, coaches and sports medicine professionals around the world. In the past five years, there has been a dramatic increase in the number of research articles on concussion. However, few of these focus on treatment options and long-term management – possibly because the majority of concussions resolve within 7-14 days, allowing athletes to return to sport as normal after a short period of symptom resolution and graduated return.

The focus on concussion recognition and assessment is paramount in early management of athletes and is aided by the wide range of tools available. But more information is needed on how we treat those 10-20% of people who experience post concussive disorders (PCD). This article will discuss sub-types of PCD and recommendations for long-term management. There are many specialists in this area who commonly see patients in the public system often following months of prolonged symptoms(2). As practitioners in sport we are at the forefront of recognizing prolonged concussion symptoms and need to address them early.

Historically PCD wasn’t diagnosed until a patient had symptoms for greater than three months. However recent guidelines report this can now be classified with symptoms greater than two weeks in adults and four weeks in paediatrics(1).


PCD diagnosis

Diagnosis of PCD should be made based on a variety of symptoms; however difficulties arise due to the strong similarities between PCD and vestibular dysfunctions, depression and fatigue. To aid differentiation, a combination of seven symptoms was found to be specific to concussion/mild traumatic brain injury(3). These are:

  • Headache
  • Dizziness
  • Intolerance of stress
  • Poor concentration
  • Taking longer to think
  • Blurred vision
  • Personality changes

Those with prior concussion, history of anxiety/depression, poor memory and light sensitivity on initial Rivermead Concussion screening were found to be at greater risk of suffering persistent symptoms(4). The consequences for athletes, a population that is known for high achievers and pushing the boundaries suffering persistent concussion symptoms can be particularly disabling.


What is concussion?

Sports related concussion is defined as “a traumatic brain injury induced by biomechanical forces”(1). This is proposed to alter the connectivity of networks in the brain, causing inefficiency, which can result in difficulty filtering sensory stimulus, difficulty maintaining spatial awareness and balance and difficulty multi-tasking using multiple systems – often leading to fatigue. The general rule of management of PCD should be as follows:

  1. Settle symptoms
  2. Gradually expose to stimuli to build tolerance
  3. Avoid prolonged rest

Settling symptoms

If symptoms are not managed adequately, it is difficult to progress to rehab. In turn, this can cause further symptoms due to increased anxiety regarding slow or no progression. As with any musculoskeletal injury, it is important to focus on what the athletes CAN do and not focus on activities they can’t, which may aggravate symptoms further. Decreasing stimulation is a useful early strategy to implement to reduce symptoms, as well as planning and pacing and identifying non-aggravating activities that may be restful. Approximately 50% of patients suffer from sleep disturbances following concussion(5)The identification and treatment of this is paramount because it can exacerbate symptoms further.

The use of sunglasses, or binasal occlusion (which aids to dampen the peripheral input) causes a change in central visual space and has been shown to decrease sensitivity to visual disturbances(6). The limited use of monitors/screens should also be discussed (if this is a stimulant), along with the use of screen modifications and light settings. Symptoms stimulated by auditory inputs could be addressed using earplugs, limited exposure to noisy environments or the use of comfortable low-level sounds such as nature noises or the use of mindfulness which can be accessed anywhere through a range of apps.

Sporting environments are often tailored to be stimulating; exposure to this kind of environment should therefore be graduated. Examples may include the injured athlete meeting with teammates or staff in a quiet location or early training being carried out in smaller groups. Complete avoidance of these environments is not recommended however due to the importance of peer support and maintaining routine. If the athlete is in the stimulating environment, quiet areas should be used during the progression to full exposure.

Pacing and planning strategies enable athletes to participate in as many activities as possible while having minimal symptoms – and avoid ‘boom and bust’ behaviour. Planning strategies when working with athletes should include all aspects of their life. Typically, athletes are familiar with following training plans. However they need to recognise the importance of planning daily tasks and social activities also. A points system (as is frequently used in athlete-specific recovery) is one way of planning, and pacing can be implemented by assigning points per activity (depending on the level of difficulty) and then establishing a daily points total that the athlete needs to stay within. This can then be progressed with the athlete’s recovery, focussing on what the athlete can do.

Gradual exposure

It is important to consider the specific domains/systems that have been affected following an athlete’s concussion. One of the great challenges in concussion is there is no ‘normal’ presentation or pathway. However, by identifying concussive subgroups we can guide treatment more effectively and improve outcomes (see table 1) .

Table 1: Concussive subgroups and their characteristics

Cognitive


Decreased concentration

Increased distractibility

Difficulty learning/retaining new information

Decreased multitasking abilities

Increased fatigue
Vestibular







Balance impairments

Difficulty interpreting motion

Difficulty co-ordinating head/eye movements

Poor stabilization of vision on head movements
Ocular
Difficulties brining eyes together/using eyes in tandem

Difficulty tracking motion
Post-Traumatic Migraine

Headaches

Nausea

Light sensitivity
Cervical


Headaches

Neck pain/dysfunction

Dizziness
Anxiety/Mood
Excessive worry

Difficulty turning thoughts off

Personality changes
Physiological Symptoms exacerbated by exercise/increased cognitive function (headache, dizziness, nausea, fatigue, difficulty concentrating)
Adapted from:http://rethinkconcussions.upmc.com/2016/10/concussion-clinical-trajectories/)

There can be overlap between concussive subsets, but thorough assessment using the wide variety of tools available can assist us in recognising driving factors, and allows us to plan treatment effectively. Cognitive changes commonly remain following the resolution of physiological symptoms, and can be affected by external noises and distractions. This indicates the importance of testing in environments in addition to the quiet room that is often chosen as the optimal location.

Cognitive retraining should be focused on graded brain stimulation and is commonly integrated with visual processing activities. The use of planning/reminder applications are useful in day to day cognitive training, along with the introduction of ‘brain training’, which is available using apps. Sport specificity can be introduced at all levels of cognitive retraining, incorporating recognising patterns, reaction-time training and tactical planning.

Balance and vestibular deficits can be recognised by carrying out battery of tests. However, it is important to remember these can cause increased symptoms due to physiological and cognitive demands. Therefore the timing and use of these need to be specific to your athlete and work within their plan.

The ‘Community Balance and Mobility Scale’ assesses dynamic balance, which is likely to be most appropriate for athletes, although it is proposed there should be a higher cut off scores in this population(7). Ocular and vestibular testing and rehabilitation is mostly done in parallel due to the high crossover between the two systems, with approximately 80% of all sensory processing thought to be directly affected by information coming from the eyes.

A simple eye test may highlight difficulties in visual acuity; however, visual processing assessment is paramount in patients with PCD to determine how they interpret what is seen using their spatial vision, focusing on spatial awareness, movement and image segregation followed by focal visionwhich is more detailed. The Vestibular Ocular Motor Screen (VOMS) was developed as a specific screening tool to recognise vestibular and ocular symptoms post concussion, and can be used to monitor improvement(8). Assessment results should be used to guide specific treatment strategies, with short and long term sport specific goals being set to aid athlete motivation (see table 2) .

Table 2: Vestibular-ocular treatment (within symptom tolerance)

Balance training



Static > Dynamic > Multi-System > Sport Specific
Sensory and peripheral awareness Tactile Sensory Stimulation

Limb mapping

Start with maximal base of support and progress

Proprioceptive input (eg. Compression)

Postural control exercises

Change of direction

Incorporate head/eye shift
Vision training
Bi-nasal Occlusion

Progress from spatial to focal progressions

Eye tracking/saccade training

http://backinactionphysiotherapy.com/concussion/concussion-exercises/

http://eyecanlearn.com/perception/discrimination/
Vestibular/visual Integration
Colour/letter finding tasks moving head between different locations

Movement while maintaining visual target

Vestibular Oculur Reflex exercises (VOR) using opposite eye and head movement.

Physical findings

Physical findings that indicate cervicogenic involvement in PCD is identified by carrying out a thorough cervical assessment. Athletes commonly report subjective neck symptoms and possible neck injury at the time of concussion. The Smooth Pursuit Neck Torsion Test is useful to differentiate cervicogenic and visual involvement(9). When an athlete is complaining of headaches, these can be classified as cervicogenic when(10):

  • Pain is related to head movement
  • There is restricted ROM
  • There is ipsilateral neck, shoulder or arm pain
  • Pain is moderate to severe and non throbbing
  • Symptoms fluctuate and are episodic and usually start in the neck

Treatment should consist of appropriate manual therapy, head/neck proprioceptive training, balance stabilisation exercises and sub-symptom threshold strengthening.

Physiological PCD is often identified first in sport, when an athlete’s concussion symptoms return or worsen with physical activity. There are often no neural findings in these athletes; however they commonly have elevated resting heart rate. Exercise has historically been thought to be detrimental in concussion and in the acute stage this can be true. This is due to the increased sympathetic and lower parasympathetic activity, thought to be caused by temporary alteration of the body’s regulatory system acting to protect the brain.

Following sufficient autoregulation, numerous studies have found sub-symptom threshold exercise to be beneficial in short and long-term recovery from concussion(11-13). The benefits of sub-symptom exercise is specifically important to reduce depression, maintain purpose and social interaction. Also, exercise post concussion is also thought to increase brain-derived neurotrophic factor, which enhances neuronal survival, growth and plasticity (see table 3).

Table 3: Physiological Treatment (Within symptom tolerance)

Sport/work/school amendments
Maintaining sub symptom cognitive and physical activities through pacing and planning
Sub-symptom threshold aerobic exercises program
Buffalo Concussion Treadmill test to identify symptom limited heart rate(14)

 20min per day of aerobic exercise at 80% HR threshold

Increase HR by 5-10 bpm if tolerating

Repeat process until 85-90% predicted age HR (or athlete baseline)

Graduated Return to Performance with repeat treadmill test if symptoms reoccur.

 Yoga frequent non-symptomatic exercise (might need balance/vestibular adaptations)

As with any musculoskeletal rehabilitation, load (physical and cognitive) should be monitored during return from concussion. Treatment should begin early, with education for the athlete and their support network. It is a good idea to write down plans, as cognitive limitations may impede the retention of information. Transition to new activities should be gradual, with recognition of different environments and impact of collective rehabilitation over the day/week. Frequent evaluation should be carried out to facilitate any need for treatment adjustment, and minimise increase of symptoms.

Summary

Although infrequent, post-concussion disorder can be disabling and extremely isolating for athletes. Although there is a long way to go in finding the optimal management for these patients, and not all of them will return to their pre injury level, it is important to recognise symptoms early, identify subsets involved in the PCD, and begin a graduated rehabilitation plan.

References

  1. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med, 2017
  2. McGuire S. Concussion Management Workshop, in: Concussion Rehab Works. Sydney, 2017
  3. Specificity of Postconcussion Symptoms at 3 Months After Mild Traumatic Brain Injury: Results From a Comparative Cohort Study Head Trauma Rehab 29, 2013
  4. Brain Inj 28: 422-430, 2014
  5. Sleep Med 13: 898-905, 2012.
  6. Brain Inj 28: 1568-1580, 201
  7. J Head Trauma Rehabil 31: 339-345, 2016
  8. Am J Sports Med 42: 2479-2486, 2014
  9. J Rehabil Med 37: 219-223, 2005
  10. Clin Exp Rheumatol 18: S3-6, 2000
  11. Scand J Med Sci Sports 26: 299-306, 2016
  12. JAMA 316: 2504-2514, 2016
  13. Sleep Med 13: 898-905, 2012

14 PM R 8: S91-S100, 2016

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