Concussion in sports has become much more recognized, due in part to the media spotlight. In 2016 the Center for Disease Control and Prevention reported 3.8 million concussions which equates to over 10,000 concussions daily. Many of these concussions are surprisingly not related to sporting activity.
Common in each case is that the individual is affected in a way that can change their life. Many people recover from concussions quickly, but others may have symptoms that last weeks, months, or even years.
WHAT IS A SPORTS RELATED CONCUSSION (SRC)
SRC is a traumatic brain injury induced by biomechanical forces. SRC may be caused by either a 
direct blow to the head, face, or neck with an impulsive force transmitted to the head. It may result in neuropathological changes and results in a disturbance in the equilibrium of the brain and its synapsis.
In the most recent Consensus statement on concussion in sport – 5th international conference held in Berlin, October 2016. Eleven sections were identified by an expert medical panel in the successful management of sports related concussions: Recognize, Remove, Reevaluate Rest, Rehabilitation, Refer, Recover, Return to sport, Reconsider, Residual effects and sequelae, and Risk Reduction. All of these are key areas that need to be addressed in the management of individuals with concussion to safely and quickly return to previous level of function. For purposes of this article, we will focus on 7 key areas that are most applicable in the athlete returning to sport following a concussion.
RECOGNIZE
The key to a concussion healing is the ability to recognize when it is present. No person involved with the athlete is exempt from this job (coaches, athletic directors, athletic trainers, trained on-field physical therapists, and parents). Any injury involving a “blow” to the head or neck needs to be evaluated by a trained medical professional for possible concussion. The evaluation consists of physical, cognitive, emotional, and sleep related symptoms that will allow for quick identification of a concussion.
REMOVE
It is common for an athlete to express they “feel fine” after suffering a concussion. They desire to get back into the game, but it is critical that they be removed form play. We call this the “Remove the Helmet” policy, meaning that the athlete is removed from play after recognizing concussion, and is not allowed to return to the game/practice that same day. This athlete is not allowed to return to play until they have been cleared by a licensed medical professional. It is imperative to involve the athlete’s parent at this time to discuss the injury and what emergency type symptoms to look for so that they can respond as required given an escalation of symptoms.
RE-EVALUATE
The athlete should be re-evaluated after a sideline assessment by a licensed medial professional. This evaluation should include a comprehensive history and neurological examination. The medical professional will oversee the athlete during the return to play protocol. The following phrase rings true in many of life’s scenarios, “ Diagnose before you prescribe”. Before prescribing treatment techniques one needs to know what the actual issue is and the severity of it.
REST
Prescribed rest is one of the most widely used interventions in this population. The basis for the prescription of complete rest in the past was to ease the discomfort during recovery due to decrease brain energy usage, ultimately promoting healing. There is currently insufficient evidence that complete rest achieves these objectives. It is no longer encouraged to have the concussed individual go to a dark room with no interaction and complete rest. After a brief period of rest (24 to 48 hours) following injury, athletes can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom – exacerbation thresholds. It is reasonable for the athlete to avoid vigorous exertion while they are in recovery. The exact amount and duration is not yet well defined in the literature and requires further study.
REHABILITATION
As doctors of physical therapy, we have seen first hand what proper rehabilitation can do for these athletes as well as other individuals returning to their functional activities. What does rehabilitation entail, and what areas can be aided in physical therapy? Rehabilitation can be done in a variety of different treatments including: cervical, psychological, and vestibular-ocular. In addition many active rehabilitation steps involve guided sub-maximal exercises with a focus on monitoring symptom response.
How can Wright Physical Therapy help? Our therapists work closely with local sports medicine physicians and medical doctors to facilitate recognition and treatment of patients with concussion. We employ thoroughly trained specialists that further improve and develop our concussion rehab protocol.
What can a doctor of physical therapy (DPT) do? The first step is to provide a comprehensive and targeted physical examination to determine exactly what areas need to be addressed, and what needs to be referred out. A DPT assesses and treats dysfunction in movement patterns of the neck, balance/coordination, and the vestibular-ocular system. Our therapists will work with the patient and their medical doctor to establish goals, address areas with the greatest deficits, and regain their function.
RETURN TO LEARN
In order for an athlete to be cleared to play they should follow the graduated 4 stage return to school protocol prior to returning to sport. Strictly following this learning program is crucial in understanding if the brain is healing and is ready for increased cognitive loads. Stage four of this Return to Learn program is where the athlete is symptom free for an entire day of school. Once symptom free, they will be eligible for progression in the graduated return to sport strategy (see below).
RETURN TO SPORT (RTS)
An exertion program that is facilitated by a skilled physical therapist does not begin until the athlete scores below a 3 on the Symptom Evaluation form in each category. This scale monitors the daily progress of the concussion based off the athlete’s symptoms. There are 6 stages to the Return to Sport protocol. It is required that each stage be completed without symptoms before an athlete is to be cleared by a medical professional. In general, each step takes 24 hours to complete. It would normally take a minimum of one week to proceed through the RTS rehabilitation protocol once they are asymptomatic at rest.
- Symptom – limited activity (daily activities that do not provoke symptoms)
- Light aerobic exercise (walking, stationary bike at slow to medium pace. No resistance)
- Sport- Specific Exercise (running, non-head impact activity)
- Non-contact training drills (may start progressive resistance training)
- Full contact practice (must have medical clearance first to participate in normal training)
- Return to Sport – Normal Game Play
CONCLUSION
While sports concussions are a focus right now, non-sports related concussions occur frequently. A sampling of non-sports related concussions occur from events such as the following: children and elderly patients after falls, status post motor vehicle accidents and whiplash injuries.
A vital sequence to successfully manage concussions is to first recognize the concussion and any life-threatening
concerns, to remove the individual from the specific activity they are participating in and perform the appropriate rehabilitation. Once these stages are complete, the appropriate return to learning and activity graduated program can ensue to ensure safe and quick recovery from concussion.
Please email Tyler Billings PT, DPT, Cert. MDT (tyler@wrightpt.com) with any questions or needs. Schedule an appointment today at any of our locations by calling 208-736-2574. We look forward to serving you at Wright Physical Therapy.
