Why You Should Consider Working with a Physical Therapist (PT)
This article is written for Concussion Alliance by Justin J Ho PT, DPT, CSCS.
The most recent international consensus is that concussion is a rehabilitative injury. Physical therapists can play a significant role in the rehabilitation process, particularly in the treatment of systems relating to neck and upper back pain as well as dizziness and balance problems. Also, physical therapists can help provide early-stage treatment of dysfunctions of the vision system, which can be caused by a concussion.
Physical Therapy for persistent concussion symptoms
The 5th international consensus statement on concussion in sport lists physical therapy as one of the primary treatments for persistent* concussion symptoms.
*Persistent concussion symptoms are defined as symptoms that last beyond what is considered to be a normal recovery time frame. The normal time frame for recovery is 10-14 days for adults, and four weeks for children. Symptoms that last beyond these time frames are considered "persistent symptoms." There is not yet a consensus on the expected time frame for recovery for adolescents.
The consensus statement was produced in 2016 by a panel of leaders and experts in concussion management and provides the most up-to-date, research-backed guidelines for the treatment of concussion patients by medical professionals. We have highlighted the section about physical therapy in this copy of the 5th international consensus statement on concussion in sport.
Physical therapy as early as a few days after concussion
Recent research suggests that working with physical therapists can be beneficial as early as a few days after the injury. An article by Ellis et al. published in 2018 discusses how it can be important, especially for athletes, to see a physical therapist within the first week following a concussion. The authors suggest that physical therapists can be a vital part of the development and administration of a personalized rehabilitation program. Physical therapists, in particular, are well suited to help the athlete retain and maintain their physiological conditioning as much as possible during the recovery process. Ellis’s group refers to a research study which found that:
“After as little as three days of bed rest, regularly exercising endurance athletes have been found to exhibit reductions in peak exercise performance and impaired neuroendocrine responses to graded exercise.”
How a PT Can Help in the Concussion Recovery Process
Most adults (75-85%) recover from their concussion within 10-14 days, and for children, the expected recovery time frame is four weeks. However, for patients who are still experiencing symptoms beyond that threshold, seeing a physical therapist may also be warranted. Physical Therapists can provide treatment in the following ways:
A concussion can result from multiple types of head trauma, and what affects the head usually also affects the neck. To protect the head, a patient’s neck will often tense or stiffen before, during, or after an impact, often resulting in chronic shoulder or neck pain following a concussion. This can be particularly acute when patients suffer from extended headaches or head pain, as the neck and shoulders attempt to guard and protect the head from further trauma. Physical therapists can improve cervical and thoracic spine mobility and implement strategies and interventions to decrease discomfort. From manual therapy to progressed therapeutic exercises, PT interventions can help improve neck function.
Physical therapists specializing in vestibular rehabilitation can help concussion patients who continue to feel dizzy or off-balance in the days and weeks following their injury. Symptoms of abnormal vestibular functioning may include, but are not exclusive to dizziness, vertigo (room spinning), disequilibrium (off balance, nausea), and visual impairment. After a thorough evaluation, these PTs can provide you with strategies and exercises to help your vestibular system adapt and move back toward functioning normally.
Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular pathology that can occur after head trauma. The primary symptom of BPPV is vertigo triggered by head motion such as rolling in bed or turning the head quickly. This vertigo lasts for seconds, often followed by a fog or lightheadedness that can last for hours afterward. If diagnosed correctly, this can typically be successfully treated by a trained professional. You find more information here.
Eye tracking and early vision rehabilitation
Those affected by a concussion often report difficulty with vision and ability to track objects. If a patient has been examined and there are no cognitive red flags that would warrant a visit to a neurologist, a physical therapist can provide oculomotor exercises in a controlled environment to slowly retrain the individual to be able to tolerate complex moving visual environments. Exercises like pencil push-ups and Brock String converging activities can help the eye to re-acclimate to changes in depths of vision. Visual targets can be used to improve the eyes’ ability to accurately direct and maintain attention without moving the head. If symptoms persist despite these exercises, a referral to a neuro-ophthalmologist and/or vision therapist is recommended.
Treadmill test and individualized aerobic exercise program
Physical therapists who are well-informed in the concussion literature can provide the Buffalo Concussion Treadmill Test, which is a form of graded exercise testing. This specialized treadmill test is used to determine at what exertion level patients can exercise without provoking the worsening of their symptoms. This information about exertion levels can then be used to develop an individualized aerobic exercise program.
An individualized aerobic exercise program (which limits for symptom aggravation) is recommended for patients whose persistent symptoms are associated with autonomic nervous system dysfunction. The autonomic nervous system regulates non-conscious bodily functions such as blood pressure regulation and breathing.
“Graded exercise testing has been studied as both a method of diagnosis and as a means of recovery in those with mild TBI [concussion], especially in those with persistent symptoms.” (5th international consensus on concussion in sport.)
The Buffalo Concussion Treadmill test and individualized aerobic exercise programs are covered in Concussion Corner Podcast Episodes 25, 27, and 30, where Dr. Jessica Schwartz hosts and interviews John Leddy MD, Dr. Carolyn Baxter, and Dr. Lenore Hergert. Concussion Corner podcast on Spreaker and Apple Podcasts.
Reducing the risk of lower extremity injury after concussion
People who have experienced a concussion may have a higher rate of lower extremity injury even a year after the concussion; working with a physical therapist may reduce this risk.
A series of research studies of high school athletes, college athletes, and soldiers have found increased risk from 38% to as much as 2x as likely to suffer a lower extremity injury (injury to legs, knees, ankles) after a concussion.
One proposed theory is that the brain and central nervous system are not integrating well with the peripheral sensory systems (vision, vestibular, etc.) and so balance, coordination, and one’s sense of where the body is in space is impaired. Though this may not fall into the category of concussion rehabilitation, orthopedic rehabilitation can help address proprioception and neuromuscular control impairments for athletes who are looking to return to play.
A clinical trial led by Dr. Jennifer Renaker found that athletes who received individually tailored physical therapy starting at ten days after a concussion recovered more quickly. The athletes who had the early PT returned to play an average of 10.5 days sooner, and their symptoms lasted 3.5 days less. Dr. Renaker has a current clinical trial studying the use of physical therapy for injury prevention. The study will use PT to address sensorimotor dysfunctions that may have been caused by a history of concussion and which could lead to increased injury risk. (See box).
“Some of the basic tests used for determining when an athlete is recovered from concussion aren't sensitive enough and don't fully tax the athlete to assess how well the brain and body are communicating. So even when we believe athletes have recovered, they often aren't fully ready to participate.” Shellie Acocello, PhD, ATC, senior author of a new study presented at the National Athletic Trainers' Association (NATA) 70th Clinical Symposia & AT Expo in June 2019.
Incorporating Physical Therapy Into Your Rehabilitation
Ask your concussion management team if physical therapy is right for you and your symptoms. If you are working with a primary care physician, or other providers such as a neurologist, they may not be familiar with physical therapy as a potential treatment. You can ask for a referral for physical therapy, and show your doctor this copy of the 5th international consensus on concussion in sport, in which we have highlighted the recommendations for physical therapy.
You can find physical therapists within your healthcare network or at a private outpatient clinic; ask if they are trained in concussion management. Also consider outpatient rehabilitation centers, which typically have physical therapists highly skilled at working with all levels of brain injuries.
A team approach is recommended for patients with persistent concussion symptoms. In addition to physical therapy, you may want to consult with other professionals for help with your symptoms. Consider neurologists (migraine/headache specialists), neuropsychologists, speech therapists, and vision therapists; see Treatments.