Written By CPR Employee: Brandon Walker, DPT, ATC
The year is 1996, you’re watching your favorite sitcom and a Snickers commercial pops on. During the commercial a football player takes a hard hit. As he goes to get up his coach runs over to him, tells him to hold on, and asks:
“Where are you?”
“Who am I”
“And who are you?
……in a deep voice “I’m Batman.”
Although the topic can make for some funny scenarios, concussions are actually a serious brain injury that can cause a disruption to everyday life. It can cause issues with returning to sport, caring for children, driving safely, or even just getting out of bed to make breakfast.
What is a Concussion?
A concussion is a complex pathophysiological brain injury induced by biomechanical forces that causes shearing or compression to the neurons. It can be caused by a direct blow to the head, neck, or face, but also by an indirect blow with an impulsive force transmitted to the brain. The biomechanical injury will trigger what is known as a neuro-metabolic cascade due to the stretching or shearing of the injury causing a disruption to the membrane or cellular permeability. Despite past beliefs a concussion does not require a person to lose consciousness. Most will recover within 7 to 10 days with 80 to 85% being symptom free after 21 days. However, that leads 15 to 20% of the population who do not recover quickly and are still quite miserable. This group of people are considered to have Post-Concussion Syndrome. Because of the complex nature of the pathophysiology of a concussion, the person could have multiple symptoms impacting different aspects of their functions. These different symptoms have been organized into clinical subgroups that help guide treatment and recovery during post-concussion syndrome. These clinical subgroups are Physiologic, Vision, Vestibular, Cervical, Anxiety, and Migraine.
Those with symptoms in the Physiologic Subgroup will have headaches and fatigue that will worsen as the day progresses. They feel tired all the time and will have changes in their sleep patterns. They are easily distracted and forget what they are doing. Headaches and dizziness will be exacerbated with physical activity and exertion. Treatment for this subgroup consist of gradual, subthreshold physical activity that does not increase symptoms.
Those with symptoms in the Vision Subgroup will often have frontal headaches or pressure felt just behind the eyes. There is trouble with reading, blurry vision, double vision, and maintaining visual focus. They will often find themselves squinting more, have difficulty tracking objects with their eyes, and have an increase in head movements when attempting to read. They may also have sensitivity to light and an increase in symptoms with a busy visual environment. Treatments for this subgroup consist of different visual and eye exercises designed to help stimulate and retrain our different ocular cranial nerves.
The Vestibular Subgroup will have some of the more common post-concussion symptoms often complained about. These include, dizziness, nausea, decreased balance, motion sickness, and a feeling of “one step behind”. This Subgroup also shares some of the Visual Subgroup’s symptoms with increased dizziness during a busy visual environment. There is also at times a feeling of illusionary movement or feeling like you are moving when you are standing still. Sometimes with the impact from the concussion you can have vertigo which is noted by physically seeing the room spin during certain head movements. The treatment for this subgroup will focus on the vestibular nerve and often the Vestibular Ocular Reflex or the connection and control between our inner ear and our eyes. Some minor dizziness during the treatment may occur, but symptoms will subside quickly.
Those with symptoms in the Cervical Subgroup will experience neck pain or soreness, headaches stemming from the base of the skull, and reduced neck motion. At times dizziness and visual symptoms will increase due to neck motion and positioning. Often these symptoms will increase with prolonged sitting and having your neck in a “reading” posture. Treatment focus for this subgroup consists of improving motion and mobility of the cervical spine, improving cervical motor control connection with the brain, and reducing painful tissue tension.
With the Anxiety Subgroup, we often find people with past issues with anxiety but were able to stay in control. With the added complexity of a concussion, those within this subgroup are no longer able to keep in control of their anxiety symptoms. Some common symptoms in this subgroup include a sense of hypervigilance, feeling overwhelmed, difficulty initiating sleep, excessive focus on their concussion symptoms, and limited time socializing. When this subgroup becomes an issue, often further evaluation is needed by a mental health specialist.
People with symptoms in the migraine subgroup will have a variable headache that can be intermittent in the severity. Sleep dysregulation, nausea, light sensitivity, and sound sensitivity are common in this subgroup. Often you may have symptoms similar to what is known as a Vestibular Migraine with increased dizziness experienced. Treatment for this subgroup will start by recognizing your specific migraine triggers. Once your triggers are identified you can focus on migraine prevention and decreased aggravation, allowing for healing to occur.
Physical Therapy and Post Concussion Syndrome
Long gone are the days of sitting in a dark room resting, waiting for the symptoms to subside. In fact, research has shown that this method of treatment can be detrimental to concussion recovery. Research has shown that Physical Therapy can help speed up the recovery process and return you to your prior capacity. For Physical Therapy, evaluation is key to a full recovery. During the Examination the skilled Physical Therapist will perform certain tests and measurements to help classify which subgroups are contributing to the continual symptoms. It is very common for someone to have symptoms consistent with multiple subgroups and rarely do we find just one area involved. Once the subgroups are recognized, a specific plan of care is made to address your needs and recovery. Therapy for each subgroup might look a little different than your typical Physical Therapy session, but it can be just as challenging. Just as muscles get fatigued and need time to recover from therapy, you may experience mental fatigue from the treatments and may need time to recover. This is why it is important to have at least a day in between each Physical Therapy session to allow the brain to recover. With Physical Therapy, adequate rest, and appropriate nutrition you’ll be on the road to recovery and back to what you love to do in no time.
Ellis, Michael J., John J. Leddy, and Barry Willer. "Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment." Brain injury 29.2 (2015): 238-248.
Eleftheriadou, Anna, Nikoleta Skalidi, and Georgios A. Velegrakis. "Vestibular rehabilitation strategies and factors that affect the outcome." European Archives of oto-rhino-laryngology 269.11 (2012): 2309-2316.
Furman, Joseph M., and Rolf G. Jacob. "A clinical taxonomy of dizziness and anxiety in the otoneurological setting." Journal of anxiety disorders 15.1-2 (2001): 9-26.
Furman, Joseph M., Dawn A. Marcus, and Carey D. Balaban. "Vestibular migraine: clinical aspects and pathophysiology." The Lancet Neurology 12.7 (2013): 706-715.
Kleinschmidt, Andreas, et al. "Neural correlates of visual-motion perception as object-or self-motion." Neuroimage 16.4 (2002): 873-882.
Mucha, Anne, et al. "A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings." The American journal of sports medicine 42.10 (2014): 2479-2486.