1. The Physiotherapist’s Role in ConcussionBy
Derek O’Neill MISCP

2. Keys to successful management
Overview
Keys to successful management
Clinical profiles
Assessments
Treatments
Case Study

3. The OLD Perception of Best “Treatment” for Concussion??
Early activity group 24.6% had PCSS; Rest group 43.5% had PCSS 5-16 yr old
Evidence suggest that early initiation of exercise is associated with faster full recovery there is very little to support rest as a treatment strategy for concussion

4. Keys to Successful Concussion Management
Proper recognition of concussion
Removal from play
Eliminate additional head injury exposure until recovered
Comprehensive concussion evaluation
Active rehabilitation
Often the physio responsibility
Graded exercises while managing symptoms

5. Post-TraumaticMigraine
Clinical Profiles
Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-TraumaticMigraine
Anxiety/
Mood
Cervical
As we can see it is an injury that effects multiple systems with differing severity
Often evolving overlapping…. And requires Multi disciplinary team for correct management.

6. On Field Assessment A&E if … Confusion Slurred speech
Worsening headache
Vomiting x 2
Behavioural changes
Ataxic Gait
LOC
ABCs
Immed 18.9 days………3-15mins 28.4………..>15mins 44.1 days continuing to play can DOUBLE the recover time, so as physios we are often frontline and need to make the call…. Don’t risk it..
Dizziness is one of the main acute symptoms---- remove
All important signs ….. Ensure they safe to mobilise and realise that many of the sign OF TBI so need to be managed responsibly

7. Side-line Assessment Symptom Evaluation Physical Signs
Level of Consciousness
Cognitive
Balance – Bess/ mBess
Neurological – VOMS
Clear Cx
Ensuring it was safe to mobilse the patient off the field.
How do they Feel.. Dizzy, nausia..
Physical signs of injury.. Wounds etc
Level Con.. Orientation … Maddox Qs… it is a cognitive task..
Maddox….. Reaction time test…
Balance… BESS or MBESS
Neuro- Voms- co-ordination, occ/motor--- smooth pursuit..
Cx brief – ensure the possibilits of what injuies might be present…
Review Video next day..
Any abnormality warrant a full medical AX– level of LOC

8. Clinical Assessment History Baseline Cervical Balance/ Gait Testing
Vestibular/VOMS
Exercise test
Education & Rehab
Give us a chance to have a more detailed look into some of those area there may have been issues with, it also allows us to better understand the individuals injury and provide individualised treatment and look to establish those pattern that turn into clinical profiles.
Also, help educate on the injury and reduce some fears or anxiety associated with the injury,, and give expectations for recovery.
Hx- loc, scans, play on, ( pre- exsiting risk factors –migraine, anxiety
BL- increases confidence in diagnosis
Cx-looking at neuro ms control and sensory function- brain communicates with the neck/ ax for cervicogenic HA
Bal – widely reported in early stages of the injury / simple tandem gait
VOMs- brief Ax occ/ vestib
Detailed ax of the injury, how long they played for, how they were after.. Amnisesia/LOC?VOM? Scan
Previous concussion/ Migrains/motion sickness/ occular history/ ---all factor into induvial characteristic
Cognitive/fatigue, mood---- neuropsyc
Cx- looking not only for joint and ligament tenderness,, and also looking at neuro/ms control and senory motor function.--- which is important as this is one of the ways the neck and brain communicate ---- as well as looking for cervicogenic HA when looking at rehab
Balance- is one the things we measure with conussion, deficits are widely reported early in the injury, or using a Outcome measure to assess gait ( Tandem gait– head movements.
Voms= 5 mins scrrening tool vestib/ occ,, used in conjunction with neuropsy, sym reporting to give a more compelet clinical picture
Exercise- co-ordination, balance, reaction time and how they react to incease HR– simple exercises can often be very challanging… start slow.. We use a UPMC stardaised exercises assessment

9. Post-TraumaticMigraine
Treatment
Vestibular Rehabilitation
Exercise
Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-TraumaticMigraine
Anxiety/
Mood
Cervical
Exercise
CBT
Psychotherapy
Medication
Vision Therapy
Orthoptics
Manual Therapy
Exercise
Injection
Acupuncture
Biofeedback
Medication
Surgery
Structured Rest
Exercise
Medication
Using valid and reliable tests to identify issues
To establish a treatment plan we must understand the profiles, If we examine literature regarding management of each of these subtype – Exercise is frequently recommended and had efficacy in management of many. We also see that as physio our scope of practice allows us to treat much more in all of theses domains.
“Matching targeted and active treatments to clinical profiles may improve recovery trajectories following concussion.”
Exercise
Behavioral Regulation
Relaxation/Biofeedback
CBT/Trigger Modification
Medication

10. GAA Case Study

11. Case History 30 yo male inter-county hurler
Possible two separate impacts 20 minutes apart.
Initial symptoms
Blurred & double vision
Nausea
Dizziness
Co-ordination
Two impacts, possible 40 days before RTP

12. 0-2 weeks post injury Two weeks rest Returned to training
Removed by physio due to symptoms during training.
Symptoms
Dizziness
Blurred vision
Sensory irritation
Poor coordination
Same symptoms arose as post impact “ patient said he was good to the physio pre training.

13. No history of ocular/ migraine or neurological diagnosis
Medical History
No history of ocular/ migraine or neurological diagnosis
Otherwise in good health
No ImPACT baseline test
Social History
Busy career, presenting/teaching
Normally outgoing with good social network
Even taking the history I could tell he was not comfortable, reduced eye contact and time in answering Q “ captain of his team

14. Initial symptoms
Physical: Headache 3-7/10, double/ blurred vision, dizziness, ataxic gait in tight space.
Cognitive: Fatigue, poor concentration in conversation, irritated by light and busy environments
Emotional: Feeling of anxiety
Sleep: Taking day time naps, problems trying to fall asleep (dizziness and restlessness)
He didn’t know how to gage this injury not like a sprained ankle
Team members asking when was he back
Difficulties in social setting

15. Assessment Bess Balance Minor deficit VOMS
-Visual ocular reflex (VOR) problems with horizontal & vertical movements 5-6/10 dizziness
Visual motion sensitivity (VMS) test Hoz>Vert
8/10 dizziness 7/10 headache.
Exertion testing
Medicine ball rotation & Jumping rotation toss 8-9/10 dizziness and 7/10 headache.
Running increased pressure behind the eyes with light ocular disturbance
94% of patients who report they are symptom free still showed sign of concussion
He didn’t realise how bad he was until he done theses tests

16. Concussion Profile 8/10 dizziness VOR Anxiety around injury and RTP
Vestibular
Anxiety/Mood
Ocular
Concussion
Poor concentration/ reduced reaction time
Cervical
Multi- domain assessment approach allowed me to match treatments to the different elements involved, and understanding that graded exercises was a fundamental component of each.
Primany issue was Vest/Oc to secondry migraine
Cognitive/fatigue
Migraine
Temporal pressure with occ visual disturbance

17. Rehab Program Gaze stabilisation: VOR
VMS: Med ball rotations jump/turn/catch 10 x 2/3
Exertions: 20mins on bike, speed steps
Advice
Environmental exposure: Graded exposure to provocative stimuli
Regulation of sleep, hydration and diet
Keep diary
Brining on symptoms at a low levels allows the body to recover thought a desensitization process. REST??
Pt found the Dairy to be very beneficial allowed him to see progress and reach his short term goals
Pt was going back to work next week and highlight his anxiety
Less impact on the bike

18. Update Week 1
VOMS
-Much improved, still sensitive to VOR dizziness/HA 3/10
VMS
-Symptoms reducing everyday now 0-3/10 CV
-Progress to jogging 20mins, allowing onset on symptoms 5/10

19. 2nd PT Visit Day 14 Impact Test- reduced reaction times noted
VOMS - normal
VMS - normal
Exertion: accel/decel jogging 20mins sym free
Cognitive fatigue Friday night, relapse of symptoms caused by anxiety around injury?
Symptoms/concerns
-One to one conversation, Computer screen, fatigue, anxiety around return to play (team & manager)
Day 40 post injury
Advised not to do rehab at night, before bedtime

20. Rehab Progression
Desensitisation: Gradual Increase computer use, reading, Tv, one to one conversation in busy Env.
VOMS: Progress to dynamic gaze stabilisation H/V- light HA 2/10 Dizziness 2-3/10
VMS: Walking backward with ball throw dizziness 2-3/10
Exertion: non- contact sports specific
Felt that he was more concerned around his issues with social interaction ( work, team, friends) went for dinner…
Discussed with Clinical lead- ok for non impact

21. Day 21 update VOMS – Normal VMS – Normal
Exertion- Normal, full training session non-contact, back in gym “I feels better when I’m training”
Reduction in ImPACT test, Significant???
Exercises aiding to reduce his anxiety
Importance of having base line testing done! Is this reduction in impacts significant.
AS THE OTHER PROFILES REDUCED HE WAS VERY MUCH AN ANXIOUS

22. 3rd PT Visit Day 27 Discussed Return to play criteria
AX: VOMS/VMS/Exertion Normal
Anxiety around semi final competition within a week??
Advice
Met with Dr
Re-test Impact – minor set back in scores
Continue non-impact training until medically cleared
Reduced aspects of the neuro cognitive testing, very competitive, wanted to beat where he was low in pervious test.
Not meeting criteria for return to play
Patient very competitive trying to beat last score)?? Anxiety??

23. Update Day 34
Did not play semi final, team lost, now playing 5 a side soccer symptom free.
Occasional gets light symptoms “ maybe because I do not know what normal is”
Education/ reassurance
Important that he was exercising, reducing anxiety

24. Return to Contact play (RTP)
Based on international consensus
Symptom free at rest
Symptoms free with exertion
Normal neurocognitive testing (ImPACT)

26. Summary
Rest as a treatment for concussion has limited benefit and may actually prolong recovery
Evidence that vestibular, oculomotor, and exertion therapies enhance recovery after concussion
Use valid and reliable tests to identify vestibular, ocular, and exertion issues following a concussion
Use of concussion clinical profiles allows targeted treatments