Concussion Management: Updates from Berlin 2017 and the Importance of Active Rehabilitation
By Holly Benjamin, MD, FACSM
University of Chicago
Sports Medicine Specialist
Associate Professor of Pediatrics
Holly Benjamin, MD is a sports medicine specialist at the University of Chicago and an expert in pediatric concussion care. The University of Chicago is the only University in Illinois that was selected to participate in the NCAA-Department of Defense CARE Research Consortium that is a $30 million dollar and 38 site multi-center investigation that is researching the natural history of concussion in men and women using an all-inclusive standardized clinical measure of both baseline and post-injury symptom screening, performance-based testing and psychological health measures in a multi-dimensional assessment strategy. With over 33,00 athletes enrolled across the country and over 2,000 concussions documented, this is the largest study to conducted that will enhance our knowledge for the proper screening, diagnosis and rehabilitation of athletes with concussion.
Concussion has a wide variety of definitions in the scientific and lay community today. The term is often used interchangeably with mild traumatic brain injury (mTBI). The Concussion in Sport Group (CSIG), who recently had their 5th international conference on concussion in Berlin, defines sport related concussion as: “a traumatic brain injury induced by biomechanical forces” They then go on to break down the features of a sport related concussion to include: a force applied to the body which then applies force to the head whether that be a direct or indirect head injury and neurologic impairment which could result from structural or functional damage to the brain.(1) This article highlights the new recommendations produced by the most recent Concussion in Sport International Conference and describes the latest research describing the effectiveness of prescribing an active rehabilitation program for concussed patients.
When an athlete suffers an injury during a sport, one should include concussion in the differential diagnosis if the athlete displays any of the following: headache, variable emotions, memory loss, loss of consciousness or trouble with balance/coordination.(1) If any of these are present, the athlete should immediately be withheld from play and must be properly evaluated with ample time to perform a thorough examination and testing. The most widely used test is the Sport Concussion Assessment Tool 5th Edition (SCAT5), which can take several minutes to complete. This can be performed on the sideline, in the office, or away from play all together. It is important to be thorough with your evaluation because early return to play resulting in a subsequent injury could increase the athlete's risk for post-concussion syndrome and is associated with significant morbidity and even mortality risks. Along with the SCAT5, injured athletes should have their vision, gait, balance and reaction time tested for abnormalities.(1)
Certified athletic trainers are often the most experienced and qualified health care professionals to perform the SCAT-5 as part of a sideline evaluation or an in-office screen for a possible concussion in an injured athlete. If a concussion is suspected after the initial assessment, the patient must be completely removed from play. Under the 2011 Illinois Concussion law, there can be NO same day return to play for concussed athletes. Past consensus was to prescribe a period of physical and cognitive rest after a concussion injury until the patient was asymptomatic. Now providers are starting to prescribe “subthreshold exercise” with promising results, occurring after the acute phase of injury, sometimes as early as 24-48 hours.(1,4) This includes activity that is below the threshold to cause concussion related symptoms or to worsen mild symptoms that are already present. Recent studies have shown that early introduction of light exercise in a mildly symptomatic patient may lead to improved outcomes and faster recovery versus a more prolonged period of complete rest until completely asymptomatic. An important question still being researched is how much rest to prescribe after a concussion prior to starting activity. One study showed that after 3 days of rest, in adults, there was no added benefit to overall recovery.(2) When athletes were not instructed how much rest to take, those who participated in a medium amount of physical activity performed superiorly on neurocognitive testing as opposed to those who chose to perform no activity or even those who participated in a high level of activity after their injury.(3)
The Buffalo Concussion Treadmill Test and modifications of it can be performed by physical therapists trained in concussion evaluation and management. (2,3) This functional test will safely and reliably determine the amount of exercise that an injured athlete can tolerated that can help restore normal physiologic functioning and enhance recovery. It also helps the therapist determine the need and benefit of vestibular therapy and oculomotor therapy, both of which also have shown promising results in promoting recovery from concussion. The vestibular system helps orient the head and body’s positions in space relative to the surrounding environment. Disruptions in the vestibular system can lead to dizziness, motion sensitivity, lightheadedness, poor eye-hand coordination and slowed reaction times among other symptoms. Compensation from the visual system which might have been injured as a result of concussion also, often causes eyestrain, headaches, and difficulty focusing and tracking. The neck is often overlooked due to the head injury, but neck stiffness, pain and altered range of motion and posture deficiencies resulting from the commonly associated “whiplash” type of injuries seen in concussion can prolong or worsen symptoms and slow recovery if not addressed by a comprehensive therapy program. (5)
It is important that families understand that for the vast majority of concussed athletes, up to 98% make a full recovery. In fact, approximately 80% of concussions resolve within 3-4 weeks in the adolescent and young adult population with little need for intervention other than close observation, relative rest and time. However, if a patient is still experiencing concussion related symptoms weeks to months after the initial injury, they may be suffering from post-concussion syndrome (PCS). PCS rates are higher in younger athletes as well as females.(1) Those with previously diagnosed depression or migraines are also predisposed to higher rates of PCS.(2) Other injuries that are sometimes overlooked may have occurred at the initial insult and can be the culprit in athletes with prolonged symptoms. Therefore, close follow-up is necessary and it is very important to perform a through physical and neurologic exam after the injury and at all subsequent clinic visits. Cervical, ocular and vestibular injuries can lead to dizziness, headaches and vision changes.(2) This is one reason why the approach to concussion management needs to involve multiple facets. Cervical, vestibular, oculomotor and psychological rehabilitation are all important in concussion recovery. Other studies have shown the benefits of medications and schooling adjustments; therefore, must be considered as treatment options in PCS patients.(1,4) Lastly, a final new recommendation from CSIG was to involve neuropsychologists in the assessment and management of patients who have suffered a concussion.(1)
At some point in concussion management, the issues of return to learn and return to play must be addressed and both are thought to be of equal importance in determining clearance. The American Academy of Pediatrics in 2010 published a return to play protocol that follows national guidelines and in 2013 published a similar return to learn protocol that helps providers and schools re-integrate into both academic and athletic environments safely and in a step-wise gradual fashion. (6,7) (see Tables 1 and 2) It is recommended that a similar approach be used for middle-school aged, club and recreational athletes as well as collegiate and NCAA athletes.
Table 1: Return-to-Learn Plan*
|Complete cognitive rest—no school, no homework, no reading, no texting, no video games, no computer work.||Recovery|
- Gradual reintroduction of cognitive activity
|Relax previous restrictions on activities and add back for short periods of time (5-15 minutes at a time).||Gradual controlled increase in subsymptom threshold cognitive activities.|
- Homework at home before school work at school
|Homework in longer increments (20-30 minutes at a time).||Increase cognitive stamina by repetition of short periods of self-paced cognitive activity.|
|Part day of school after tolerating 1-2 cumulative hours of homework at home.||Re-entry into school with accommodations to permit controlled subsymptom threshold increase in cognitive load.|
- Gradual reintegration into school
|Increase to full day of school.||Accommodations decrease as cognitive stamina improves.|
- Resumption of full cognitive workload
|Introduce testing, catch up with essential work.||Full return to school; may commence Return-to-Play protocol (see Step 2 in Table 2).|
*adapted from Halsted, et al. Pediatrics; 2013
Table 2: Graded Return to Play Protocol**
|Rehabilitation Stage||Functional exercise at each stage of rehabilitation||Objective of each stage|
- No activity
|Complete physical and cognitive rest.||Recovery|
- Light aerobic exercise
|Walking, swimming, stationary bike with HR < 70% maximum.||Increased heart rate|
- Sport specific exercise
|Running drills without contact.||Add movement|
- Non-contact training
|More complex drills without contact.||Exercise, coordination and cognitive load|
- Full contact
|Normal training.||Restore confidence|
- Return to play
** adapted from Halsted, et al. Pediatrics; 2010
Research continues to advance our knowledge of concussion and lead to improved ways of managing this condition. With the advent of active rehabilitation, along with the other concepts outlined above, we can better manage our concussion patients on the field and in the clinic. For those providers who care for concussed athletes, it is important to stay up-to-date on the complex and ever-changing recommendations for concussion treatment and rehabilitation; particularly given the robust amount of research that is being conducted in this area. Lastly, in order to provide comprehensive care for concussed athletes, it is important whenever possible to employ a multi-disciplinary approach with proper use of all necessary rehabilitation strategies offered by physical therapists and athletic trainers as well as involving school personnel, families, counselors, sports medicine specialists, neuropsychologists and other specialists such as ophthalmologists or optometrists as needed.
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1. McCrory PM et al. “Consensus Statement on Concussion in Sport—the 5th International Conference on Concussion in Sport Held in Berlin, October 2016” . Br J Sports Med 2017;0:1-10. doi:10.1136/bjsports-2017-097699
2. Leddy, J. Baker, J. G. and Willer, B. “Active rehabilitation of concussion and post-concussion syndrome,” Physical Medicine & Rehabilitation Clinics of North America, vol.27, no.2, pp.437–454, 2016.
3. Leddy, J., Hinds, A., Sirica, D., Willer, B., 2016. The role of controlled exercise in concussion management. PM R 8 (3 Suppl), S91–S100. http://dx.doi.org/10.1016/j.pmrj.2015.10.017
4. Schneider KJ, Leddy JJ, Guskiewicz KM, et al “Rest and treatment/rehabilitation following sport-related concussion: a systematic review,” Br J Sports Med 2017;51:930-934.
5. Whitney SL, Sparto PJ. Principles of vestibular physical therapy rehabilitation . Neurorehabiliation. 2011;29(2):157-66.et al.
6. Halsted ME, et al. Council on Sports Medicine and Fitness, Council on School Health. AAP Clinical Report: Sport-Related Concussion in Children and Adolescents. Pediatrics; September 2010; 126(3).
7. Halsted ME, et al. Council on Sports Medicine and Fitness, Council on School Health. AAP Clinical Report: Returning to Learning Following a Concussion. Pediatrics; November 2013; 132(5).