Physio rehab post concussion
Physio rehab post concussion
From our physio Maddie Green
Since working with the South Adelaide Football Women's team, concussions are a concerningly frequent injury seen by physios like myself in the SANFL. The trouble is, most are managed by sports doctors, who are not present at training to monitor the player’s rehabilitation closely. Furthermore, concussions can affect multiple body systems which are rarely addressed in their staged return to play. Thus, I undertook Laura Fazzari’s masterclass in rehabilitation following a concussion to help players reach their optimal recovery and prevent ongoing associated complications.
Here are my take aways:
What is a concussion?
A concussion is an immediate and transient alteration in brain function from a mechanical trauma. It is an evolving injury which means that symptoms can be delayed for several hours and typically lasts up to three weeks. A good way to explain a concussion to clients is that it’s “not a hardware injury, it’s a software injury”, and this is why concussions don’t show up on imaging.
Immediate action
Players should be immediately removed from participation and be assessed. Orientation questions can be used such as: "What day is it?", "Who are we playing?", "Who did we play last week?", "Did we win or lose?", "Are we winning or losing?".
Panadol may be used to help alleviate headache symptoms but NSAIDs or opioids should be avoided as there is an increased risk of bleeding and post headache withdrawal. In the initial 24-48 hours post-concussion, the athlete needs both physical and cognitive rest but can't do tasks that do provoke symptoms. The player can also sleep normally as there is no evidence to support no sleep. A client should be referred onwards if there are increasing or severe symptoms to rule out a brain bleed.
Concussion assessment by physiotherapists
A vestibular ocular motor screening (VOMS) should be undertaken, outlined below. During these tests, concussions symptoms may be reproduced or increased.
Smooth pursuit
Saccades
Convergence
Accommodation
Horizontal VOR
Vertical VOR
VOR suppression
Dynamic visual acuity test
Other tests that can also be performed are the dix-hall pike if the client is describing BPPV symptoms, a tandem balance test, and neck range of motion. A neck flexor endurance test should also be conducted as concussions can reduce neck flexor strength which is linked to increased recovery times.
Physiotherapy rehabilitation
Exercises should start with neutral head positions with possible visual fixation in the gym to help ease symptoms. Additionally, if their horizonal or vertical VOR is provocative, it can dictate what plane people do their exercises in. For example, if vertical VOR is provocative, they may not be able to cope with squats as it involves vertical displacement of the head.
Exercises should also be incorporated from the athlete’s VOMS assessment to try and train their vestibular system without re-aggravating their symptoms. An example of an exercise could be focusing on a 1x1cm letter X whilst swiftly rotating their head 30 degrees left and right without the letter X blurring. This could then be made more challenging by placing the letter X against a ‘busy’ background such as on a window with cars moving past. Cervical neck treatment is also indicated for neck pain relating to possible whiplash and headaches which may be more cervicogenic in nature due to the coup contrecoup movement.
If the athlete’s convergence or accommodation does not improve within a few weeks (>10cm), or the dynamic visual acuity test is poor (>two lines), a referral to an optometrist should be made.
Stages for return to sport
Symptoms limited activity. Graded return to school/work activities
Light aerobic exercises. Graded increase heart rate e.g. bike starting with 5-10mins of steady state and slowly building from this.
Sport specific exercise with no contact e.g. running
Non-contact training drills. Combine exercise, coordination, cognition
Full contact practice. A medical clearance is required first, and SCAT test needs to be at baseline
Return to play with appropriate medical clearance