Concussion Care: Moving Beyond the Standard

Introduction

The world of concussion has changed dramatically. With increased media coverage, parents, and athletes are more aware of concussions. This is positive change, but can also lead to an increase in anxiety and misinformation about the condition. At the same time, the approach to treating concussions has shifted in very recent years. We are now moving past “basic” concussion care for a better understanding of treatments that are showing great promise. Incorporating an integrated, whole-body approach to treating concussions, including specialized therapy, early exercise, nutritional support, and psychological evaluation is effective. In addition, neuromuscular, vestibular, and visual assessments are key to improved outcomes.¹

Evaluation and Return to Play

The standard of care for concussions is moving away from complete brain rest for an extended period of time to a controlled and gradual introduction to activities of daily living (including school and social activities) as tolerated.¹ Slow, controlled physical activity, such as walking or riding a stationary bike, below symptom threshold is now encouraged to help improve symptoms and aid in recovery, especially in cases of prolonged symptoms.^1,2,3 A discussion of this along with the most recent clinical research and an updated Sport Concussion Assessment Tool version 5 (SCAT 5) is available in the new Consensus Statement on Concussion in Sport. Additional useful evaluation measures include reaction time, balance assessment, and oculomotor screening.^{1, 4}

When returning a concussed athlete to play, ensuring that they are completely recovered is vital to minimize the risk of re-injury and serious complications. Graded exercise testing is a beneficial tool to ensure complete recovery. The Buffalo Concussion Treadmill Test (BCTT) uses a graded exercise protocol to take the athlete to full exertion.⁵.⁶ When the athlete completes this without an exacerbation of any concussive symptoms, they are considered physiologically recovered.² If concussive symptoms are provoked by the BCTT, an exercise program is prescribed at 80 percent of the symptom threshold, and the test may be repeated until full recovery.^5,6 Then it is important to take the athlete through a gradual return to play progression, including re-introduction of sport-specific activities over a period of seven days before returning to sport competition.¹ Effective concussion management requires a team approach between medical providers and school officials, and return to play decisions should be made based on multi-faceted assessments including graded symptom checklists, neuropsychological testing (such as the SCAT5 or ImPACT test) and balance assessment.³ See Figure 1.

Figure 1.

Some of our commonly used post-concussion evaluation techniques. From left to right- Vestibular/Ocular-Motor Screening (VOMS), Breathing pattern assessment, Cervical movement pattern assessment, vestibular screening using the Modified Clinical Test for Sensory Interaction in Balance (mCTSIB)

Neuroplasticity and Concussion Recovery

At Mercy Sports Medicine, we have created a system of recovery to help with concussion patients that have severe or lingering symptoms. Our therapy philosophy is based off of the concepts of regional interdependence and neuroplasticity. We utilize this type of approach with all of our patients and have relied on the rehabilitative model created by the Movement Restoration Project, outlined in a recent article in this publication.^7,8 These concepts translate well to patients with orthopedic as well as neurologic complaints. The idea of neuroplasticity is examined in the book The Brain that Changes Itself, by Norman Doidge, MD. He writes that “the brain changes its very structure with each different activity it performs, perfecting its circuits so it is better suited to the task at hand.”^9(xvii) The brain is remarkable in its ability to adapt in the presence of dysfunction, and concussion is no different. In rehabilitation, it is important to avoid using exercises that are simply a rehearsal of outputs and do not create neuroplastic change. To create real neuroplastic change, there must be a novel experience that is learned with highly intense focus, and the brain must be given “the right stimuli, in the right order, with the right timing.”⁹⁽⁸⁸⁾ With these concepts in mind, we can create rehabilitation methods to decrease pain and physical symptoms, improve posture and movement and aid in a patient’s recovery.

Post-Concussion Therapy and Rehabilitation

A full post-concussive evaluation includes multiple body systems and functions. Post-concussive symptoms are not related exclusively to brain injury, but have multi-factorial causes.¹⁰ Patients may have symptoms related to cervical, vestibular, oculomotor, biomechanical and autonomic (breathing) dysfunction, and often a combination of these.^2,11 We assess the breathing pattern of every patient that comes through our doors, regardless of diagnosis. A person’s breathing pattern affects a person’s neuromuscular tone, posture, core stability, emotional regulation, and overall health.^12,13,14 Breathing evaluation becomes even more essential in concussion because of its effect on autonomic regulation and heart rate variability.¹⁵ Both are contributing factors to exercise intolerance following concussion.² The resulting imbalance between sympathetic and parasympathetic activity in the autonomic nervous system may also contribute to impairment in cognitive abilities and emotional regulation.¹⁵ Teaching a patient diaphragmatic breathing can help decrease pain, muscle tension, improve posture, and even lessen or eliminate physical and cognitive signs and symptoms.¹⁴ Our experience with patients with oculomotor and vestibular dysfunctions is that these issues often normalize in less than five minutes of diaphragmatic breathing practice. More long-term practice of diaphragmatic breathing may contribute to overall symptom improvement and clinical recovery.

Treatment techniques vary based on the outcome of the evaluation, but typically include manual therapy, myofascial release, visual and vestibular training, and corrective exercises. See Figure 2. The Selective Functional Movement Assessment (SFMA) is an excellent tool that we use to seek out and diagnose movement pattern dysfunctions. This looks at more than simply range of motion and strength, but the pattern of movement and postural control as well.¹⁶ With concussion, special attention is paid to the cervical spine. Neural receptors in the cervical spine have important connections to the vestibular and visual systems as well as alter afferent input to the central nervous system.¹⁷ Dysfunction in the cervical spine can have effects on multiple areas of post-concussive symptoms. If a patient demonstrates dysfunctional cervical movement patterns, they are taken through further testing (SFMA “breakouts”) that will isolate specific dysfunctions. These can be a joint mobility, tissue extensibility dysfunction, or a stability/motor control problem. With this knowledge we can target the specific dysfunction and improve the patient’s symptoms. In our experience, many concussion patients present with spasm and pain in the sub-occipital muscles. We have had success in eliminating oculomotor and vestibular dysfunctions, as well as cervical pain, with a simple and quick sub-occipital muscle release and other manual therapy techniques.

Figure 2.

Some of our commonly used post-concussion treatment techniques. These are just a small sample of the many techniques and exercises used to treat concussive symptoms and complications.

Top row: Manual therapy techniques (left to right) - Suboccipital release, Positional Release Therapy (PRT) of the cranium

Middle row: Visual/Vestibular training (left to right) - Ocular convergence training - Pencil push up exercise, Vestibulo-ocular reflex (VOR) training - gaze stabilization exercise

Bottom row: Movement and postural corrective drills (left to right) - Half kneeling head turns, Kettlebell deadlift

While targeted cervical spine treatment is often successful, it is also important to look at the rest of the body. A concussion patient with dysfunction involving their shoulder complex, spine, core, hips, or even ankles/feet will demonstrate compensations that could affect their condition. We isolate these dysfunctions using the SFMA and breakouts, and correct using the Movement Restoration system. A case in point: a patient who had suffered a concussion came in with a complaint of dizziness upon running. She was able to complete other low impact aerobic activities to full exertion. Upon evaluation, it was found that her vestibular and oculomotor systems were normal, but that she had poor foot and ankle mobility and demonstrated poor lower body running mechanics which affected proper force absorption. This led her visual system to have to “over-compensate” to keep her visual field level. These dysfunctions likely pre-existed the concussion but her healthy brain had compensated easily. She was given a few simple lower body mobility and stability exercises, and this patient was able to return to running and sports without symptoms.

New Evidence

The newest evidence that we have began to implement is nutritional considerations to limit the metabolic effects of concussive injury and provide neuroprotective effects. Studies show that humans may be more susceptible to brain injury due to “diminished brain resilience syndrome,” or a disrupted homeostatic state due to functional nutrient deficiency. This may lead to increased concussion risk and potential severe metabolic consequences following a concussive injury, leading to increased neuronal loss and more severe or longer lasting symptoms.¹⁸ Functional nutrient deficiencies may include zinc, magnesium, omega 3 fatty acids, vitamin D, polyphenols, and flavonoids.¹⁸ Much of the neurological dysfunction that occurs following a concussive injury is due to a secondary metabolic cascade involving glutamate-mediated exitotoxicity, intracellular calcium overload, mitochiondrial dysfunction, and the creation of reactive oxygen species. This mechanism is similar to features of other classical neurodegenerative disorders, such as dementia and ALS.²⁰ Magnesium levels in the brain fall rapidly following a traumatic brain injury and replenishing these levels has been shown to prevent and reverse neurological injury.¹⁹ Nutritional supplementation with lithium and zinc may also be helpful during acute and chronic phases of concussion to stimulate the healing process and decrease effects of oxidative stress and inflammation.¹⁹ A ketogenic (high fat) diet has been shown to provide neuroprotective effects in Alzheimer’s and Parkinson’s disease patients.²⁰ This may also be beneficial in traumatic brain injury.

Chronic issues after a concussion may be related to persistent neurologic and systemic inflammation. Although Chronic Traumatic Encephalopathy (CTE) has been proposed to be related to a buildup of tau protein in the brain, recent studies have found the cause to be more multi-factorial and related to persistent neuroinflammation.^21,22 Treatment strategies aimed at decreasing systemic inflammation include nutrient supplementation and lifestyle modifications such as the ketogenic diet, as discussed previously. Further research is needed regarding long term effects of repetitive concussions or sub-concussive head impacts, and whether CTE represents a unique pathologic syndrome. An understanding of comorbid health problems, psychiatric disorders and other factors that contribute to a patient’s risk for cognitive decline is essential.²³

Conclusion

The concussion evaluation and treatment methodology has moved far beyond watchful resting. While rest and time will always be a vital component of treatment, it is not enough for every patient and it is important to consider the whole person that is being treated and thorough evaluation of the entire body. The methods described above allow the patient to be an active participant in their recovery and have produced very positive results. We hope that this information will allow clinicians to more thoroughly evaluate and treat patients with concussion and help patients to me more informed and empowered in their recovery.

Biography

Amanda Keenan, ATC, MS, (left), is an Athletic Trainer at Mercy Sports Medicine, St. Louis. She works as a rehabilitation specialist and as a physician extender with Mercy Sports Medicine Concussion Clinic. Brian Mahaffey, MD, MSPH, CAQ, FAAFP, MSMA member since 1999 and Missouri Medicine Editorial Board member for Sports Medicine, is a Primary Care Sports Medicine physician at Mercy Sports Medicine – St. Louis. He is the Medical Director of Mercy Sports Medicine and Team Physician for the St. Louis Cardinals.

Contact: Brian.Mahaffey@Mercy.Net