PT Classroom - Concussions/mTBIs and Clinical Management in PT ׀ by Mallory Washington, SPT



In recent years, the medical field has seen a shift away from the term concussion, redefining this injury as a mild traumatic brain injury, or mTBI (Quatman-Yates et al., 2020). When thought of as a TBI, the injury carries more weight with even more serious consequences. According to the University of Pittsburgh Medical Center (UPMC), between 1.7-3 million sports and recreation-related mTBIs are reported annually (n.d.). While sport related mTBIs are the most commonly researched, they can also occur from a wider range of mechanisms including falls, motor vehicle crashes, blast exposures, and assaults (Mayo Clinic Concussion, 2020). Additionally, the Center for Disease Control and Prevention (CDC) reports that there are 2.53 million emergency department visits related to TBI, with 812,000 occurring in children, showing the high incidence of brain related injuries (2019). Due to the elevated occurrence of mTBI’s, it is crucial that physical therapists (PTs) and other healthcare professionals understand what a concussion is and how to best treat it. While this article will try to provide guidance through summarization and a general overview, reading the clinical practice guideline (CPG) will provide more detailed explanations and answers.

What is a Concussion/mTBI?
According to CPG released by the Journal of Orthopaedic & Sports Physical Therapy in 2020, a concussion (mTBI) is defined as “traumatic injury. That affects the brain, induced by biomechanical forces transmitted to the head by a blow to, or forces exerted on, the body, but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury” (Quatman-Yates et al.). Due to the mechanism, damage can occur both to the brain and other structures in close proximity to the brain, including the cervicothoracic spine and vestibular system (Quatman-Yates et al., 2020). Common symptoms of a concussion range from a variety of cognitive, physical, emotional, and sleep dysfunctions (Collins, 2019). Some of the most common include headache, feeling “slowed down”, inability to concentrate, dizziness, fogginess, fatigue, blurred/double vision, photophobia, memory dysfunction, and balance deficits (Collins, 2019). Due to the wide range of symptoms, mechanisms, and structures involved, it is impossible to define a gold standard for treatment.

Potential Pathophysiology
Despite the differences in presentation, however, there has been some speculation around the pathophysiology of a mTBI that would draw similarities among affected individuals. A popular pathophysiology map was created by Giza & Hovda in 2014 and includes a step by step breakdown of a neurometabolic pathway. This neurometabolic cascade begins when axons are damaged or stretched following linear/rotational acceleration/deceleration forces resulting from the mechanism (Collins, 2019). After the acute injury, increased depolarization of the synapses occurs, a greater frequency of action potentials (Giza & Hovda, 2014). These action potentials cause an increase in glutamate release from the neurotransmitters, allowing potassium to efflux outside of the cell (Giza & Hovda, 2014). In order to balance the sodium-potassium ratio within the cell, the sodium-potassium pumps use excessive ATP and work to restore balance of potassium in the cell, resulting hyperglycolysis (Giza & Hovda, 2014). As a byproduct of hyperglycolysis, lactate then begins to accumulate in the cell, leading to an increase in calcium that is sequestered into the mitochondria to cause dysfunction (Giza & Hovda, 2014). A positive feedback loop is then created, as the mitochondria are less able to produce ATP and further increases the ATP deficit caused by increased workload for the sodium-potassium pumps (Giza & Hovda, 2014). As a result of this process, certain enzymes within the cell are activated to initiate apoptosis (Giza & Hovda, 2014). If this cycle is allowed to chronically occur, the influx of calcium can lead to compaction of the neurofilaments, microtubule disassembly, and inflammation (Giza & Hovda, 2014). Thus, mTBIs may lead to this chronic state of inflammation if it is not properly managed. Despite this relatively recent hypothesis, more research is needed to truly understand the precise pathophysiology that occurs acutely and chronically in those who suffer an mTBI.

CPG Foundation
The CPG released in 2020 titled Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury serves as a researched guideline for PTs to help clinically manage mTBIs in those ages 8 and older. In general, this CPG is not a standard of medical care and recognizes the importance of clinical judgement and experience in patient care. To help organize the research to date, the CPG has a framework of 3 components: process for determining if a PT examination is appropriate, the PT examination and evaluation process, and development/implementation of a plan of care. This framework is built on the principle of active rehabilitation, defined as a 24-48 period of relative rest post-injury followed by a phased increase in activity level based on symptoms. When completing active rehabilitation, a patient’s current activity level can be resumed if symptoms are considered mild and do not cause acute exacerbation, and a new activity level can occur if no symptoms are present at the current level and the new level produces mild symptoms. This recommendation is based off of the idea that symptom provocation is necessary to guide the plan of care and return to pre-injury functional status. When looking at mTBI impairments that fall within the PT scope of practice, there are 4 categories that are consistently discussed within the CPG, including: Cervical musculoskeletal impairments, vestibulo-oculomotor impairments, exertional tolerance impairments, and motor function impairments. Following are screening and diagnosis, examination, and intervention recommendations based on these 4 impairment groups (Quatman-Yates et al., 2020).

PT Screening and Diagnosis
While patients are often diagnosed and cleared of a serious brain or spinal cord injury before beginning PT for mTBI, there is strong evidence to suggest that a screening processes should occur in PT in unique cases. This strong evidence suggests that all individuals who have undergone a concussive event should be screened for a concussion and signs of severe or emergent pathology. Further, patients without a diagnosed concussion and with a reported concussive event should be evaluated for signs and symptoms. Conversely, there is weak evidence for evaluating a patient for another diagnosis in the lack of signs and symptoms of a concussion. There is also weak evidence for the determination of whether a PT evaluation is indicated for those who have experienced a concussive event or have signs and symptoms of one, however, this grade is likely due to a lack of necessary research. A PT should always determine the appropriateness of evaluation and treatment (Quatman-Yates et al., 2020).

PT Examination
In a general mTBI examination, there is moderate evidence to suggest that the examination should include elements for the 4 impairment categories recognized by the CPG and listed above. However, there is weak evidence to suggest that the examination should be sequenced based on patient irritability of symptoms, due to insufficient evidence. The lack of gold standard for sequencing is likely due to the variety of symptoms present and patient irritability. Regardless, the PT should consider the frequency, severity, and ease of provocation/resolve of patient symptoms when conducting the examination. Overall, there is no gold standard and it is best to use clinical judgement to gather the most information possible while also focusing on building rapport and avoiding severe exacerbation (Quatman-Yates et al., 2020).

Cervical musculoskeletal impairments: Weak evidence suggests that the cervicothoracic spine should be examined if there are any symptoms related to these areas, such as neck pain, headache, dizziness, fatigue, difficulty focusing, and balance deficits. While this evidence is rated as weak, the CPG discusses that this should be performed due to the potential of this impairment category to cause dizziness and other non-traditional cervical/thoracic symptoms. The examination should consist of palpation, joint mobility, ROM, strength/endurance, and joint position error testing (Quatman-Yates et al., 2020).

Vestibulo-oculomotor impairments: There is strong evidence to suggest that if the patient is having signs and symptoms consistent with BPPV (dizziness, vertigo, loss of balance, nausea, and vomiting) the PT should perform the Dix-Hallpike and other positional tests to rule in/out this diagnosis (Mayo Clinic BPPV, 2020; Quatman-Yates et al., 2020). Additionally, there is moderate evidence to suggest that if the patient is having signs and symptoms consistent with the vestibular or oculomotor systems, these systems should be analyzed using tests such as ocular alignment, smooth pursuits, saccades, vergence, visual acuity, visual motion sensitivity, orthostatic hypotension, etc. (Quatman-Yates et al., 2020). The vestibular-oculomotor screening tools (VOMS) is generally used for sport to analyze these systems but may be useful in general populations as well (Quatman-Yates et al., 2020).

Exertional impairments: There is moderate evidence to suggest that the PT should test a patient with a potential concussion for orthostatic hypotension and autonomic nervous system (ANS) dysfunction by monitoring heart rate and blood pressure in supine, sitting, and standing. The same level of evidence also suggests that for patients with reported exertional deficits and desire to return to a high level of activity, a graded exertional test based on symptoms should be conducted on a bicycle or treadmill. However, if the patient has cervical or vestibulo-oculomotor dysfunction, this graded test may be performed on a bicycle according to weak evidence. There is also weak evidence to suggest that exertional testing may be used to determine the role of ANS dysregulation and general fitness level, which can be helpful to make return to play decisions. Lastly, there is only expert recommendation to suggest that exertional testing can be helpful in determining exertional targets for brain healing in those that do not desire to return to vigorous activity levels. Despite the evidence, clinical decision making should be utilized for this category due to the potential for exacerbation, decreased tolerance, or lack of appropriate fitness level (Quatman-Yates et al., 2020).

Motor function impairments: According to the CPG, a moderate level of evidence suggest that a PT should examine static/dynamic balance, motor coordination/control, and dual/multi-tasking. Dual and multi-tasking impairments have growing support through evidence due to its potential ability to determine subtle motor function impairments that may not otherwise be observable clinically (Quatman-Yates et al., 2020).

PT Intervention
In general for mTBI, there is strong evidence suggest that a PT should educate their patients about potential symptoms, impairments, and functional limitations. In doing so, the PT should also emphasize the generally quick recovery of most individuals with mTBI (often within 14 days). This strategy can help reduce any rumination and negativity surrounding the injury that could lead to delayed recovery and return to function. Further, there is moderate evidence to suggest the importance of self-management, relative rest within an active rehabilitation approach, progressive re-integration into normal activities, safety, and sleep. Moderate evidence also suggests a personalized plan of care based on impairments, limitations, and symptoms; however, this is clinically common. A plan of care may begin in the first week if appropriate, and in doing so, often leads to shorter recovery times. Finally, if the PT feels that the patient symptoms are not within their scope of practice (mental health, cognition impairments, persistent migraines, visual/auditory impairments, etc), it is important to refer to a more appropriate healthcare professional (Quatman-Yates et al., 2020).

Cervical musculoskeletal impairments: The CPG suggests that there is moderate evidence to support the use of cervical interventions to improve cervicothoracic dysfunction. Interventions should consist of ROM, strength, postural re-education, sensorimotor improvements, and manual therapy. This category may also be helpful in the reduction of future concussion risk, as imbalances within the cervical musculature are associated with increased risk of mTBI (Quatman-Yates et al., 2020).

Vestibulo-oculomotor impairments: After Dix-Hallpike or other positional tests are performed and BPPV is found to be present, there is strong evidence to suggest the use of canalith repositioning maneuvers to decrease symptoms and improve vestibular function. Further, moderate evidence suggests that PTs with vestibular experience should provide an individualized program, including a visual-motion habituation program if vertigo is present as an impairment. An individualized program is shown to decrease dizziness, increase balance abilities, and lead to quicker return to sport. However, the PT must be sure to choose interventions wisely, as cervical dysfunction may be irritated by quick cervical motions, such as with VOR. Finally, it is expert opinion and ethically important to refer to another PT if you are not familiar with or lack appropriate knowledge within this field (Quatman-Yates et al., 2020).

Exertional impairments: The CPG suggests that there is strong evidence for the utilization of a progressive aerobic program guided by symptoms in patients with the desire to return to a high level of activity. An aerobic program can be individualized based on patient preference, goals, functional status, and access to necessary space/equipment. The CPG also suggests that there is no gold standard of protocol for increasing aerobic fitness/tolerance, so time or symptom-based protocols may be used. Moreover, there is foundational/theoretical evidence to suggest the use of an aerobic program for populations that do not wish to return to a vigorous activity level to reduce deconditioning, improve mental health, and promote brain healing. In a less active population, aerobic activity may decrease recovery time (Quatman-Yates et al., 2020).

Motor function impairments: There is weak evidence to suggest the use of a motor function program for any motor deficits that are either identified through examination/observation or suspected, despite a growing interest in this research body. Regardless, the use of a motor function program may allow the patient to progress to a higher functional level. Interventions targeting motor function may include both static and dynamic balance, motor coordination and control, or dual/multi-tasking activities. Although some of these motor function impairments may be difficult to identify clinically and may seem unimportant as a result, they may still be beneficial for the reduction of future mTBI risk (Quatman-Yates et al., 2020).

While the CPG is based on the most recent evidence and is a good tool to guide PTs through a full plan of care, there are some limitations to adhering to these recommendations. First off, the number of tests and measures recommended to perform in the initial examination and re-evaluations may not be feasible to conduct clinically within productivity requirements and time allotments. For most of the outcome measures listed within the CPG, the time until re-evaluation is every 1-2 weeks, which consumes large amounts of treatment time. Furthermore, many of the signs and symptoms associated with each impairment category overlap, making it more challenging to identify the accurate impairment category. Continuing, for diagnostics, protocols, and outcome measures, there is no recommended gold standard. PTs must rely on clinical decision-making skills to make many of the decisions, creating inconsistencies among practitioners. Lastly, while there is a growing body of evidence around mTBI, there is still limited evidence among all facets of this topic. Much of the research conducted is also on a young, athletic population, making it challenging to determine what is most appropriate for a the general public (Quatman-Yates et al., 2020).

Concussions, or mTBIs, have continue to push toward the forefront of interest and conversation in the PT world. This injury needs to be taken seriously, as it can have serious pathophysiological, mental, and physical outcomes. In order to best manage the condition, the CPG is an important tool to guide PTs through the complexity of the condition. Further, the impairment categories of cervical musculoskeletal, vestibulo-oculomotor, exertional, and motor function can be useful for both an examination and interventions to allow patients the quickest and safest return to functional activity. All in all, while there is no one definitive way to treat mTBI, there are some general principles to help guide decision making.

Center for Disease Control and Prevention. (2019). Traumatic brain injury & concussion. Center for Disease Control and Prevention.
Collins, M. (2019). Rehabilitation of Prolonged Concussion in Young Athletes [PowerPoint slides]. Children’s Hospital of Wisconsin. PDF.
Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75 Suppl 4(4), S24–S33.
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Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., Landel, R., Alsalaheen, B. A., Hanke, T. A. & McCulloch, K. L. (2020). Physical therapy evaluation and treatment after concussion/mild traumatic brain injury. Journal of Orthopaedic & Sports Physical Therapy, 50(4), CPG1-CPG73. doi: 10.2519/jospt.2020.0301
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Last revised: December 20, 2020
by Mallory Washington, SPT

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