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A mild brain injury due to a traumatic event when the brain is violently shaken is called a concussion. A Traumatic Brain Injury is commonly referred to as TBI and it is estimated that about 80-90% of all TBI’s are mild. It is estimated that 600 out of every 100,000 of population will suffer some form of concussion or mild TBI every year. As per The Centres of Disease Control (CDC) estimate, this number was as high as 2.5 million concussions in the United States in 2010. The true number of concussions is not known as many of these injuries are not diagnosed or reported as concussion or mTBI due to limited knowledge in this field.
What is Concussion?
Mild TBIs or concussions can occur when the head is rapidly moved by an object hitting it or the head hitting a surface or when the body has rapid movement changes such as whiplash. The brain injury may have immediate or delayed symptoms and depending of its severity, the injury may change chemical balance of the brain and its function. Concussion may cause short-term and/or long-term physical, emotional and mental symptoms and dysfunctions. These symptoms may vary depending on what area of the brain has been injured. The problems with brain function, vision function or balance may be temporary or permanent. Healthcare providers consider every concussion a serious injury. Concussions can occur from a variety of causes and in any age. These causes include:
- Car accidents when the injury happens due to a head impact, whiplash, or the force of an airbag
- Accidents at work due to a fall from heights or head trauma
- Accidents in a playground such as falling from a slide or swing
- Sports injury to the head or neck
- Fall from heights, stairs, or losing balance causing a trauma to the head, face, or neck in elderly
- Violent events during which the head is shaken or when the person is too close to a blast or explosion
How does concussion (mTBI) feel?
Many body functions can be affected by concussion. This may include sensory impairments such as:
- Changes in vision or hearing or even sense of smell
- Increased sensitivity to light & noise
- Weakness in arms or legs
- Loss of balance and coordination
- Changes in mood and personality such as increased irritability, lack of energy, depression, difficulty focusing and concentration
- Headaches or migraines
In the majority of cases concussion is mild but the patient may sometimes lose consciousness (“blacking out”) which can last from seconds to days in more severe brain injuries.
There is no predictive way of relating the severity of the injury to the symptoms. Severe symptoms may occur with seemingly mild injuries and thankfully, many severe accidents cause only minor symptoms. Also, there is no pattern as to how soon symptoms are present. Sometimes symptoms are immediate, many times they occur within a few hours or days post injury and on occasions, symptoms gradually worsen or show up months or years after a concussion.
How is concussion diagnosed?
Although in the majority of cases the symptoms are mild, it is important to seek medical assessment and possibly treatment immediately following any head injury. Immediate and appropriate assessment by a qualified healthcare practitioner such as a trained physiotherapist can identify the risk factors for permanent brain injury and initiate proper referral to hospital or medical facilities. The diagnosis of concussion is usually done by taking very detailed note of symptoms and performing some clinical tests of balance, vision and cognition. It does not usually rely on hi-tech testing, however, computerized neurocognitive tests such as ImPACT are commonly used in the clinics to develop a baseline for measuring progress with treatment. A brain MRI or CT may be ordered to rule out more serious causes such as a brain hematoma (bleeding inside the brain). CT scans and MRI often appear normal in patients with mild TBI. The MRI cannot show microscopic tears and contusions that are considered to be the major cause of symptoms in mild to moderate brain injury.
CT scans and MRIs may help to identify severe cases where concussion occurs along with more serious brain injuries such as bruising, tearing or severe contusions of brain tissue, in which case the medical team will include specialized services of doctors such as neurosurgeons or neurologists.
These immediate interventions can minimize the risk of death or more severe brain damage from a concussion.
What are common concussion symptoms?
Common physical symptoms after a concussion are headache, dizziness, difficulty with balance and coordination. Fatigue, double or blurred vision, sensitivity to light and sound, increased sleepiness and nausea/vomiting are also reported by patients. Many patients report cognitive (thinking) problems such as difficulty with memory (short term or long term), confusion, lack of concentration and difficulty problem solving and fogginess. Concussion can affect a student’s performance in school. It is important to know that 95% of mTBI patients show no cognitive impairment deficits after 3 months.
Concussion can also cause emotional symptoms ranging from irritability, anxiety, depression, mood swings, aggression to as extreme as a change in personality or behaviour.
How long are concussion symptoms expected to last?
Many factors including severity, age and the number of previous injuries can affect the recovery from concussion. It can take several weeks to several months. The most crucial of this time is the first 7-10 days. Mild concussion symptoms slowly recover in 80-85% of cases with no need for treatment. The expected time frame for concussion symptoms to go away is usually 12 weeks. However in some cases symptoms persist longer than this time frame. Further assessment, testing of vision or the vestibular system by trained practitioners such as a vision therapist or occupational therapists may be needed.
What is Post-Concussion Syndrome (PCS)?
Post-Concussion syndrome is a term used when symptoms such as headaches or dizziness persist for weeks or months beyond the expected time frame of recovery after the initial injury.
What is Second-Impact Syndrome?
Although preventable, second-impact syndrome is a complication that can occur following a concussion when the person who recently had a concussion experiences another concussion. This is a serious condition and can result in permanent brain damage or death. Second-Impact Concussion Syndrome is seen in pro sport players and in younger players who return to play before their recovery is completed. It is also seen in workers who have not been diagnosed properly or have returned to physical jobs and suffer a second injury.
Research suggests that the chance of permanent brain damage increases by 100% in a person who suffers a second concussion before the initial injury has healed. Permanent brain damage has debilitating consequences such as learning disabilities, brain disabilities such as Parkinson’s like tremors, walking disabilities as well as personality changes. The chance of dying from a Second-Impact Syndrome is increased as much as 50%.
IT IS IMPERATIVE TO TAKE EXTREME CARE AFTER A CONCUSSION TO PREVENT A SECOND INJURY.
How is concussion managed?
Early intervention is critical in managing concussion or mTBI to manage symptoms effectively and includes:
- Educating the patient and parents about symptoms and recovery times
- Educating the patient and parents about the stressors and risk factors
- Educating the patient and parents to prevent secondary injury
- Gradual return to activities
- Rehabilitation if needed
- Safe and timely return to work and play
- Cognitive therapy
mTBI due to an accident
In patients with multiple injuries, or whiplash, it is important to recognize that the person has experienced a brain injury. In many cases, a patient’s brain injury is overlooked since the patient who has been in an accident may have other injuries such as fractures and neck and back soft tissue injuries (whiplash). This causes the patient to miss the opportunity for benefiting from early intervention.
mTBI due to a sports injury
In sports events and practices when an athlete may have suffered a concussion, the athlete must be removed from play immediately to prevent further brain damage and second-impact syndrome.
How is concussion tested in a clinic?
Immediately after a concussion or mTBI occurs, a few basic screening tests are usually performed by coaches or paramedics to identify a concussion. These are usually simple tests of vision, eye movements and short term memory and will help paramedics or coaches to decide whether or not a referral to a hospital is needed.
Once a concussion or mTBI is suspected and the patient has been referred to our concussion management program in North York , a comprehensive assessment including a battery of clinical tests is usually performed to measure how well the brain functions. These tests will measure memory, eye movements, processing of visual information by the brain, reaction time, motor strength and proprioception. A computerized neurocognitive test may be used to complete this assessment.
The ImPACT test is an FDA approved computerized test commonly used in concussion assessment. Although ImPACT is a highly regarded standardized test, it is only a part of the concussion assessment and should not be solely relied upon for treatment planning.
When the injury occurs as the result of an accident or fall, an ImPACT is completed to measure how well the brain functions and the data collected provides assistance in planning a successful and effective rehabilitation program. In the concussion management program at Physiomobility, after a course of treatment, a repeat of the test provides information about how effective the treatment has been.
What is a Baseline Concussion Testing?
When it comes to sports related concussions, at Physiomobility we employ a comprehensive approach to concussion management which starts before the injury actually occurs. We perform a Baseline Concussion Test at the beginning of the season when the athlete has not yet started training or competition. This is to establish a pre-injury baseline of brain function. This information will be used for comparison and goal setting in case a concussive injury happens during the season. The same test is performed post injury and the scores are compared before and after the injury. These computerized tests not only measure the brain’s executive functions but also record baseline concussion symptoms such as headaches and dizziness in addition to the athlete’s history with concussion.
What is needed for a Baseline Concussion Test?
At Physiomobility, we use ImPACT for the neurocognitive component of our Baseline Concussion Testing. It is a computer-based test which can be used for athletes as young as 5 years of age and can practically be taken anywhere where there is access to the internet. An ImPACT test typically can take anywhere between 30-45 minutes to complete, and can be administered individually or in a group of athletes. Physiomobility staff is trained to analyze and interpret the test result. These scores can be shared with other healthcare practitioners such as a family doctor or team doctor in the event that an injury happens.
The concussion management team at our North York physiotherapy clinic would be happy to talk with you about setting up a Concussion Baseline Testing program for you and your organization. Please contact us anytime.
What practitioners are qualified to treat concussion?
Managing concussion is a team effort. Depending on the severity and range of symptoms, trained physiotherapists, occupational therapists, vision therapists (optometrists with special training), medical doctors, neurologists, neuropsychologists, nurses and case managers can all be involved to effectively manage Post-Concussion Syndrome (PCS).
In mTBI or concussion, a trained physiotherapist usually is one of the first health care practitioners who is involved in assessing symptoms to determine if a concussion is present. Physiotherapists can treat the injury by guiding the patient through a safe and individualized recovery program while collaborating with other practitioners as needed.
The assessment by a trained physiotherapist in concussion will include asking many questions to understand all of the symptoms that are experienced by the patient and will include numerous tests for sight, hearing, memory, balance and coordination to identify problems caused by a concussion. Often a neurocognitive computer test such as ImPACT will be administered to establish a baseline to measure the effectiveness of treatment and for future reference.
The findings of these tests will be used to evaluate what type of program is required to manage symptoms and rehabilitate the patient for a safe return to recreational and work activities or play. The treatment usually includes exercises for vision, head movement, balance, physical excursion and work related activities. This may include computer games and the use of Wii fit and virtual reality equipment in advanced stages of rehabilitation and return to play or work. During treatment, you will be tested frequently to gauge your progress and make a decision regarding your return to work, school, sport, or recreational activities. The goal of a comprehensive mTBI or concussion program is successful reintegration of the patient back into school, work and play.
When the recovery is not as expected and cognitive, somatic and emotional symptoms develop, a referral to a head injury clinic may be necessary. Currently there are only a few head injury clinics in Ontario:
- St. Michael’s Hospital
- Sunnybrook Health Sciences Centre
- St. Joseph’s Health Care, London
These clinics provide highly specialized and comprehensive management protocols for TBI patients.
More on how a physiotherapist can help?
No two concussions are the same. Your physiotherapist examines your individual symptoms and problems, so to design a safe and individualized treatment program just for you. Treatment usually includes:
Rest and Recovery: Limiting activities is very important, especially in the first 7-10 days. A physiotherapist will help you and your family to understand why you should limit most activities and screen time after a concussion. This includes physical, sport, recreational, electronic, school and work until it is safe to return to these activities. A period of rest speeds up the healing process and helps symptoms clear up fast.
Restoring Strength and Endurance: Muscle weakness and general deconditioning can quickly set in after a concussion. A decrease in physical endurance affects energy level, sleep and recovery time. Your physiotherapist helps you to regain your strength and endurance with a safe and effective exercise program both in clinic and at home. In later stages of your rehabilitation, the therapist designs exercise drills suitable for the physical demand of your job or based on sports activities. The ultimate goal is to return you to an active lifestyle without making your concussion symptoms worse.
Controlling Dizziness and Improving Balance: Dizziness symptoms and difficulty with balance following a concussion are not uncommon. A physiotherapist trained in vestibular rehabilitation may help to manage these symptoms. The vestibular system includes the inner ear and brain and is one of the systems involved in balance. A qualified vestibular physiotherapist helps to reduce or eliminate dizziness or balance problems after a concussion. This will be achieved by teaching specific exercises to not only reduce dizziness and fear of movement but improve confidence.
Returning to Normal Activity or Sport: A full return to activities of normal life requires that you engage in exercises with no or very little aggravation of your symptoms. A trained physiotherapist will integrate activities to stimulate and challenge your nervous system and brain without overloading it. A safe and quick return to normal life is a collaborative effort between the patient and the healthcare team.
For baseline testing or concussion management in Toronto and North York, contact Physiomobility .