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Part 2: Role of the Physical Therapist in Recovery from Concussion

Friday, November 1, 2019

By: Jennifer Ciardulli, PT, DPT

Your child has suffered a sport-related concussion (SRC), now what? Once the injury has been recognized, and your child has been removed from play, further examination is performed and a plan for clinical management can be established. A brief period of physical and cognitive rest is recommended during the acute phase (24-48 hours post-injury). This does mean that your child may miss a day or two of school. After this time, gradual and progressive exposure to activity should be encouraged while maintaining a sub-symptom threshold, meaning that activity should not bring on or worsen symptoms. Clinical recovery following SRC is defined as a return to normal activities, including school, work and sport, and this typically occurs in less than 4 weeks in children and adolescents1. Should your child experience prolonged or persistent symptoms outside of the expected time frame, rehabilitation is the appropriate next step.

A physical therapist specializing in the management of concussions can perform a clinical assessment including a comprehensive history, a physical examination focused on cervical spine, vestibular and oculomotor function, postural control, and physical deconditioning, and referral to other healthcare providers to address any persistent cognitive or mood issues. Once physical factors contributing to symptoms are identified, an individualized treatment plan can be initiated. Treatment will likely include a closely-monitored, active rehabilitation program at subsymptom threshold, and use of targeted exercise and manual techniques to improve disorders of the cervical spine and vestibular system2,3.

What about return to sport? Firstly, children and adolescents should not return to full participation in sporting activity until they have successfully returned to school. Another consideration prior to return to sport, is use of pharmacological management of symptoms; if use of medication is required to reduce or relieve symptoms, return to play should be discussed with the treating clinician. Every four years a group of experts, the Concussion in Sport Group, provides a consensus statement outlining principles in concussion management, and have provided a graduated, stepwise rehabilitation strategy for both return to sport and return to learn1 provided in Table 1 and Table 2, respectively. Each stage should last 24 hours (or longer), and if symptoms worsen during any activity, the child should return to the previous symptom-free step for an additional 24 hours before advancing to the next stage. This may sound confusing, but your physical therapist can assist in progressing through this process. A return-to-sport protocol should be followed in all cases; if each stage lasts 24 hours, the athlete should remain off the field of play for at least one week.

Table 1 - Graduated return-to-sport (RTS) strategy

Stage

Aim

Activity

Goal

1

Symptom-limited activity

Daily activities that do not provoke symptoms

Gradual reintroduction of work/school activities

2

Light aerobic exercise

Walking or stationary cycling at slow to medium pace; no resistance training

Increase heart rate

3

Sport-specific exercise

Running or skating drills; no head impact activities

Add movement

4

Non-contact training drills

Harder training drills; may start progressive resistance training

Exercise, coordination, increased thinking

5

Full-contact practice

Following medical clearance; participate in normal training activities

Restore confidence and assess functional skills by coaching staff

6

Return to sport

Normal game play

Table 2 - Graduated return-to-school strategy

Stage

Aim

Activity

Goal

1

Daily activities at home that do not give the child symptoms

Typical activities of the child during the day as long as they do not increase symptoms (reading, screen time); start with 5-15 minutes and gradually increase

Gradual return to typical activities

2

School activities

Homework, reading or other cognitive activities outside of the classroom

Increase tolerance to cognitive work

3

Return to school part-time

Gradual introduction of schoolwork; may need to start with partial school day or with increased breaks during the day

Increase academic activities

4

Return to school full time

Gradually progress school activities until a full day can be tolerated

Return to full academic activities and catch up on missed work

Understanding of sport-related concussions continues to evolve, and individual management of recovery should be guided by a healthcare professional. Persistent concussion symptoms as defined above, are difficult cases and a multidisciplinary and collaborative approach will best support recovery. If your child has suffered a concussion and you’re unsure of how to proceed, contact your local physical therapist for a consultation.

About the Author:

Jennifer Ciardulli, PT, DPT is the physical therapy supervisor for the ProPT division of Connecticut Orthopaedics. Jen earned her doctorate of physical therapy from American International College and she has been serving the Greater New Haven area since that time. She has experience in post-concussion management in a variety of populations.

References:

  1. 1. McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med Published Online First: 26 April 2017. Doi: 10.1136/bjsports-2017-097699
  1. 2. Makdissi M, Schneider KJ, Feddermann-Demont N, et al. Br J Sports Med Published Online First: 8 May 2017. doi:10.1136/ bjsports-2016-097470
  1. 3. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial.
          Br J Sports Med 2014;48:1294–8

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