As a physiotherapist with many years of experience working in concussion rehabilitation, I am always updating my skills and knowledge based on the latest evidence-based research and cutting-edge techniques.
I recently participated in and completed an informative and innovative course called the ‘Athlete Brain Rx: Rehabilitation Course’ by Katie Mitchell at Thrive Neurosport. The course showed me a number of new ways to think about concussion assessment and rehabilitation.
In this article, I discuss a few take-aways from the course that have changed the way I will be treating clients after concussion and other injuries going forward.
How Does Concussion Affect Your Overall Health?
A concussion is a type of traumatic brain injury caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to move around inside the skull, which can result in chemical changes in the brain and sometimes stretching or damage to the brain cells.[i]
This definition of a concussion allows us to understand that a concussion does not affect just one or two parts of the brain, but affects multiple areas of the brain all at once and that concussion is a central injury that affects the functional communication of the brain.[ii]
There are often a wide variety of symptoms and impairments that affect a client after a concussion. The most common dysfunctions include dizziness, headache, blurry vision, confusion, being more emotional, and poor sleep, just to name a few.
As you can see with these concussion symptom examples, concussion affects multiple aspects of our daily lives and overall health, including our:
- Visual system – how we see
- Vestibular system – how we control our head and body in space
- Cognition – how we think
- Emotions – how we feel
- Motor system – how we move, and even how we sleep
These wide-ranging symptoms and systems that are affected, are the reason why concussion rehabilitation for clients often involves a multidisciplinary approach. From a physiotherapist perspective it is also why we need to treat the ‘whole’ client, and not just one or two symptoms that the client is reporting, such as neck pain or headache.
A Multi-Systems Integrated Concussion Rehabilitation Approach
After a thorough assessment of these multitude of systems (including cervical, vestibular, vision, oculo-motor, balance, autonomic, etc.), it usually becomes evident that there are a lot of issues that need to be addressed. Therefore, to treat these many different systems and impairments, concussion rehabilitation for these clients will also need to incorporate treating multiple systems and cover a wide variety of functional goals. It can not be a ‘one size fits all’ type of approach.
For example, after concussion a common impairment is oculo-motor dysfunction, which affects the brain’s ability to coordinate the eyes to move with accuracy and control. This dysfunction can cause headaches, dizziness, blurry vision, etc.
A common treatment approach to this dysfunction is eye-tracking exercises and/or head movement exercises. This treatment usually occurs while seated in a quiet environment with all focus on the eye or head movements.
This type of exercise is often very effective in the beginning stages of a rehabilitation program, and possibly as much as a client can tolerate at that point. Unfortunately, this is where rehabilitation starts and ends for some clients if these exercises are not appropriately progressed.
These exercises are useful in the beginning stages, in a quiet clinic setting. However, the client still has to go back to their busy home or work environment. These settings can aggravate their symptoms much more than these simple exercises do. Therefore, we need to find ways to challenge the clients in a progressive and realistic way in the clinic setting.
In addition, this is a very isolated treatment approach and may not be addressing many of the other impairments found during a thorough concussion assessment, such as balance impairments, vestibular dysfunction, movement and coordination issues, and autonomic dysregulation. To progress from the beginning stages of rehab, to create more real-life functional exercises, and to challenge and stimulate multiple systems, a more dynamic and multi-systems approach is often needed.
For example, doing a sit to stand exercise with the client maintaining their focus on a target on the wall in front of them, challenges the oculo-motor system just like the previously mentioned exercise. However, instead of only challenging one system like that exercise, the movement and increased challenge of the sit to stand motion stimulates the client’s vestibular, balance, coordination, motor and autonomic systems too.
This added stimulation creates increased demand on multiple systems, can be easily progressed, and is a functional exercise that is often a challenge for people in everyday life. Incorporating exercises like this into a concussion rehabilitation program helps to challenge clients and increases engagement with their functional goals.
Customized Concussion Rehabilitation Programs
The concussion rehabilitation program will also need to be tailored to the individual themselves, not just the dysfunction. When a client comes into the clinic, they bring with them years of experience being who they are. They already have their own specific goals, strengths, weaknesses, hobbies, sports training, work experience. These personal factors shape the way the concussion is affecting them and how they will respond to different rehabilitation exercises.
Therefore, a thorough discussion, during both the assessment and throughout the treatment program, about these different layers is critically important to develop the specific therapy intervention that will be most appropriate and beneficial to them.
For example, let’s think about a client who sustained a concussion a few months ago and now wants to return to their job as a landscaper. This job is very physically and cognitively demanding, requires coordination and motor skills, and also requires a lot of bending forward or kneeling down. If this client is not progressed through multiple stages of rehabilitation which create high demands on his oculomotor, vestibular, motor, autonomic and cognitive systems, the chances of a successful return to work are limited.
A client-centered concussion rehabilitation exercise program for this client should involve challenging and stimulating the multiple systems that his job requires in a safe and controlled environment. For example, by working on repetitive forward bends, standing to kneeling exercises we can start to address the oculomotor, vestibular, motor and autonomic systems.
But this still leaves out the cognitive demands of the job and the fact that he will likely be working in a busy environment with other co-workers. To add to the challenge of this exercise, we could ask the client to complete math tasks (e.g., such as counting backwards by 7s), listing things in a specific category (e.g., name 10 types of trees), or even have the client picking up different objects from the ground based on their answers.
The details around these interventions can vary, and this is the flexible and fun part of creating a challenging and tailored concussion rehab routine! The goals here is that these practical and demanding exercises will allow the client to progressively build back tolerance to these job-related demands through the multiple systems that are being challenged with these exercises.
As an experienced therapist in neurological rehabilitation, it was great to learn some new evidence-based guidelines, clinical tips, and therapist experiences to help shape my always evolving clinical practice.