Compiled by our Masters trained Physiotherapist Chris Smith. To book an appointment with Chris, or read his Meet the Team profile CLICK HERE. 

A concussion is defined as "a complex pathophysiological process affecting the brain". It is caused by “traumatic forces" to the head when the brain is knocked either directly, or indirectly through the body being knocked. The transmitting forces to the head result in the brain hitting the inside of the skull and causing a mild traumatic brain injury.

No structural issues can be identified on scanning the brain, therefore the condition is classified as functional, meaning a loss of normal function of the brain, rather than structural which is a lesion in the brain tissue itself.

The trauma causes an interruption in the brain at a cellular level and can have significant ongoing effects on someone's quality of life. It has been shown that the effects of trauma to the brain leads to alteration in normal nerve function, which leads to reduced blood flow to the brain tissues (cerebrum). Your brain controls all aspects of human function and thus the symptoms of concussion can be widespread as is the case in a stroke. 

Symptoms

These symptoms can be broadly classified as below, although this list is not exhaustive.

• Physical signs - Loss of consciousness, amnesia, headaches, nausea, neurological deficit, dizziness, fatigue, light and noise sensitivity. 

• Balance disturbance - Gait, unsteadiness.

• Behavioural changes - Irritability, lability, getting upset/emotional.

• Cognitive impairment - Reduced focus, lack of concentration, confusion, poor reaction time.

• Sleep - Poor sleep patterns, drowsiness. 

If the brain suffers a second trauma whilst recovering from the initial concussion the results can be far more serious, and even fatal. This "Second Impact Syndrome" has been well documented in sports such as football, boxing, rugby and NFL. It is imperative not to miss a diagnosis and also for appropriate concussion management advice to be followed for taking time off sport and when to safely return to physical activity.

In New Zealand we have 35,000 head injuries annually (Feigin et al., 2013). While most people associate concussion with sports, the majority of head-knocks (almost 80 per cent) happen in daily life (ACC). Infact, only 21% of head injuries are generally associated with sport (Theadon, 2014).

Recovery

Below are the typical timeframes for recovery 

• 70% recover in 14 days

• 95% recover within 4-6 weeks

• 5% take longer to recover and of these 30% have previous mental health issues

There is also an increased risk of 2nd concussion for up to a year. 

Assessment and Management  

If symptoms of a concussion are diagnosed pitchside, the player should be taken out of sport immediately. New Zealand rugby guidelines suggest a 21 day stand down from sport, "if in doubt, sit them out". A 48 hour respite for the body and brain recommended along with constant supervision in the first 24 hours to monitor their level of consciousness for any more serious injuries. 

After the acute management patients should be referred for concussion management, usually by their GP or sports physician. This is where physiotherapists have a large role to play. Dependent on the clients symptoms they may benefit from a range of rehabilitation including neck treatment, vestibular rehabilitation, graded physical activity management and return to sport testing. Physiotherapists can also refer to other members of a wider multi-disciplinary team including psychology, dietician, neurologist, occupational therapy, and personal trainers.

Physiotherapy management

1.  Many concussions are associated with ongoing neck pain, therefore physiotherapy can help to treat neck pain associated with the concussion.

2.  Vestibular - Testing of your vision and balance systems and how your brain works to relay messages between the two. Often after a concussion the reflex between your brain and eyes are affected leading to feelings of dizziness and loss of balance. Specialised physiotherapy targeting your visual system can aid in re-training this reflex and parts of the brain.

3.  Graded physical and mental activity - Due to the reduced function of the brain following a concussion and the subsequent rest needed for recovery, patients will usually need guidance with graded return to exercise. Whilst some exercise is good for increasing blood flow to the brain too much can aggravate symptoms. Repetitive overload of physical activity and not following a safe and graded exercise approach can lead to recurrent symptoms and prolong recovery. Likewise, mental exertion can aggravate symptoms after a concussion. Graded mental task and activity modification at home and work may be needed after a concussion. Physiotherapists can help with both and do physical activity testing to ascertain and give advice on a safe level of physical activity to return to. 

4.  Graded return to play - People should have fully returned to work/school and social activities and be symptoms free before returning to sport. Physiotherapy can help with a graded return to play programme however officially clearance by a doctor is required before return to sport. 

References

Elbin, R. J., Sufrinko, A., Schatz, P., French, J., Henry, L., Burkhart, S., … Kontos, A. P. (2016). Removal From Play After Concussion and Recovery Time. Pediatrics, 138(3), e20160910. doi:10.1542/peds.2016-0910​

Feigin V, Theadom A, Barker-Collo S et al. Incidence of traumatic brain injury in New Zealand: A population-based study. The Lancet Neurology. 2013;12(1):53-64.​

Halstead, M, Walter, K.Clinical Report - Sport-Related Concussion in Children and Adolescents.  Pediatrics. 2010;126(3): 597-615.​

McCrory P, Meeuwisse WH, Aubry M et al. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine. 2013;47(5):250-8​

Signoretti, S., Lazzarino, G., Tavazzi, B., & Vagnozzi, R. (2011). The pathophysiology of concussion. Pm&r, 3(10), S359-S368.

Theadom, A., Parag, V., Dowell, T., McPherson, K., Starkey, N., Barker-Collo, S., ... & BIONIC Research Group. (2016). Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract, 66(642), e16-e23.

Wang, Y., Nelson, L. D., LaRoche, A. A., Pfaller, A. Y., Nencka, A. S., Koch, K. M., & McCrea, M. A. (2016). Cerebral Blood Flow Alterations in Acute Sport-Related Concussion. Journal of neurotrauma, 33(13), 1227–1236. doi:10.1089/neu.2015.4072​

Wangui, A. M., Kaniaru, D., & Wambui, M. (2019). Pathophysiology and Mechanism of Concussion.