By: Dr. Jill Murphy, DPT, LAT, CSCS
This article is the third in a series on concussions. So far we have presented an overview of concussions, concussion assessment, and this article will address concussion treatment including information on post-concussion syndrome and second impact syndrome. An athlete might be diagnosed with a concussion by their athletic trainer, team/family/sports medicine physician, neurologist, or any other medical concussion specialist. Keep in mind that no concussion assessment is complete without neurocognitive testing, because assessment based solely on symptoms will miss important cognitive, visual, and processing impairments that should be monitored during the recovery process.
Concussion rehabilitation is essentially management of the activity and environment of the athlete to allow their brain the optimal recovery - meaning a recovery resulting in full restoration of normal physical, neurological, and cognitive abilities as quickly as possible. The time required for complete concussion recovery is unique to each athlete and each concussion that athlete sustains. Unfortunately, predicting a timeline for safe return to play can be challenging, since at times even a mild appearing concussion can take an unexpectedly long time frame for complete resolution of symptoms. This is why athletes receive a very general prognosis upon concussion diagnosis. Certainly if the athlete has sustained more than one concussion, especially in a short period of time (in the same sports season), this will prolong the recovery time necessary for safe return to competition. Sustaining more than one concussion in one season may also preclude returning to sport in that same season. This determination is made by the physician managing the case.
Historically, athletes with concussions were removed from all stimulation, lying down in dark rooms, with no tech devices, no studying, a light diet, and complete rest for long periods of time. However, recent research indicates that athletes do better with a more limited timeframe of complete stimulation removal, followed by a slow progression of stimulating activities. These activities include attending school, cardiovascular activity, and social interaction with family and friends once these activities are tolerated by the athlete. Progression timeline is based completely on the individual athlete and their symptoms each day. If symptoms increase, activity will be cut back, if symptoms remain the same, current participation level will be maintained, if symptoms improve, additional stimulus can be added. This is why day-to-day guidance from a rehabilitation professional experienced in treating concussions is so important, whether your high school or collegiate athletic trainer or a physical therapist with concussion rehabilitation training and experience if an on-site athletic trainer is not available.
Activity modifications start with the athlete’s daily activities. Participation in classes at school and test taking may be modified for any moderate to severe concussion, and sometimes even for more mild concussions if school activities stimulate additional symptoms. Students may also be given more time to complete tests in the initial days or weeks after suffering a head injury if cognitive and/or visual deficits are present. Very light aerobic activity will be allowed when the athlete demonstrates some tolerance to everyday life, including attending a full day of classes at school, walking to and from school, watching practice, etc. Light cardiovascular activity may be started with short durations of 5-10 minutes to start. Based on the patient symptoms during and after this activity, minutes will be added or held back in consultation with the managing clinician.
Continuing to attend practice and games with teammates as well as participating in age appropriate social activities are important to reduce the risk of depression as the athlete is recovering from a head injury, as long as such activity is tolerated without symptom provocation. Athletes with concussions who exhibit on-going emotional changes, moodiness, anxiety, or depression that is not improving over time should be referred to a neuropsychologist so these issues can be addressed before the athlete is cleared to return to sport.
Most mild concussions improve and athletes can return to sport with limited participation in a specific rehabilitation program that addresses each individual deficit such as headache, dizziness, and balance. However, for more significant concussions or for concussion symptoms that are not improving a little each day, the athlete may be diagnosed with post-concussion syndrome, and specific rehabilitation activities addressing remaining impairments will be required.
For most patients, reducing the heightened sensitivity of the nervous system in rehabilitation is quite effective at swiftly reducing lingering concussion symptoms. Again, working with a rehab professional who is experienced in treating patients with concussions is critical to returning to normal function as soon as possible. If patients are quite symptomatic, they should be actively treated several times per week to eliminate impairments and get back to their normal life and activities as quickly as possible.
The athlete may have some neck pain and headaches that linger as a result of their concussion. These symptoms can be effectively addressed in physical therapy with manual therapy techniques directed at tight soft tissue (muscles and fascia) and joints in the spine. Balance deficits can also be addressed with proprioceptive training in rehabilitation. Dizziness and visual changes that are not improving should also be addressed by a rehab professional experienced in treating post-concussion syndrome, and possibly even vision therapy, especially if the athlete is struggling with returning to studying, reading, and test-taking due to remaining visual processing deficits.
The decision to release an athlete to participate in sports is typically made by a physician who specializes in treating concussions or whoever first diagnosed the concussion. The athlete must have no remaining symptoms, even during and after heavy cardiovascular activity, return to full participation in school without restrictions, pass neurocognitive testing (their score should return to the athlete’s pre-season baseline score or reach the normative score for the patient’s age), and pass functional sport and position specific testing with their athletic trainer or physical therapist.
It is imperative that the athlete be completely honest about any symptoms that might be stimulated during physical and neurocognitive testing. If an athlete is released to participate in sports before their symptoms have fully cleared and they have not fully recovered from the concussion, he or she is at a higher risk of sustaining a second concussion. Even if the athlete is fully recovered, the risk of a second concussion is three to six times higher than in athletes who have never sustained a concussion. If the athlete has a second concussion before the brain has fully recovered from the first, he or she could manifest second impact syndrome. An athlete diagnosed with this syndrome after a second or third concussion in a season or even within a year means that their concussion symptoms are magnified compared to what signs and symptoms would be expected for a given trauma to the head, leading to the risk of serious, permanent traumatic brain injury due to bleeding on the brain and subsequent brain swelling. Because the brain is confined by a closed bone (skull) without the ability to expand to allow space for a hematoma, second impact syndrome is extremely serious and is managed in a hospital setting as a traumatic brain injury or TBI. Athletes who suffer this condition may never be cleared to participate in contact sports again.
Thankfully, most athletes recover from concussions relatively quickly and successfully make a smooth transition back to their sports activities with the sound concussion management strategies. Sometimes, athletes get a little stuck in the process, and do require additional rehabilitation assistance. If you have any questions about the treatment of concussions or post-concussion syndrome, contact MotionWorks Physical Therapy’s concussion specialist Dr. Jill Murphy at or call us at 920-215-2050.