Physical Therapy Guide to Concussion
Concussion is a traumatic brain injury that can cause lasting effects on brain tissue and change the chemical balance of the brain. Concussion may cause physical, cognitive, and behavioral symptoms and problems, both short-term and long-term. Every concussion is considered a serious injury by health care providers. If you have experienced a head injury, seek medical help immediately.
The Centers for Disease Control (CDC) estimates that 1.6 million to 3.8 million people experience concussions during sports and recreational activities annually in the United States. These numbers may be underestimated, as many cases are likely never reported. A physical therapist can assess symptoms to determine if a concussion is present, and treat the injury by guiding the patient through a safe and individualized recovery program.
What Is Concussion?
Concussion is a brain injury that occurs when the brain is violently shaken. The injury can happen during rapid movement changes (such as whiplash) or when the head is directly hit. This shaking or hitting of the head causes unpredictable injury to any area of the brain, resulting in immediate or delayed changes in the brain's chemistry and function. Less than 10% of concussions involve a loss of consciousness. Depending on which area of the brain suffers injury, many different temporary or permanent problems with brain function can occur.
Concussions can occur at any age, from a variety of causes, including:
- Motor vehicle collisions (ie, head impact, whiplash)
- Work accidents (ie, falls, head trauma)
- Playground accidents (ie, falling from a slide or swing)
- Sports injury to the head or neck
- Falls (which are the leading cause of concussions)
- Violent events, such as:
- Physical abuse during which the head is shaken
- Being too close to a blast or explosion
- Direct blow to the head, face, or neck
- Assaults, domestic violence
Recovery from a concussion can take several weeks to several months and sometimes years, depending on many factors, including severity of the injury and the age of the person affected.
Concussion may occur along with other injuries, such as those to the neck and surrounding tissues, which should be managed by a licensed physical therapist. More serious brain injuries, such as bruising, bleeding, or tearing, may also occur and require the immediate care of a medical doctor, such as a neurosurgeon.
CAUTION: Concussions can potentially lead to long term brain damage. Seek medical help from a licensed health care provider following any suspected head injury.
How Does It Feel?
A concussion is a brain injury; patients living with a brain injury often don’t have the language to express how they feel after injury. Therefore, it is important to work with a physical therapist who gets to know you, your family, teammates, and/or coworkers who may notice any changes in you.
Signs and Symptoms
There are many symptoms related to concussion, and they can affect your physical, emotional, and mental well-being. Some symptoms occur immediately, some a few hours after the injury, and some show up months or years after a concussion.
It is important to seek medical treatment immediately following any head injury. The risk of death or permanent brain damage from a concussion can be minimized by immediate and appropriate treatment from health care providers, like a physical therapist. Only health care providers have the knowledge and training to identify concussion in the maze of symptoms that can occur following a head injury.
Immediate and short-term symptoms
Physical symptoms of a concussion can include:
- Difficulty with balance and coordination
- Difficulty sleeping
- Increased sleepiness
- Double or blurred vision
- Sensitivity to light and sound
- Slurred speech
- Glassy-eyed stare
Cognitive (thinking) symptoms can include:
- Difficulty with short-term or long-term memory
- Slowed "processing" (eg, a decreased ability to think through problems)
- Difficulty concentrating
- Worsening grades in school
Emotional symptoms can include:
- Mood swings
- Decreased tolerance of stress
- Change in personality or behavior
- Loss of libido
- Loss of menses/menstruation
- Growth problems (children)
- Weight gain
- Low blood pressure
- Muscle weakness
- Chronic headaches or dizziness
- Muscle spasticity
- Early dementia/chronic traumatic encephalopathy (brain disorder)
Some concussion symptoms do not go away in the expected time frame. These symptoms may need further testing and treatment by a team of health care providers, including a physical therapist.
Postconcussion syndrome is the term applied to symptoms such as headaches or dizziness that persist for weeks or months after the initial injury.
Second-impact syndrome is a serious, although preventable, complication that can occur after a concussion. If a person who has suffered a recent concussion experiences another concussion, permanent brain damage or death can occur. Permanent brain damage can include learning disabilities, personality changes, walking disability, or other brain or nerve disabilities. Research suggests that a person who suffers a second concussion before the initial concussion has healed, has a 100% chance of permanent brain damage, and a 50% chance of dying.
An example of second-impact syndrome would be a football player who suffers a concussion in a game, keeps playing, and is hit again; or a person who suffers a concussion from whiplash in a car accident, and then falls at home and endures another concussion very soon after the initial injury.
Extreme care should be taken after a concussion to prevent a second injury.
Athletes who suffer a concussion during practice or competition must be removed immediately from play, in order to prevent subsequent concussions and second-impact syndrome. A physical therapist will work to develop safe guidelines for return to play, return to work, and return to life’s daily requirements.
A longer recovery time may be required for those with a history of prior concussions, eye tracking/movement issues from childhood, migraines, attention deficit hyperactivity disorder, or a learning disability. It's important to disclose your entire medical health history to your physical therapist.
How Is It Diagnosed?
Concussion is most often diagnosed through careful testing by your health care provider, such as a physical therapist. Unfortunately, no single test or tool exists to diagnose a concussion. The diagnosis usually does not rely on hi-tech testing, such as an MRI or CT scan, because brain scans often do not show any brain abnormality, even when the person has symptoms of a concussion.
Your physical therapist will ask you many questions to understand all of the symptoms that you are experiencing. He or she also will perform numerous tests to identify problems caused by a concussion, including muscle strength, coordination, balance, sight, smell, hearing, and memory tests.
During treatment, your physical therapist will repeat the same questions and tests frequently to gauge your progress and help judge when you can return to work, school, sport, or recreational activities.
If you are an athlete who underwent preseason memory (neuropsychological) testing, your physical therapist may collaborate with the health care provider who performed that testing to help determine if you have a concussion.
Your physical therapist may also examine your neck for problems following a concussion. Neck injuries can occur at the same time as concussions, and can cause or increase headaches and dizziness.
How Can a Physical Therapist Help?
Physical therapists can evaluate and treat many problems related to concussion. Because no 2 concussions are the same, a physical therapist will examine your neurological, orthopedic, and cardiovascular systems in order to best prescribe a routine to address your particular symptoms and your needs in all of your daily environments.
Treatment may include:
Rest and recovery. Your physical therapist will help you and your family understand why you should limit any kind of activity (daily tasks, work, school, sports, recreation, the use of electronics) after a concussion, until it is safe to return to these activities. A period of rest helps the brain heal and helps symptoms clear up as quickly as possible. Your physical therapist will prescribe the rest and recovery program most appropriate for your condition.
Restoring strength and endurance. The physical and mental rest required after a concussion can result in muscle weakness, and a decrease in physical endurance. Your physical therapist can help you regain your strength and endurance when the right time comes, without making your concussion symptoms worse. It is common for elite-level athletes and fit “weekend warriors” to experience exercise intolerance with concussion and brain injury. Your physical therapist will work with you to identify and treat your particular concussion symptoms.
Your physical therapist will design a therapeutic exercise program just for you, and closely monitor your symptoms as you participate in the program.
Stopping dizziness and improving balance. If you have dizziness or difficulty with your balance following a concussion, a type of physical therapy called vestibular physical therapy may help. The vestibular system, which includes the inner ear and its connections with the brain, helps you keep your balance and prevent dizziness. A qualified vestibular physical therapist may be able to help reduce or stop your dizziness or balance problems after a concussion by applying special treatments or teaching you specific exercises, some of which you may be able to do at home.
Reducing headaches. Your physical therapist will assess the different possible causes of your headaches, and use specific treatments and exercises to reduce and eliminate them. Treatment may include stretches, strength and motion exercises, eye exercises, hands-on techniques like specialized massage, and the use of technologies such as electrical stimulation.
Returning to normal activity or sport. As symptoms ease and you are able to regain your normal strength and endurance without symptoms returning, your physical therapist will help you gradually add normal activities back into your daily routine. Your physical therapist will help you avoid overloading the brain and nervous system as you increase your activity level. Overloading the brain during activity after a concussion interferes with the healing of the brain tissue, and can make your symptoms return. Your physical therapist will help you return to your normal life and sport activities in the quickest and safest way possible, while allowing your brain to properly heal.
Can This Injury or Condition Be Prevented?
While initial injuries can’t always be prevented, it is very important to prevent further injuries to those with concussion. The injured person should be closely protected until all symptoms have cleared, and normal activity can resume.
The risk of concussion can be greatly reduced by taking the following precautions:
- Avoid motor vehicle collisions:
- Drive defensively, not aggressively.
- Eliminate distractions while driving, such as eating, talking on a cell phone, or texting.
- Choose cars with airbags.
- Make sure the airbags in your car are in good working order.
- Avoid risky behavior in sports:
- Absolutely avoid football techniques that increase the risk of concussion, such as "spearing" and headbutting.
- Avoid or limit "heading" the ball in soccer.
- Don’t ignore or hide signs of concussion, even in an important game or competition. Report them immediately to your coach.
- Stay current with state and federal guidelines.
- Remember that neither helmets nor mouth guards prevent concussions.
- Clear your walking areas at home of any objects that might increase the risk of falling, such as loose throw rugs, dropped objects, loose flooring, torn or rumpled carpets, and pet toys or dishes.
- Make sure that all traffic areas in your home are well-lit.
- Avoid exposure to blast explosions and violent events.
- Do not shake babies, or anyone of any age!
It is imperative to prevent second-impact syndrome after an initial concussion. The injured person should be closely protected until all symptoms have cleared, and normal activity can resume.
Real Life Experiences
Sara is a 15-year-old star soccer player. After today's game, she admits to her parents that she is feeling a bit dizzy after "heading" the ball a number of times. She says a little dizziness is “common” for her, but now she has a headache and the bright headlights of oncoming cars are hurting her eyes. Sara has trouble concentrating at home as she tries to do her homework. She also has trouble falling asleep. Her dizziness gets worse when she changes her head position. Her parents worry that she may have a concussion, and check on her throughout the night. They call their physical therapist the next morning, and take her to see him right away.
Sara's physical therapist asks her all about her symptoms. He tests her eye motion, balance, strength, coordination, memory, and face and neck motion. He gently touches her neck and upper shoulder muscles to check for tightness. He also assesses her heart rate’s response to exercise. After a thorough examination, he determines that Sara has indeed suffered a concussion and needs to begin treatment immediately.
First, he explains to Sara and her parents that she will need to "rest her brain" for a few days. That means that she will avoid school, homework, sports, exercise, reading, and TV, cell phone, tablet and computer use, plus anything else that makes her symptoms worse. He encourages Sara to sleep as much as she wants. He explains the importance of avoiding second-impact syndrome. He learns from Sara that her coach had all the athletes take a preseason memory test, so he arranges for her to be retested by the same health care provider.
Sara's physical therapist then begins to address her dizziness by performing some special techniques for the inner ear. After a few minutes, Sara notes that her dizziness is much less. He then gently treats Sara’s tight neck by applying electrical stimulation and specialized massage techniques. He teaches her some easy stretches that she can do at home, and reminds Sara to “rest her brain” for the rest of the day. He gives her parents a handout of directions for symptoms to watch for in Sara while at home, and when to call him or their family physician.
When Sara returns for her next physical therapy treatment, she reports that she has slept much better. She says bright lights are not hurting her eyes as much, and her dizziness is almost gone. Her physical therapist rechecks all the tests he performed before, and notes that she has better neck motion. At the end of her treatment session, Sara says that her headache seems to be less as well.
Sara returns for physical therapy treatment several more times over the next week, and her symptoms rapidly improve.
In the second week, Sara is free of symptoms for 48 hours; her physical therapist determines that she is ready to try a gradual return to activity. He develops a “return to activity” plan, using Sara’s goals and input. She starts performing a little bit of aerobic exercise and low-level strength training during her physical therapy treatments. Her physical therapist watches her closely to see if any symptoms and problems return during the exercises. Sara is able to gradually increase her exercise each day, without the symptoms returning. She also goes back to school for half-days.
During the third week of treatment, Sara's physical therapist determines that she is ready to try easy soccer drills. She is able to remain at school for full days, now, and to complete her homework, with no return of symptoms.
In the fourth week of treatment, Sara is able to perform vigorous soccer drills during her physical therapy treatments, without the concussion symptoms returning at all—even within the following 24 hours. Her physical therapist determines that Sara is ready to attend a short soccer practice; he collaborates with her soccer coach to plan a gradual return to practice and games. Her physical therapist advises her to avoid "heading" the soccer ball for several weeks, and to limit all use of that technique in the future.
Six weeks after the concussion, Sara plays her first game back with her team, is symptom-free, and helps set up a winning goal!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with post-concussion problems. Some physical therapists have a practice with a neurological or vestibular rehabilitation focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with concussion.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of problems related to concussion. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport: the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;61:838-847. Free Article.
Tapia RN, Eapen BC. Rehabilitation of persistent symptoms after concussion. Phys Med Rehabil Clin N Am. 2017;28:287–299. Article Summary in PubMed.
Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930–934. Free Article.
Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135:213–223. Free Article.
Centers for Disease Control and Prevention. Heads up to parents. Published 2015. Accessed November 20, 2015. Free Article.
Fauntleroy G. Head cases: pituitary incidents arising from traumatic brain injury. Endocrine News. October 2014:13. Accessed November 20, 2015. Free Article.
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. Br J Sports Med. 2013;47:250-258. Free Article.
Leddy JJ, Cox JL, Baker JG, et al. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil. 2013;28:241–249. Article Summary in PubMed.
Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010;34:87–93. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Authored by Anne Mucha, PT, board-certified clinical specialist in neurologic physical therapy, and the APTA Neurology Section. Reviewed by the editorial board.