• Feature

    Beyond Rest: Physical Therapists and Concussion Management

    A growing body of evidence reinforces the value of physical therapy for this patient population. PTs are getting the word out—to the public and their peers.

    Concussion

    These are—if you'll pardon the expression—heady times for the role of physical therapists (PTs) in care management of people with concussion. Research advances and work being done by PT clinicians across the country have firmly established PTs' place at this table.

    "There's an ever-stronger evidence base to what we're doing in the treatment arena," says Anne Mucha, PT, DPT, coordinator of vestibular rehabilitation for the Sports Concussion Program and Centers for Rebab Services at the University of Pittsburgh Medical Center (UPMC)—a global leader in testing, treating, and researching sports-related concussions.

    "Better and better data lends support to how PTs—as members of multidisciplinary, multifaceted health care teams—consider, manage, and create treatment pathways for concussion in optimal and efficacious ways," says Mucha, a board-certified clinical specialist in neurologic physical therapy. She offers as examples 2 recent findings—1 study showing the benefits of cervicovestibular rehabilitation in decreasing time to medical clearance1 and another indicating slower symptom resolution in a group of adolescents prescribed strict rest, as opposed to "usual care."2

    "Some medical professionals still are of the opinion that there's no way to treat concussion other than to rest the patient," Mucha comments, "but there's been rapid evolution of evidence to the contrary."

    The physical therapy profession long has promoted PTs as key participants in treatment of this serious, widely variable, but highly treatable condition. The APTA House of Delegates' position, issued in 2012, "recognizes that physical therapists are part of the multidisciplinary team of licensed health care providers that provides concussion management."3 That role, the position states, includes "examination and evaluation to establish a diagnosis, treatment through implementation of a plan of care, monitoring of progress, and making return-to-participation decisions by using best available evidence and standards of care."

    Now it's time, says Tim Rylander, PT, MPT, for PTs to "enlighten people to the benefits of taking an active approach to recovery from concussion. We need to get the message out," he says, "that exertion—provided it's very well gauged, very well monitored, and injected at the proper sequence of the recovery phase—can play a key role in returning people who've been concussed to full participation in their daily lives." He references in particular research on the benefits of exertional treadmill testing in return-to-activity management of people with concussion.4

    "As movement experts, physical therapists know the positive aspects of physical activity and exercise," notes Rylander, a board-certified clinical specialist in orthopaedic physical therapy and certified brain injury specialist. He is vice president of clinical development at Doctors of Physical Therapy, which has 13 practice locations in Illinois and Wisconsin.

    "Concussion is exactly in our wheelhouse," says Jessica Schwartz, PT, DPT, program director for concussion management certification at Evidence in Motion, whose work is shaped in part by her own experience with the condition. (See "For Them, It's Personal" on page 22.) She points out that 4 of the 6 clinical trajectories for concussion cited in UPMC's interdisciplinary model for understanding the assessment, treatment, and rehabilitation of the condition—vestibular, cervical, ocular, and posttraumatic migraine—are squarely within PTs' scope of practice. The remaining trajectories—cognitive/fatigue and anxiety/mood—are "directly correlated to other 4," she adds.

    Karen Skop, PT, DPT, echoes Rylander's call for PTs who have educated themselves on concussion and its optimal management to shout their qualifications from the rooftops—or at least from the nation's playing fields.

    She notes that a study presented last fall at the 5th International Consensus Conference on Concussion in Sport in Berlin found that "when the team PT makes return-to-play decisions, concussion is managed just as safely as it is when the team physician is making that call."5

    Skop, a clinical specialist in vestibular rehabilitation at the James A. Haley Veterans Hospital and Polytrauma Center in Tampa, Florida, crisscrosses the country teaching an advanced vestibular-balance course on concussion. "Why," she asks, "aren't we marketing our profession more strongly as the health care provider to be seen after a concussion?"

    Exception Is the Rule

    The answer to that question lies partially in the fact that, as Mucha puts it, "concussion is new"—at least as an area of intensive study.

    "It's only been in recent years that concussion has been taken seriously as a brain injury for which people come to physical therapy," notes Mary Beth Osborne, PT, DPT, a board-certified clinical specialist in neurologic physical therapy who chairs the Academy of Neurologic Physical Therapy's Brain Injury special interest group.

    Evidence of brain injury from repeated blows to the heads of professional football players has sharply heightened media and public interest in postconcussion syndrome, which the Mayo Clinic defines as "a complex disorder in which various symptoms, such as headaches and dizziness, last for weeks and sometimes months after the injury that caused the concussion." However, an estimated 80% to 90% of concussions resolve themselves within 7 to 10 days.6  

    But the devil's very much in the details of those other 10% to 20% of cases. And, given that about 75% of the estimated 1.7 million traumatic brain injuries sustained by Americans annually—from causes ranging from sports injuries to car accidents and falls—are concussions or other forms of mild traumatic brain injury (mTBI),7 that adds up to a lot of details.

    "I wish we could eliminate the word ‘concussion,' because to some people it still means, ‘So, you got your bell rung—you'll be fine,'" says Lauren Ziaks, PT, DPT, ATC. "But when you get a concussive force surging through your body, there's a shearing of axons inside your brain, with corresponding areas of cell death. That," she emphasizes, "is a brain injury."

    Ziaks speaks from experience as well as clinical training. Her own concussion history led her to direct the concussion management program at Wasatch Physical Therapy and Sports Medicine in Park City, Utah, and to create, with a physician assistant colleague, a website focusing on concussion education and management. (For more on her story, see "For Them, It's Personal" on page 22.)

    Given that the brain is the body's most complex and least understood organ, there's nothing cut-and-dried about concussion management.

    The UPMC Sports Concussion Program annually sees about 20,000 people with the condition at its facilities across western Pennsylvania. "We try to make people understand that concussion isn't the same for each individual," Mucha says. "Many different clinical profiles present after concussion, and they all require different evaluations and management approaches."

    For that reason, Ziaks finds treating patients with concussion deeply fulfilling but also quite challenging.

    "Five percent of my patients with concussion track in predictable ways, and it's all beautiful, but the other 95% have their own unique presentations and issues," she says. "That means you have to be agile as a PT. You have to be educated, and you have to be ready to refer out to other health care providers when issues are beyond your scope of practice, or when your patient would do better to see another PT with greater expertise in a given area."

    Bob Cochrane, PT, DPT, puts that last point in stark and simple terms. "You cannot do this alone," he says. "If you try to do so, your patients won't get better."

    The Portland, Maine-based clinician for OA Centers for Orthopaedics attributes his success in concussion management not only to what he knows, but also to readily acknowledging what he doesn't know, and referring out accordingly. "I know when to tell the patient, ‘You will benefit from seeing an occupational therapist, or a speech-language pathologist, a neuropsychiatrist, a neuro-optometrist, or a neuro-ophthalmologist,'" Cochrane says.

    "As with all of our patients, regardless of presentation," Rylander echoes, "PTs serve patients with concussion best when we're fully aware of our own limitations and reach out to our colleagues in health care to identify the best person for a given role."

    What managing the sometimes-vexing condition boils down to, Schwartz says, is, "Concussion is not an event—it's a process."

    A "Recoverable" Injury

    If the good news is that concussion is being taken much more seriously nowadays, the down side is that the white-hot media glare from efforts to better protect the health of National Football League players—reflected in the release last November of a nearly 500-page legal and ethical analysis produced by Harvard University8—has created what Rylander deems an outsized and counterproductive "hyper-vigilance" toward concussion among a wide swath of the American public.

    For every person who, per Ziaks's concern, doesn't take concussion seriously enough, there's another, it seems, who is unduly fearful of it.

    A national survey of 2,012 Americans 18 and older conducted in April 2015 by the Harris Poll on behalf of UPMC9 found that although roughly 9 of 10 respondents couldn't correctly identify what concussion is, about the same number consider it a moderate to severe health concern, 32% of parents "live in fear" that their child will sustain a concussion, and 1 in 4 parents forbid their children to play some contact sports because of that fear.

    The implications of such forced inactivity are sobering, given that more than one-third of American children or adolescents were overweight or obese in 2012.10 But, also, the misapprehension that concussion somehow is tragic—41% of the survey respondents considered it a "living nightmare"—is incorrect in the vast majority of cases, Rylander says.

    "Concussion is a very recoverable injury," he emphasizes, "particularly if the examination is multidimensional, multiple subsystems are considered, and concussion is viewed from an enablement rather than a disablement model."

    That message was driven home in a "statement of agreement" by concussion researchers published in December in the journal Neuroscience.11 The paper, which grew out of a concussion symposium hosted by UPMC in 2015, attested to concussion's treatability and challenged the idea that rest is the best treatment approach.

    Mucha welcomes the scientific backing and attendant publicity because, she says, "We don't want to overdramatize concussion. We don't want people reducing their physical activity for fear of it. What we do want, as PTs, is to continue exploring ways to lessen postinjury morbidity in that subset of people whose recoveries are lengthier."

    Cochrane provides a thumbnail sketch of how concussion management looks in practice at his clinic.

    "The typical symptoms and presentations I see include headaches, dizziness, sensitivity to light and sounds, mental fog, disturbed sleep, irritability, and quick cognitive fatigue," he says. "I'm very thorough when I take the patient's history. I ask a lot of questions about what the patient experienced at given points in time, his or her primary symptoms, and what's going on now. This gives me a good sense of where he or she is cognitively, and where things need to go with managing that individual's symptoms."

    Cochrane's tests and measures include the dizziness handicap inventory and the postconcussion system inventory—the latter part of the widely used ImPACT test. "I clear the cervical spine and neck to see what's going on there, and I conduct a thorough vestibular exam," he says. "I also administer a heart rate-based treadmill to determine heart rate ceiling and prescribe the appropriate dose of aerobic exercise."

    "Again," he adds, "you need to take a multidisciplinary approach. When I recognize that my patient would benefit from seeing an expert in another health care field, or another physical therapist with greater expertise in a specific area, I refer out." Most patients with concussion require his care for less than a month, he says.

    In his part of the Midwest, Rylander sees encouraging signs that the need for interdisciplinary teamwork in concussion management is increasingly understood and accepted.

    "We're seeing fewer and fewer instances of physicians just kind of holding people up until the point of being asymptomatic and saying, ‘Okay, you can return to participation in your sport now,'" Rylander says. "There's increasing recognition of the value of a staged, thought-out, patient-specific trajectory of recovery. And," he adds, "we're seeing this heightened level of communication and collaboration not just between PTs and other health care professionals—such as other therapists, optometrists, neurologists, and sports medicine doctors—but within our own profession."

    On that later score, Rylander sees longstanding "walls" between neurologic, orthopedic, and sports physical therapists gradually being broken down.

    Skop also has observed—and applauds—this trend.

    "You can't just wear your ortho hat or neuro hat when it comes to concussion and think those aspects aren't going to overlap," she says. "You can't be a neuro PT, for example, and say, ‘I don't do necks.' You need to look at the neck, too, then determine whether it's prudent to send that patient to an ortho PT. Or, even better, learn the orthopedic skills necessary to meet that patient's entire needs."

    Skop adds, "All PTs should be able to identify the red flags for patients with concussion who have persistent symptoms beyond normal recovery. And don't disregard anything your patient reports," she emphasizes. "Address it. Ask questions: ‘What makes it feel better?' ‘What makes it feel worse?' ‘Where's the headache coming from?' ‘What's the pattern of it?' Don't just check off ‘headache' and take the approach, ‘You're here for your shoulder, so I'm not going to ask you about that.'"

    Challenges Ahead

    A study titled "Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists"12 published in the July 2016 issue of Physical Therapy concluded that the PTs surveyed "demonstrated a solid foundation of concussion knowledge," but that "gaps existed in the utilization of concussion severity scales, management of youth concussion, and use of neuroimaging for the diagnosis of concussion." The authors added, "Recognizing the appropriate utilization for vestibular and balance rehabilitation, manual physical therapy, and graded exertional training based on individual patient presentations is needed to best manage patients referred for physical therapy for concussion."

    The study recommended that "future professional development opportunities be developed to target identified gaps in knowledge and current practice patterns."

    "There's definitely a need for additional training in concussion management, because many physical therapists are seeing patients with concussion in their daily practice," Mucha says. To that end, UPMC is in the "early stages" of developing a fellowship in concussion management.

    PTs will be challenged to keep up with constant developments in this burgeoning research field, the PTs interviewed for this article say, given the "big questions" that remain.

    "With the on-field tests and other tools that exist today, we've moved beyond the identification phase with concussion," Skop observes. "The questions now become, ‘What's the best dosing? What rehab is optimal, in what order?' We will need more randomized trials to get at the answers."

    More research also is needed to address the "why" of concussion. Cochrane's patients often ask him why they sustained a concussion after what seemed like a fairly minor blow to the head. The current research doesn't provide a good answer.

    "Let's say you and I were hit in the head in the exact same place, with the exact same force. I might get a concussion, but you might not. Why is that?" he asks. "We don't yet know the underlying reasons. But that's where the research is going."

    Rylander poses another significant question that research presumably will answer in the near or longer term: "What are the cumulative effects of many, many subconcussive blows to the head?"

    Future research, he says, "might lead not only to new recovery strategies and intervention procedures, but to overall health policy and even lifestyle changes."

    All of which means "there's tremendous potential for minimizing the effects of concussion in our patients and getting them back to their lives more quickly," Rylander enthusiastically observes. "Physical therapists will be key members of the health care teams facilitating that."

    Eric Ries is the associate editor of PT in Motion.

    References

    1. Schneider KJ, Meeuwisse WH, Nettle-Auirre A, et al. Cervicovestibular rehabilitation in sports-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48:1294-1298.
    2. Thomas DG, Apps JN, Hoffman RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223.
    3. American Physical Therapy Association. The Physical Therapist's Role in Management of the Person With Concussion. (HOD P06-12-12-10) http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/ManagementConcussion.pdf#search=%22concussion house position%22. Accessed December 12, 2016.
    4. Leddy JJ, Willer B. Use of graded exercise training in concussion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370-376.
    5. Fremont P, Castonguay E, Pepe-Esposito F, et al, Safe return to play after protocol-based concussion management by a team therapist: a prospective study. Poster presentation, 5th International Conference on Concussion in Sport, Berlin, Germany, October 2016.
    6. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, Switzerland, November 2012. Br J Sports Med. 2013; 47:250-258.
    7. US Department of Health and Human Services Centers for Disease Control and Prevention. Statistics on Traumatic Brain Injury in the United States. http://cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf. Accessed December 12, 2016.
    8. Deubert CR, Cohen IG, Lynch HF. Protecting and Promoting the Health of NFL Players: Legal and Ethical Analysis and Recommendations. November 2016. https://footballplayershealth.harvard.edu/wp-content/uploads/2016/11/01_Full_Report.pdf. Accessed December 12, 2016.
    9. UPMC. How knowledgeable are Americans about concussion? Assessing and recalibrating the public's knowledge. http://rethinkconcussions.upmc.com/wp-content/uploads/2015/09/harris-poll-report.pdf. Accessed December 12, 2016.
    10. US Department of Health and Human Services Centers for Disease Control and Prevention. Childhood Obesity Facts. http://www.cdc.gov/healthyschools/obesity/facts.htm. Accessed December 12, 2016.
    11. Collins MW, Kontos AP, Okonkwo DO, et al. Statement on agreements from the targeted evaluation and active management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15-16, 2015. http://journals.lww.com/neurosurgery/Citation/2016/12000/Statements_of_Agreement_From_the_Targeted.27.aspx. Accessed December 12, 2016.
    12. Yorke AM, Littleton S, Alsalaheen BA. Concussion attitudes and beliefs, knowledge, and clinical practice: survey of physical therapists. Phys Ther. 2016;96(7):1018-1028.

    For Them, It's Personal

    Neither Jessica Schwartz, PT, DPT, nor Lauren Ziaks, PT, DPT, ATC, envisioned making concussion management her career focus. But sometimes life's best-laid plans get jolted, with dizzying implications.

    Schwartz was driving in Manhattan one sunny afternoon in October 2013 when the car behind hers surged ahead as the traffic light turned green, rear-ending Schwartz's vehicle at low speed. The PT wasn't hurt—or at least she didn't think so at first. She was, however, hugely annoyed.

    "In true New Yorker fashion, I unbuckled my seatbelt, got out of my car and was ready to give the other driver the business," Schwartz says. "I was about to shout, ‘Are you kidding me?' But before I could get the words out of my mouth, I almost fell over and had to grab the hood of my car. I was incredibly dizzy."

    She was diagnosed with concussion by an emergency department physician. But her concussion story would not end in self-resolution a week to 10 days later, as do the majority of such mild brain injuries. Her recovery, rather, would be protracted and physically and psychologically painful. It would prompt self-education and self-advocacy that she ultimately felt compelled to share with her peers.

    "A seemingly benign fender-bender turned into the trajectory of the rest of my life," she reflects.

    It would be 14 months before Schwartz would return to work—and not at the private practice where she'd been named junior partner the week of her accident. During her enforced hiatus she endured balance and vision issues, migraines, pain in her neck and shoulders, difficulty expressing herself, and depression.

    "I required physical therapy for vestibular and orthopedic issues, occupational therapy for vision problems, speech therapy for communication and receptive disorders, and neuropsychology for thought and cognitive processing," she recounts. At the 3-month mark she joined, online, an international concussion support group. She didn't participate at first, but spent months monitoring similar conversations being conducted all over the world about concussion mismanagement and related frustration and fear. It was then, she says, that she vowed to do what she could to help change the global architecture of medicine with respect to concussion management.

    "‘When I get better,' I thought, ‘I need to be part of bridging the gap between patients and providers,'" Schwartz recalls. "Patients share information with me on a different level because they know that I've lived through things that they've lived through. And providers listen to me with a different ear because they sincerely want to help but don't fully know how."

    Most of Schwartz's education happened in her own bedroom.

    Unnerved by the cognitive fogginess that sometimes enveloped her, "I was determined to keep my brain as sharp as possible," she says. She channeled that desire into self-advocacy, using social media to ask questions and tap the expertise of researchers and clinicians in various health care disciplines. She read a lot about concussion—which, prior to her accident, she'd "never realized has the potential to be a life-changing event." She also visited—virtually—a lot of professional conferences.

    "I virtually attended hundreds of meetings, stateside and overseas, during that year—of emergency physicians, sports docs, PTs, occupational therapists, other health care disciplines, and business groups," she says.

    Schwartz developed her own "theoretical framework" about concussion and the place of PTs in its management. She built it on 2 themes from the dissertation of Lorelei Lingard, a Canadian researcher in the study of communication and collaboration within health care teams: (1) individual competence does not in itself produce high-quality health care, and (2) patients are ill-served by a maze of disconnected care episodes.

    Schwartz made overcoming those obstacles the focus of the concussion management certification program she now directs at Evidence in Motion, a provider of postgraduate and continuing education programs for PTs and other health professionals. The 12-month web-based and in-person course taps the expertise of a multidisciplinary faculty that includes, in addition to Schwartz, PTs with expertise in orthopedic, sports, neurologic, and geriatric physical therapy, as well as in pain science; emergency medicine and neurology physicians; a neuropsychologist; an occupational therapist; a speech-language pathologist; and a certified brain injury specialist.

    "I essentially built this program from my home office during my recovery process," Schwartz says.

    Ziaks's concussion story began just a few months after Schwartz's—in January 2014—and in many respects parallels that of the New York PT. Ziaks, a clinician in Utah, recounted it herself in a June 2016 PT in Motion Defining Moment essay1 provocatively titled, "They Call Me the Queen of Concussions." She'd been so dubbed by a newspaper columnist who'd noted that her life-altering snowboarding accident 3 years ago resulted in the athletic-but-unlucky PT's ninth concussion.

    Like Schwartz, Ziaks endured an array of painful and emotionally distressing symptoms—hers included headaches that reached 8 on a scale of 10 and the inability, at times, to retain information she'd just read. She, too, received care that could be excellent but too often was disconnected and inadequate to her particular needs.

    Also like Schwartz, Ziaks channeled her extensive self-education into desire to become part of the concussion solution—in Ziaks's case, with patients who see her for visuo-vestibular issues and rely on her for further referral, as needed. She directs the concussion management program at Wasatch Physical Therapy and Sports Medicine in Park City and administers, with a physician assistant colleague, a website (PhoenixConcussion.com) focusing on concussion education and management.

    Extended cases like Schwartz's and Ziaks's are concussion outliers. Still, they remain "far too common" for the liking of Tim Rylander, PT, MPT, vice president of Doctors of Physical Therapy in Naperville, Illinois.

    Rylander, a board-certified clinical specialist in orthopaedic physical therapy, notes that for every comprehensive concussion management program, such as the one at the University of Pittsburgh Medical Center—or multidisciplinary referral networks like the one he and his colleagues have pieced together at Doctors of Physical Therapy's 13 Midwest clinics—interdisciplinary gaps remain.

    "Unfortunately," says Rylander, who's helping develop a home-study course on concussion management for the Orthopaedic Section of APTA, "people with concussion sometimes run into stumbling blocks—such as not being evaluated by an optometrist who specializes in visual processing and ocular motor coordination simply because their health care provider isn't sufficiently knowledgeable about the optometry profession."

    In such cases, he says, "Being able to refer that patient to the right subspecialty can quickly make a world of difference in his or her life."

    References

    1. Ziaks L. They call me the queen of concussions. PT in Motion. 2016;8(5):68-70.

    Resources

    APTA

    Also Cited by PTs Interviewed for This Article


    Comments

    I can speak from 1st hand experience. With vision/vestibular/balance issues after a concussion. Being a PT is was so hard. But working with my PT's was the best part of rehab. They made it fun and rewarding. Could see progress quickly. Thanks for sharing.. It's kind of made me want to get into this in my private practice more. Now that i've been there on the other side.. ;) Aloha- great article.. Shelley
    Posted by Shelley on 3/1/2017 12:17:38 AM
    A question that you may be able to help me with. I'm retired PT who received a toxic dose of gentamicin two years ago. Had all of the symptoms from flipping vision, tintinus, inability to do tasks when standing and other vestibular problems. I lose balance almost exclusively in sagittal plane: can't see tabs to brush teeth, take stuff out of frig, etc. Docs say this is permanent. Any research on this that will help me. Thanks so much.
    Posted by Sylvia Sabia on 3/1/2017 2:22:19 PM
    Hello, I'm a current physical therapy student at Cleveland State University, and an ATC who recently finished working for an NFL team. I'm comfortable in recognizing and diagnosing concussions and with current return to play protocols. I was looking at some of the links at the end of the article and I couldn't seem to find the specific interventions that are utilized. Are they consistent with the current protocols or do they take current protocols and take things a step further? I've suffered from concussions myself and I've had a number of former athletes go through the same thing. My goal is to return to the professional sports arena once I graduate and I'd like to use the most current evidence in my practice to help patients return to activity as quickly and safely as possible. If you would be so kind as to send a link to specific interventions used in the treatment of individuals with concussions I'd be very appreciative.
    Posted by Patrick Moran -> CMYb?H on 3/1/2017 9:20:10 PM

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