Ask the Expert: Concussion
Physical Therapist: Shelly Massingale, PT, MPT
1. Concussion has received significant media attention over the last few years. What is a concussion?
The CDC defines concussion as “a type of traumatic brain injury or TBI- 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.” Concussion is commonly referred to as a mild traumatic brain injury (mTBI) and is typically associated with normal structural imaging (normal CT/MRI). Symptoms of concussion can include dizziness, headache, cognitive changes, mood changes, balance problems, and nausea and vary from person to person and from injury to injury. Concussion is considered a transient injury that typically lasts a few days to a several weeks before full recovery.
2. Dizziness and balance problems are common after concussion. Why are these symptoms so common?
Dizziness and balance problems that occur after a head injury are often the result of damage to either the peripheral or central vestibular system. Our vestibular system is comprised of our inner ear (peripheral vestibular system), the vestibular nerve (connects the peripheral to the central vestibular system), and the areas in the brain that process that information (central vestibular system). If any of these areas have been affected, the injured person could experience feelings of dizziness, being off balance, vertigo or a combination of these. Our vestibular system is highly sensitive to movement, so any damage or disturbance to these areas cause symptoms while performing activities of daily living.
3. Do you recommend that patients pursue vestibular rehabilitation after a concussion?
If a patient sustains a concussion and has any symptoms of dizziness, vertigo, imbalance, or nausea that last more than a few days, I highly recommend pursuing vestibular therapy. Vestibular therapy an effective treatment, and having a specialist take you through a course of treatment will allow you to recover more quickly. The patient’s physician typically makes the initial referral to vestibular therapy after a thorough medical evaluation of concussion.
4. If so, what vestibular rehabilitation techniques help to reduce symptoms and improve function?
The technique used in vestibular therapy depends on the nature and severity of the symptoms, as well as the underlying cause. When someone sustains a concussion, symptoms of vertigo may occur with positional changes. This diagnosis is called Benign Paroxysmal Positional Vertigo (BPPV), which commonly occurs after head injury. The treatment for BPPV is very specific and should be performed by a trained clinician. If BPPV is not present, then balance exercises and vision retraining exercises that address how the head and eyes move together are very effective in reducing dizziness and imbalance. Exercises selected are highly specialized and very specific to the individual’s symptoms and daily activity demands, and should only be performed by a clinician that has training in this type of therapy.
5. Are there specific exercises or strategies most helpful for improving symptoms after concussion?
See above answer 4.
6. Do you recommend vestibular rehabilitation for all patients post-concussion? Are there patients with certain symptoms who benefit most?
Vestibular therapy is not indicated for every patient who sustains a concussion. Some people will be diagnosed with a concussion and will not have any symptoms related to dizziness, imbalance or vertigo. These patients do not need to participate in vestibular therapy. On the other hand, any person who is experiencing dizziness, vertigo, and/or imbalance after sustaining a concussion would likely benefit from participating in vestibular therapy, especially if the symptoms persist for more than a few days.
7. I’ve had quite a bit of neck pain and stiffness after a car accident. Could this be the cause of my dizziness?
Cervicogenic dizziness can occur with a whiplash injury and is often diagnosed with concussion. Cervicogenic dizziness is defined as the presence of dizziness, imbalance or unsteadiness related to movements or position of the cervical spine or related to a stiff or painful neck. The treatment for cervicogenic dizziness is therapy for the neck to help decrease the discomfort and stiffness. Reducing stiffness and muscle imbalance in the neck can help to decrease the sensation of dizziness.
8. Are there any screening measures or tests available that you’d find helpful to have prior to seeing a patient referred for VRT?
Prior to starting VRT, a patient should be evaluated by a physician with specialized knowledge about concussion and brain injury. A concussion can cause a myriad of symptoms in addition to dizziness/imbalance, so a thorough and complete assessment of post-concussion symptoms is necessary to determine the correct course of treatment for each individual. Depending on the severity of the injury and the symptoms, an audiology evaluation may be helpful to more thoroughly assess inner ear function. The physician overseeing the case usually determines which clinical tests need to be performed prior to initiating vestibular therapy.
9. What would you want the general public to know about concussion rehabilitation?
Concussion rehabilitation is most effective and efficient when the patient receives a multidisciplinary evaluation and individualized approach to care. Concussion is a complex injury which should not be addressed using a “cookie cutter” approach to treatment and focusing on treatment of only one aspect of concussion may lead to a longer recovery.
10. What is your overall key take home message for providers working with patients with suspected post-concussion dizziness?
I would highly recommend that the provider working with post-concussion dizziness complete specialized training that addresses the nature of concussion/brain injury and reviews appropriate treatment protocols. I cannot stress enough the importance of having a multidisciplinary team of clinicians overseeing the treatment, management and rehabilitation of patients to ensure the patient is receiving the best care for his or her injury.
Shelly Massingale is the senior director of Banner Concussion Services in Arizona and Colorado. She is a physical therapist and has been a specialist in vestibular and balance therapy for the past 22 years. Shelly has focused her treatment and research primarily in mild traumatic brain injury since 2013 and has lectured nationally and internationally on evaluation and treatment of vestibular and balance deficits related to mild traumatic brain injury.