Physiotherapy for Concussion: Treatment and Recovery

Physiotherapy for Concussion: Treatment and Complete Recovery

Physiotherapy is an essential treatment for recovery after a concussion. This specialized approach combines several techniques, including vestibular rehabilitation, cervical treatment, graded aerobic exercise, and oculomotor training. Studies show that active physiotherapy significantly speeds up recovery compared to rest alone, challenging older recommendations that advised complete inactivity.

You might have persistent headaches since a head injury, dizziness when you move, or difficulty concentrating. These symptoms can be truly bothersome and significantly affect your daily life. The good news is that most people recover completely with the right professional support. Understanding what physiotherapy can do for you is the first step towards recovery.

What is Physiotherapy for Concussion?

Physiotherapy for concussion is a multidimensional approach that treats the various systems affected by head trauma. The vestibular system, responsible for balance; the cervical system, which concerns the neck; the oculomotor system, which controls eye movements; and physical exertion tolerance are all evaluated and treated in an integrated way. This approach aims for complete recovery and a safe return to activities.

A concussion can disrupt several systems simultaneously. This is why treatment must be comprehensive and personalized. A specialized physiotherapist evaluates each component and creates a treatment plan tailored to your specific needs, taking into account your symptoms, activities, and goals.

How Does Post-Concussion Physiotherapy Work?

Physiotherapy works on several fronts simultaneously. First, it re-educates your vestibular system, which controls balance. Next, it treats your neck, which is often injured during the initial impact. Finally, it helps you gradually and safely resume exercise, respecting your symptom tolerance threshold.

The brain has a remarkable capacity for recovery, called neuroplasticity. Physiotherapy activates this healing ability by stimulating the right systems at the right time. Contrary to previous beliefs, complete rest is no longer recommended beyond the first 24 to 48 hours. Measured physical activity is now an integral part of modern concussion treatment.

How is this different from regular physiotherapy?

Physiotherapy for concussion requires additional specialized training. A physiotherapist trained in this area is proficient in evaluating and treating vestibular disorders, research-validated protocols for gradual return to activity, treating post-concussion visual disturbances, and managing the multiple symptoms that characterize this condition.

This specialization allows for more effective and safer care. The physiotherapist understands the complex interactions between the different affected systems and can adapt treatment accordingly.

What Symptoms Does Physiotherapy Treat?

Physiotherapy effectively treats a wide range of post-concussion symptoms. Headaches, dizziness and vertigo, balance problems, sensitivity to light and noise, concentration issues, fatigue, and neck pain can all be addressed with specific techniques tailored to each patient.

Post-Concussion Headaches

Headaches are the most common symptom after a concussion, affecting up to 90% of those impacted. They can stem from several distinct sources. Tension in the neck muscles, dysfunction of the neck joints, vestibular irritation, and central nervous system sensitization can all contribute to post-concussion headaches.

Physiotherapy identifies the source of your headaches through a thorough evaluation. If your neck is the cause, manual therapy and exercises can significantly reduce the frequency and intensity of headaches. If the vestibular component is predominant, balance retraining helps resolve the problem. Often, a combination of both approaches yields the best results.

Dizziness and Vertigo

Dizziness affects 50 to 80% of people after a concussion. It can be a spinning sensation (vertigo), or more vague, manifesting as a feeling of floating or unsteadiness. These symptoms often arise from a disturbance in the vestibular system located in the inner ear.

Vestibular rehabilitation uses specific exercises to help your brain correctly re-interpret movement signals. This progressive approach helps desensitize the vestibular system and restore normal balance function.

Visual and Oculomotor Problems

After a concussion, your eyes may have difficulty following moving objects, converging to look closely, or coordinating their movements with your head. These problems often lead to visual fatigue, headaches when reading, and difficulty concentrating.

Oculomotor exercises retrain the connections between your eyes and your brain. Visual tracking, saccades, and convergence exercises are part of the rehabilitation program. These exercises are done for a few minutes each day and gradually increase in difficulty according to your tolerance.

Neck Problems

The neck is almost always affected during a concussion. The impact that causes a concussion also causes a sudden movement of the head on the neck, similar to the mechanism of a traumatic whiplash. The cervical muscles, joints, and ligaments can be injured during this trauma. These injuries contribute to headaches and dizziness, creating a vicious cycle of symptoms.

Cervical treatment includes manual techniques such as joint mobilizations and manipulations to release tight muscles and restore joint movement. Stabilizing muscle exercises complement the treatment to strengthen the muscles that support the neck.

How Does Physiotherapy Aid Recovery?

Physiotherapy accelerates recovery by actively targeting the systems disrupted by the concussion. Instead of passively waiting for symptoms to disappear, it stimulates your brain to reprogram itself through specific exercises. Studies show that patients who start physiotherapy early recover faster than those who remain at prolonged rest.

Controlled Stimulation versus Passive Rest

For a long time, complete rest was recommended after a concussion. Staying in the dark, avoiding screens, and refraining from any effort. We now know that this approach can prolong symptoms rather than resolve them. Complete rest for more than 48 hours does not help and can even hinder recovery.

Physiotherapy offers controlled and progressive stimulation. You gradually expose your brain to activities that provoke symptoms, within a safe and supervised setting. Over time, your tolerance increases. It's like desensitizing an allergy: gradual exposure reduces the nervous system's reaction.

Reintegration of Sensory Systems

Your brain uses three systems to maintain balance: vision, the vestibular system in the inner ear, and proprioception, which is the sense of your body's position in space. After a concussion, these systems can send conflicting signals. Your brain then has difficulty interpreting them correctly, which creates symptoms of dizziness and imbalance.

Physiotherapy helps your brain reintegrate this information harmoniously. Specific exercises stimulate each system individually first, then together progressively. Your brain relearns to coordinate signals and maintain balance automatically.

Treatment of Peripheral Components

Concussion is often accompanied by neck injuries and eye problems. These peripheral components can perpetuate symptoms even when the brain has recovered from the initial impact. Therefore, treating the neck and eyes is an integral part of complete recovery after a concussion.

What to expect at your first appointment?

The initial evaluation generally lasts 60 to 90 minutes and includes several essential elements. A detailed questionnaire about your accident and symptoms helps to understand your situation. A comprehensive evaluation of the vestibular, cervical, and oculomotor systems identifies specific deficits. Effort tolerance tests determine your symptom threshold. The development of a personalized treatment plan concludes this first appointment.

The Initial Questionnaire

Your physiotherapist aims to thoroughly understand your situation. Expect questions about how the accident happened, your current symptoms and how they've changed since the accident, what makes your symptoms better or worse, your activities before the accident (whether work, sports, or hobbies), any history of concussions or headaches, and your current physical activity level. This information helps identify the affected systems and allows for optimal treatment planning.

Physical Assessment

The physical assessment systematically tests several systems. The vestibular assessment includes balance tests with eyes open and closed, the tandem walk test, the head impulse test, and vestibular provocation tests. The cervical assessment examines your neck's range of motion, palpates muscles and joints, and includes tests to reproduce your symptoms. The oculomotor assessment tests visual tracking, saccades (quick eye movements), convergence (eyes turning inward), and the cancellation of the vestibulo-ocular reflex (which stabilizes vision). The exercise tolerance assessment uses a walking test or the modified Buffalo protocol to determine your symptom threshold during physical activity.

What Happens Next

At the end of the assessment, your physiotherapist will explain their findings and how different systems contribute to your symptoms. You will receive a treatment plan with clear goals and a realistic timeline. You will likely have a few exercises to start doing at home after this first appointment.

What Treatment Techniques Are Used?

Treatment combines several approaches tailored to your specific needs. Vestibular rehabilitation, neck treatment, graded aerobic exercise, oculomotor training, and education on symptom management are the cornerstones of this multidimensional approach, targeting all affected systems.

Vestibular Rehabilitation

Vestibular rehabilitation uses specific exercises to correct problems with balance and dizziness. It involves three main types of exercises.

Gaze stabilization exercises involve focusing on a target while moving your head. These exercises retrain the vestibulo-ocular reflex, which helps stabilize your vision during head movements. Habituation exercises gradually expose you to movements or positions that trigger your symptoms. Over time, your nervous system adapts and reacts less strongly. Balance exercises are progressive and increasingly challenge your system. This includes standing with feet together, then on one leg, on stable surfaces then unstable ones, and with eyes open then closed.

Neck Treatment

Neck treatment involves several complementary techniques. Manual therapy allows your physiotherapist to use their hands to release tense muscles and mobilize stiff neck joints, often providing quick relief. Strengthening exercises target the deep neck muscles, which are often weak after a concussion. Exercises like chin tucks help strengthen these essential stabilizing muscles. Mobility exercises involve gentle neck movements in all directions to maintain and improve your range of motion.

Graded Aerobic Exercise

Aerobic exercise is a powerful treatment for concussion. It increases blood flow to the brain and promotes healing. The Buffalo protocol is the standard for safely prescribing exercise after a concussion.

First, your symptom threshold is determined, which is the heart rate at which your symptoms increase. Then, you exercise at 80% of this threshold for 20 minutes daily. As your tolerance improves, the intensity gradually increases. Types of exercises used include brisk walking, stationary cycling, and elliptical training. The goal is to increase your heart rate without causing any impact to your head.

Oculomotor Training

If your eyes have difficulty tracking objects, converging, or coordinating with your head, oculomotor exercises can help. Pursuit exercises involve slowly following an object with your eyes without moving your head. Saccade exercises involve quickly moving your eyes from one target to another. Convergence exercises involve bringing an object closer to your nose while keeping it in focus. These exercises are performed for a few minutes daily and gradually increase in difficulty based on your tolerance.

How Does the Progressive Rehabilitation Program Work?

The rehabilitation program follows established protocols to gradually help you return to your normal activities, whether it's school, work, or sports. Each stage has clear criteria that must be met before moving to the next. This gradual progression minimizes the risk of setbacks and ensures a lasting recovery.

Stages for Returning to Cognitive Activities

The first stage involves relative rest for the initial 24 to 48 hours, allowing light activities but no screen time or prolonged reading. Light walking is permitted and even encouraged. The second stage introduces light cognitive activities with short periods of reading and limited screen time of 15-20 minutes, interspersed with frequent breaks. The third stage allows for a gradual increase in screen time and cognitive work, with a possible return to classes with adaptations such as extended time and reduced homework. The fourth stage represents a full return to cognitive activities without restrictions.

Stages for Returning to Sport

Returning to sport follows an internationally validated six-stage protocol. Each stage lasts at least 24 hours. If symptoms return, you must go back one stage and wait for your symptoms to stabilize.

Stage 1 is relative rest for initial recovery. Stage 2 introduces light aerobic activity, such as walking or stationary cycling, at 50-70% of your maximum heart rate. Stage 3 allows for sport-specific exercises like skating or running, but without contact. Stage 4 permits non-contact training with more complex exercises and passing drills. Stage 5 involves full-contact training, including normal practice after medical clearance. Stage 6 represents a full return to play and competition.

Progression criteria

To advance to the next stage, you must complete the current stage without an increase in symptoms, wait at least 24 hours between stages, be symptom-free at rest, and have your healthcare professional's approval for stages 5 and 6. If your symptoms increase, you must rest until they return to your baseline level, then restart at the previous stage.

Returning to Work

Returning to work follows principles similar to returning to sport. Depending on your job requirements, you might need temporary adjustments such as reduced hours, more frequent breaks, a quiet environment with less noise and dimmed lighting, or less cognitively demanding tasks. These adjustments gradually decrease as you recover.

What is the duration and frequency of treatment?

Most people recover from a concussion within 2 to 4 weeks with appropriate active treatment. More complex cases or those with prolonged symptoms may require 2 to 3 months of treatment. Typically, this involves 1 to 2 clinic sessions per week, along with daily exercises to do at home.

Factors influencing duration

Several factors can affect how long it takes to recover. Age plays a role, as adults sometimes recover more slowly than teenagers. A history of concussions is important, as repeated concussions generally prolong recovery. The time before starting treatment is significant, because the sooner you begin, the faster you will recover. The initial severity of symptoms also influences the prognosis. Associated conditions like migraines or anxiety can complicate recovery. Commitment to home exercises is also crucial, as consistency speeds up results.

The importance of home exercises

Home exercises are essential for successful treatment. Aim for 20 to 30 minutes per day, divided into 2 or 3 sessions. Doing a little each day is more effective than pushing intensely once a week. Consistency is the key to success.

Frequently Asked Questions about Concussion Physiotherapy

Several questions frequently arise regarding the treatment of concussions. Here are the answers to the most common inquiries.

Regarding when to start physiotherapy, you can begin as soon as possible, often within the first few days following the accident. It is no longer necessary to wait for all symptoms to disappear. On the contrary, starting early speeds up recovery.

As for symptoms worsening due to exercises, well-managed exercises can cause a slight, temporary increase in symptoms. This is normal and even desirable to some extent. Symptoms should return to normal within 15 to 20 minutes after exercise.

Regarding resting in the dark and avoiding screens, this approach is no longer recommended beyond the first 24 to 48 hours. Gradual exposure helps your brain adapt rather than creating hypersensitivity.

For sports during recovery, you can do light aerobic exercise fairly quickly after the accident, as long as it doesn't significantly worsen your symptoms. Returning to contact sports follows a specific protocol and requires authorization from a healthcare professional.

In Quebec, you can consult a physiotherapist directly without a medical prescription. This is a good starting point if you have persistent symptoms after a concussion.

Getting Help for Your Concussion

You don't have to endure your symptoms in silence. Even if you haven't been feeling your best for several weeks, physiotherapy can help you make a full recovery. Our specialized physiotherapists are here to support you in your rehabilitation.

A comprehensive evaluation will identify the affected systems and help develop a personalized treatment plan. With the right interventions at the right time, the vast majority of people regain their previous level of function. Book an appointment today to start your journey towards full recovery.

Sources

McCrory P, et al. Consensus statement on concussion in sport. British Journal of Sports Medicine. 2017.

Leddy JJ, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine. 2010.

Schneider KJ, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine. 2014.

Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Current Treatment Options in Neurology. 2006.