Move Forward Guide

    Physical Therapist's Guide to Concussion

    Concussion is a traumatic brain injury that can damage brain tissue and change the chemical balance of the brain. Concussion may cause physical, mental, and emotional symptoms and problems, both short-term and long-term. Every concussion is considered a serious injury by health care providers.

    The Centers for Disease Control (CDC) estimates that 2.5 million concussions occurred in the United States in 2010, the most recent year for which the CDC has statistics. 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. This can happen during rapid movement changes (such as whiplash) or when the head is 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. Depending on which area of the brain suffers injury, many different temporary or permanent problems with brain function can occur..


    Concussion: See More Detail

    Concussions can occur at any age, from a variety of causes, including:

    • Car accidents (ie, a head impact, or whiplash)
    • Work accidents (ie, falls, head trauma)
    • Playground accidents (ie, falling from a slide or swing)
    • Sports injury to the head or neck
    • Any type of fall or direct blow to the head, face, or neck
    • Violent events
      • physical abuse during which the head is shaken
      • being too close to a blast or explosion

    Recovery from a concussion can take several weeks to several months, depending on many factors, including severity and age.

    Concussion may occur along with other brain injuries such as bruising, bleeding, or tearing of the brain tissue. These injuries are very severe and require the immediate care of a medical doctor, such as a neurosurgeon.

    CAUTION: Concussions can be fatal or can result in permanent brain damage.

    Seek medical help immediately following any head injury.


    How Does it Feel?

    A concussion can cause a variety of symptoms and problems in many different body functions, such as:

    • The senses (eg, vision, hearing, or sense of smell problems)
    • Body movements (eg, weakness or loss of balance and coordination)
    • Personality and mood (eg, newly-developed irritability, depression, or trouble concentrating)
    • Pain (eg, headaches or migraines)

    Concussion sometimes causes loss of consciousness (“blacking out”), but not always.


    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:

    • Headache
    • Dizziness
    • Difficulty with balance and coordination
    • Nausea/vomiting
    • Fatigue
    • Difficulty sleeping
    • Increased sleepiness
    • Double or blurred vision
    • Sensitivity to light and sound
    • Slurred speech
    • Glassy-eyed stare
    • Seizures

    Cognitive (thinking) symptoms:

    • Difficulty with short-term or long-term memory
    • Confusion
    • Slowed "processing" (for instance, a decreased ability to think through problems)
    • "Fogginess"
    • Difficulty concentrating
    • Worsening grades in school

    Emotional symptoms:

    • Irritability
    • Restlessness
    • Anxiety
    • Depression
    • Mood swings
    • Aggression
    • Decreased tolerance of stress
    • Change in personality or behavior

    Longer-term symptoms

    • Loss of libido
    • Loss of menses/menstruation
    • Growth problems (children)
    • Fatigue
    • Weight gain
    • Low blood pressure
    • Muscle weakness
    • Chronic headaches or dizziness
    • Muscle spasticity
    • Early dementia/chronic traumatic encephalopathy

    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 further brain damage and second-impact syndrome.


    How Is It Diagnosed?

    Concussion is most often diagnosed through careful testing by your health care provider, like a physical therapist. The diagnosis of concussion 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. Your physical therapist also will perform numerous tests to identify problems caused by a concussion, including 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 they 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, your physical therapist's examination will assess your individual symptoms and problems, so that the physical therapist can design a safe and individualized treatment program just for you. Treatment may include:

    Rest and Recovery. Your physical therapist will help you and your family understand why you should limit any kind of activity (physical, sport, recreational, electronic, school) 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. 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. There even may be some simple exercises that your physical therapist can teach you 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 return you 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?

    The risk of concussion can be greatly reduced by taking the following precautions:

    • Avoid motor-vehicle accidents:
      • 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.
    • 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, 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 female 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. 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, TV, cell phone, tablet and computer use, reading, and 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.

    The next day, Sara returns for physical therapy treatment and says 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 the day 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 a few weeks, and to limit 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 postconcussion 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 in neurologic physical therapy. This 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.

    Further Reading

    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.

    Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. 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. Free Article. Published 2015. Accessed November 20, 2015.

    Fauntleroy G. Head cases: pituitary incidents arising from traumatic brain injury. Endocrine News. October 2014:13. Free Article. Accessed November 20, 2015.

    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 on PubMed.

    Revised by Andrea Avruskin, PT, DPT, ATC, LAT, CKTP, CWP, CCWC.  Originally authored by Anne Mucha, PT, NCS, and the APTA Neurology Section. Reviewed by the MoveForwardPT.com editorial board.