When approaching post-injury concussion management, it’s important to think of this as a process rather than a protocol.  The paradigm shift in concussion management is ever-evolving and to achieve best practices, it is necessary to have this mindset.  Once an athlete has been diagnosed with a concussion by a qualified medical professional (Athletic Trainer, Physician, PA-C) and emergency response no-longer a concern, our focus shifts to the process of healing.  Remember that every concussed athlete presents uniquely, and therefore we must individualize their post-injury care.  If the athlete is a student-athlete, this process also includes appropriate academic accommodations prescribed by a physician as the athlete continues to heal.  Mental and physical stress above a threshold can be adverse for these individuals, so our plan and approach need to be comprehensive.  Academic accommodations can include reduced workload, intermittent breaks, assignment extensions etc.  In some cases, complete cognitive rest is necessary early in the process.  

As we discussed relative to concussion diagnosis, post-injury management requires regular implementation of neurocognitive testing and evaluation to provide the most objective information possible.  These tools should be consistent with the baseline and diagnostic tools (SCAT5, for example) you are using as this allows for direct comparison and progress tracking.  If baseline information is not available, most concussion assessment tools allow clinicians to compare results to normative data relative to the individual’s demographics.  While not ideal, this can at least provide some level of baseline expectancy when analyzing these testing measures.  It may not be desirable or necessary to expose the athlete to the rigors of these tests daily, so supplement these with daily symptom checklists.  Daily symptom checklists allow us to evaluate the athlete’s subjective reporting and can alone provide indicators of progression within the healing process.  

In correspondence with the treating medical professionals, athletes may begin low-grade exercise prior to being asymptomatic.  This includes tasks like walking and utilizing a stationary bike.  Remember, we don’t want the concussed athlete participating in anything that would potentially cause additional exposures, like road biking for example.  If these activities cause a significant increase in symptoms, the athlete should stop immediately for that day.  Old-school theories like spending time in isolation and avoiding all external stimuli are now universally regarded as obsolete within the sports medicine community.

Coupled with regular evaluation and low-grade exercise, we can also use rehabilitative techniques, especially with those who have prolonged symptoms.  Similar to evaluation techniques, we can use Vestibular Ocular Reflex (VOR) exercises to rehabilitate concussed athletes and re-train their vestibular and oculomotor systems to function at pre-injury status.  These rehab techniques are the same used to treat Benign Paroxysmal Positional Vertigo (BBPV) in the general population.  Concussion rehab is where it becomes most vital to view this as a process and not a protocol.  Just like any musculoskeletal injury, concussion requires an individualized rehab plan. 

Lastly, especially when prolonged symptoms are present, it’s important we address any mental health (anxiety, depression, etc) that may result from concussion.  These cases absolutely need to be managed closely by a qualified physician.   Once the athlete is asymptomatic, the stepwise return-to-play progression can be implemented.

-Greg Shedd, MS, LAT, ATC