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CRM: Tx: Physical SxS
Concussion Recognition & Management
Module 6 Delayed Recovery

Tx: Physical SxS


For patients with delayed recovery, treatment should be problem-specific.

Tx inside body silhouette

Treatment
for
Physical Symptoms

Select each tab below for more information.

Headache

Primary care doctors are familiar with normal headache presentations, but post-concussive headaches can be multifactorial. Some physicians, usually neurologists, specialize in the medical management of headaches. In addition, the expertise of a multidisciplinary team can provide insights into the potential causes as well as a range of treatment options.

Post-traumatic headache can be a major culprit in delayed recovery, but it is not a diagnostic label. Knowing pre-existing headache causes and frequency will enable you to determine the origin of the patient’s post-traumatic headache. A persistent headache may be unrelated to the mTBI. It could result from a neck injury, for example. Knowing the headache type (cervicogenic pain, occipital neuritis, migraine, tension headache, or vision-related) will help you treat it.
see-through body with hand holding head in pain
variety of testing glasses

Possible Headache Tx

  • Manual therapies to address cervicogenic component.
  • Vision rehabilitation (since the headache is unlikely to resolve until visual perception and oculomotor problems are treated).
  • Medications.
  • Biofeedback relaxation.
  • Sleep stabilization.
  • Self-management skills.
After three months, if headache pain is chronic without a basic physiological cause, other contributors should be considered, including psychological issues that can trigger or exacerbate headache presentation.

Balance / Vestibular

There are multiple types of balance disorders. Some resolve quickly, but others require more time. Balance can be multifactorial, involving:
  • The vestibular system.
  • Visual perception.
  • Postural stability.
Specialists in balance disorders (such as physical therapists, some occupational therapists, and audiologists) may assess and treat complex interactions among sensory, motor, and central processes involved in posture and balance.

Postural stability is less likely to be an issue in young athletes, but should be considered when assessing the patient.
close-up legs as therapist helps patient use steps
therapist helping boy use Proprio-Balance machine

Possible Balance / Vestibular Tx


Depending on the etiology (causation), some symptoms respond quickly to treatment. For example, when correctly diagnosed, Benign Paroxysmal Positional Vertigo often resolves in a few sessions of proper treatment. By contrast, central balance (i.e., arising from the brain) or dizziness problems may require weeks of specialized exercises and desensitization therapies.

Vision Disturbance

As mentioned in Module 4, a primary care doctor can carry out visual assessments, including tests for pupil sensitivity and nystagmus. Again, the patient’s history is very important. Specialists (such as vision-certified occupational therapists, neurooptometrists, and neuroophthalmologists) may address a variety of visual symptoms:
close-up eye
  • Double vision.
  • Blurry vision.
  • Visual perception.
  • Sensitivity to light.
  • Motion hypersensitivity.
  • Decreased visual processing speed.
  • Headaches due to visual strain.
Frequently, patients with delayed recovery from concussion present with previously undiagnosed visual disturbances. (There are various estimates as to how often.) Head injury sometimes brings such disturbances to light.1
therapist and young man responding to Dynavision machine

Possible Vision Disturbance Tx


Treatments may involve special lenses and prisms, tinted lenses for contrast sensitivity, and / or binasal occlusion. Appropriate therapy may also include:
  • Integration of vision with the balance system.
  • Work on depth perception.
  • Training in oculomotor coordination and visual tracking.
Knowledge in this area is rapidly evolving. Unusual or atypical disturbances sometimes occur and may warrant further evaluation.

Fatigue

When you assess fatigue, it’s important to determine the type of fatigue the patient is experiencing. Fatigue has two components: physical and mental. Activities that previously took little effort may require great amounts of energy after an mTBI. As a result, the patient may experience an overwhelming sense of tiredness that can be physical, mental, or both.

Fatigue may directly impact a young person’s academic and physical performance by making sustained daily activities, attention, concentration, memory, communication, and emotional control more difficult.
young man depressed with head in hand
young woman asleep on stack of books

Possible Fatigue Tx


  • Improving sleep patterns.
  • Decreasing pain.
  • Conserving energy.
  • Undergoing endurance therapy.
  • Practicing pacing techniques.
  • Taking medication.
Though it is clear that high-risk activity must be discontinued entirely during recovery, low-level exercise is being shown to have some value for mTBI patients.2

Sleep

Issues with sleep are not the same as issues with fatigue. Sleep is important. It is healing time for the young person recovering from an mTBI. Your patient must not return to his or her previous sleeping pattern if it was insufficient. For example, a teenager’s typical seven hours per night is not enough.



Visit the National Sleep Foundation website for recommended sleep times per age group.
young woman asleep in bed
young woman yawning

Possible Sleep Issues Tx


There are two major considerations in treating sleep problems.
  1. If the sleep issues are chronic, the issues should be addressed by sleep specialists, such as ENTs, otolaryngologists, and / or neurologists.

  2. It’s important to make sure the patient is getting enough sleep acutely. This is true for all youth, but especially true if a child is injured. A concussion patient may need to sleep more, immediately after injury as well as in cases of Post-Concussion Syndrome. Naps, even in school, may be important to recovery. Parents should let the young person sleep, and even encourage sleep if necessary, intervening to help reduce bad bedtime habits:
    • Make bedtime bedtime. Ensure the youth goes to bed at a consistent time every night.
    • Practice good sleep hygiene: no computers, phones, screens, or LEDs close to the bed.
    • Make sure the patient doesn’t do anything in the bed except sleep: for example, no reading or watching television.



skeleton holding head in pain with other pain glows showing on body

A Special Note about Pain

Pain is a huge, complicating factor. You may confound pain with head injury or head injury with pain, treating one but missing the other. Pain is a distractor. For example, pain from a knee injury might distract the patient’s attention and undermine the patient’s performance on tests. A major concern with multiple concussions and PCS is the impact of headaches and chronic pain. Regardless of whether pain is due to the head trauma or due to a different source, you will need to understand the pain’s relationship to the head injury. You need to diagnose the cause of the pain and treat it.

1 Ciuffreda KJ, Kapoor N, Rutner D et al. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry 2007; 78: 155-161.

2 Maerlender, A., Rieman, W., Lichtenstein, J., Condiracci, C. (2015). Programmed Physical Exertion in Recovery from Sports-Related Concussion: A Randomized Pilot Study. Developmental Neuropsychology, Published online, July 31, 2015; DOI:10.1080/87565641.2015.1067706.
Module 6 Delayed Recovery

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