|Year : 2020 | Volume
| Issue : 2 | Page : 31-35
Efficacy of physical therapy intervention in sports-related concussion among young individuals age-group – A narrative review
Mousa Mohammed Jabali1, Anas Mohammed Alhakami2, Mohammed Ahmed Qasheesh3, Shadab Uddin3
1 Senior Physical Therapist, King Fahd Central Hospital, Medical Rehabilitation Center, Jazan, Kingdom of Saudi Arabia
2 Senior Musculoskeletal Physical Therapist, King Faisal Medical City for Southern Regions, Medical Rehabilitation Center, Kingdom of Saudi Arabia
3 Department of Physical Therapy, Faculty of Applied Medical Sciences, Jazan University, Jazan, Kingdom of Saudi Arabia
|Date of Submission||06-Nov-2020|
|Date of Acceptance||16-Dec-2020|
|Date of Web Publication||20-Jan-2021|
Dr. Shadab Uddin
Jazan University, Jizan
Kingdom of Saudi Arabia
Concussion has always been described as a suddenly and unexpectedly inflicted transitory functional brain illness and implicated as a diverse pathophysiological mechanism. A thread of mild traumatic brain injury is a concussion that are normally “self-limited and at the less-severe end of the brain injury spectrum.” Various studies have covered sport-related concussions in young athletes. Approximately 75% of these injuries occur at secondary school and college level with higher predilection among females, especially in soccer. Risk factors for concussion are male gender, high body mass index, and some sports, for example, American football. Consequentially, it may lead to diverse somatic, cognitive, and emotional signs and symptoms including memory disturbances, mental confusion, and difficulty concentrating. Disparate physical therapy evaluation methods and interventional strategies are being employed in this context to achieve the therapeutic goal. Any article concerning concussion injury and associated physical therapy among young individuals age group concerning football is lacking. Therefore, the purpose of this article is to focus on concussions in young football players, who have the highest chance of being injured or reinjured after returning to play.
Keywords: Brain trauma, physiotherapy intervention, sports head injury, young football player
|How to cite this article:|
Jabali MM, Alhakami AM, Qasheesh MA, Uddin S. Efficacy of physical therapy intervention in sports-related concussion among young individuals age-group – A narrative review. Saudi J Sports Med 2020;20:31-5
|How to cite this URL:|
Jabali MM, Alhakami AM, Qasheesh MA, Uddin S. Efficacy of physical therapy intervention in sports-related concussion among young individuals age-group – A narrative review. Saudi J Sports Med [serial online] 2020 [cited 2022 Jan 22];20:31-5. Available from: https://www.sjosm.org/text.asp?2020/20/2/31/307524
| Introduction|| |
Many studies have covered sport-related concussions in young athletes. Sport-related concussions happen in many sports, especially football and soccer. Football training and competition puts players at risk of severe head injuries including brain injuries associated with physical, cognitive, and emotional symptoms. “A brain injury is characterized as a traumatically induced transient brain function disorder and encompasses broad pathophysiological mechanism. Concussion is a form of mild traumatic brain injury (MTBI) that is usually self-limited and far less significant at the end of the brain injury scale.” According to the American Academy of Neurology, with or without loss of consciousness, a concussion alters the mental state caused by biomechanical force in the brain. Health issues of MTBI often include instant cognitive impairment, confusion, lightheadedness, and nausea. These symptoms may also affect an individual's participation and functional abilities. According to, the recovery after a concussion is fast, spontaneous, and complete. However, the real challenge in concussion management happens when recovery from the concussion takes longer than expected and leads to a delay in restoring the previous level of functioning or managing symptoms that continue for months or years. Nevertheless, there are various management strategies available in physical therapy for concussion injuries. And any article mentioning their efficacy, holistically, among young people age-group (10–24 years) is sparse. Therefore, the purpose of this paper is to focus on concussion injuries in football players belonging to young people age-group, who have the highest chance of being injured or reinjured after returning to play. In addition, this article will narrate disparate evaluation, interventional, and follow-up strategies in physical therapy management concerning these injuries.
| Etiology and Pathophysiology|| |
As per the Centers for Disease Control and Prevention, nearly 1.7 million people sustain traumatic brain injury due to various reasons every year in the USA. It is claimed that athletes from high school had the highest rate of concussions, 24/100,000. According to Laker, around 75% of brain injuries at the secondary school and college levels are caused by football. Almost half of all concussions in female athletes are due to soccer. Nevertheless, the incidence of death as a direct result of MTBI is very low.
The concussion can cause a “cascade” of brain metabolic disorders, including reduced cerebral blood flow, increased glucose and glutamate production, as well as irregular cellular ionic fluxes that can return to balance in minutes, hours, or days. The activity of acceleration and deceleration forces transmitted to the head causes the brain to shake via MTBI, which can lead to a series of sequential interactions of the neuromechanical and neurometabolic processes. It is possible to characterize the pathophysiology of a concussion as a neuronal and axonal membrane stretch that causes a flux of ions and transient physical membrane defects. This process allows a multitude of neurotransmitters to be released, resulting in a change of neuronal ionic homeostasis. Mitochondrial calcium overload is the main reason for ionic cellular imbalance after the trauma, responsible for creating improvements in the permeability of the inner membrane leading to malfunction, separation of the oxidative phosphorylation, and organelle swelling.,
| Risk Factors For Developing a Concussion|| |
There are several variables which enhance the risk of an individual for getting a concussion. The gender of an individual can reflect the higher rate of concussions. Studies indicate that males have a greater rate of concussions in all sports than females. Nevertheless, this high rate of concussions seems to be a result of the higher number of male athletes participating in sports, whereas other studies stated that the female's higher rate of concussion may be the result of the higher reporting of concussion symptoms by female athletes. The risk of concussion is associated with the type of sport. For example, the risk of concussion in American football and soccer is high, while a lower risk is associated with sports such as baseball, volleyball, and gymnastics. Additional risk factors of concussion depend on the individual athlete, including a body mass index >27 kg/m2 and training time of fewer than 3 h a week. According to Finnoff et al., the variables that increase the probability of a bad result after MTBI may include female gender, prior concussion, preconcussion anxiety or depression, posttraumatic amnesia, excessive postinjury exercise, and younger age.
| Body Function and Structure Impairment|| |
Concussions may lead to numerous complications, such as prolonged symptoms of postconcussion, chronic traumatic encephalopathy, cognitive decline, dementia at early onset, movement disorders, and even death. Postconcussion symptoms persist for long time. Symptoms may last for weeks or months depending on the seriousness of the accident, and may result from structural damage to the brain. Concussions can include somatic, cognitive, and emotional signs and symptoms such as immediate memory disturbance, confusion, clumsiness, dizziness, vomiting, difficulty concentrating, and sadness. Loss of consciousness and amnesia are considered the most important signs to help identify the severity of the injury. These factors also indicate the need of further imaging and intervention. By asking questions about the specifics of incidents leading up to and following the concussion, amnesia may be measured. According to Duff, most of the children will show complete recovery from a single concussion, despite the length of recovery period [Table 1]. A variety of physical and structural impairments are commonly reported after MTBI such as headaches, dizziness, and visual disturbances. Evaluation of attention span, orientation, memory, and executive function should include postconcussion cognitive screening. After true cognitive deficits, emotional symptoms can present and superimposed. Some emotional symptoms may be considered as secondary impairment after the concussion.
|Table 1: The primary and secondary function and structural impairment associated with mild traumatic brain injury|
Click here to view
| Activity Limitation and Participation Restrictions|| |
When the symptoms of concussion are present in an individual's behavior, it may lead to many activity limitations, based on the severity of the injury. Gait, reaction time, standing, and walking could all be affected after a concussion. The functional and structural impairments associated with a concussion may also lead to dramatic participation restrictions in reading, problem-solving, walking to classes, ability to play sports with friends, and overall quality of life.
| Physical Therapy Management|| |
According to Duff  more than 22 guidelines were published for grading the sport related concussions in young athletes and there is specific guideline regarding return to play(RTP). The American Academy of Neurology guideline for grading concussions includes three levels. The most challenging type of concussion to identify is Grade 1 concussions. For <15 min, the athletes do not lose consciousness but have temporary confusion. The athlete does not lose control in Grade 2 concussions but will have confusion or other abnormalities in mental state for >15 min. The athlete loses awareness for a few seconds to minutes during Grade 3 concussions.
On-field assessment of a concussion starts within minutes after the injury. Important aspects of the on-field test are the initial evaluation of the “ABCs” (airway, breathing, and circulation) and stabilization of the cervical spine. The sideline assessment includes the child's symptoms, cognitive review, and evaluation of the intellect of the child in sport-related concussions using the Sports Assessment of Concussion Tool 5 (SACT5), Structured Concussion Assessment (SAC), and Balance Error Scoring System (BESS).,, [10,
BESS is a postural stability assessment carried out with the subject in three places, first on a solid surface and then on a 10-cm thick piece of foam. The three positions include standing flat with hands put on the iliac crests on both feet, standing on the nondominant foot on a single knee, and standing flat with eyes closed on both feet. Each test lasts 20 s. By summing up the amount of mistakes the competitor makes over the six measures, a score is obtained.
Child SCAT5 is a standardized concussion evaluation method intended for use by doctors and licensed health-care practitioners. Children aged 5–12 years are measured by the infant SCAT5. If the child is 13 years of age or older, the use of SCAT5 is recommended. The Standardized Assessment of Concussions test can help in understanding the postinjury results. Standardized assessment of concussions has shown to be 95% sensitive with a specificity of 76% for the concussion.,
A detailed evaluation in the emergency department after a concussion should include signs and symptoms, previous head injuries, head-and-neck examination, and neuropsychology (NP) examinations. Any deterioration in his or her condition is recorded. Neuroimaging should be regarded if there is a problem with a systemic brain abnormality. A concussive injury is associated with disorders in brain function and brain activity correlations that can be tested by neuropsychological (NP) research.
The main objective of handling an individual with MTBI is to speed up recovery by avoiding behaviors and situations that can slow recovery to provide adequate time for complete recovery. It is challenging to treat young people with a concussion because their brains are still developing. The foundation of all MTBI intervention should be schooling and cognitive and physical rest; according to Reddy, “physical rest means refraining from aerobic exercise that can be increase the heart rate and blood pressure or contribute to increased fatigue.” Cognitive rest is equally important because symptoms can often be aggravated by changes in cognitive exertion. Patients should be encouraged to organize more regular breaks of rest, recognize when they become “cognitively exhausted,” and restrict their exposure to situations that are overstimulating. It is also recommended to provide schools or workplaces on behalf of patients with recommendations for academic or job accommodations. A recent research by Thomas et al. found that strict rest (specifically 5 days of strict rest at home, no school, work, or physical activity) post injury did not improve outcome which may have contributed to increased symptom reporting, while the current normal treatment resting for 1–2 days with gradual return to activity is now the management strategy. They also found that the reporting of symptoms by adolescents could be impaired by limiting behavior. The treatments of concussions should be individualized to the patient's symptoms because symptom presentations might differ among patients. The people move through a concussion recovery program once there are no signs at rest, as long as he or she remains asymptomatic. The progress should be monitored by the parent or an athletic trainer. It will take at least 24 h for each level of concussion recovery, and it would take a minimum of 5 days for athletes to expect a complete return to competition. If during the return to play (RTP) protocol, the symptoms return, suggesting incomplete recovery from the injury. The child can resume from the previous stage after the athlete is asymptomatic again for 24 hours.
The rehabilitation stages/step-wise return to activity protocols are:
- A full physical and cognitive rest is not an activity level
- Swimming, and stationary cycling at 70% maximum heart rate are part of the light aerobic activity stage; there are no resistance exercises
- Stage of sport-specific drills, which is a particular sport-related drill but no head effect
- A step of noncontact training exercises is a more complex drill and can initiate training in light resistance
- Step of full-contact activity that needs medical clearance and takes place in regular training
- In ordinary gameplay, return to action.
| Vestibular Rehabilitation Therapy|| |
A research by Alsalaheen et al. showed that after Vestibular rehabilitation therapy (VRT), individuals who have chronic dizziness and gait and balance disorder appear to have improved after getting a concussion. After vestibular pathology (disease or disorder), vestibular rehabilitation therapy is an exercise-based program to minimize dizziness and improve gait and balance. According to Alsalaheen et al., vestibular rehabilitation can reduce dizziness and enhance gait and balance after MTBI. Vestibular recovery therapy (VRT) consists of activities that the therapist or those at home may apply. Gaze stability exercises; for example, holding a fixed location of the gaze while moving the head from side to side; standing balance, for example, standing with feet apart and feet together on foam with eyes open and closed and canalith repositioning maneuvers. These improvements may benefit both children and adults. This study recommended that VRT should be included in all postconcussion management strategies for patients with continuing symptoms that do not resolve with rest.
Postconcussion syndrome has been described as the degree of signs and symptoms following MTBI for more than 3 months, according to Cantu and Register-Mihalik, well beyond the more usual recovery period of 7–10 days. Neuroimaging, such as magnetic resonance imaging and computed tomography, may be appropriate to rule out any factors that may contribute to these symptoms if the symptoms continue for a prolonged time. It is important to prevent all action and return to play before the athlete's symptoms subside.
Second-impact syndrome happens when there is another head injury before the initial concussion-related symptoms have cleared up. Second-impact syndrome results in cerebral vascular obstruction, which can progress to diffuse cerebral swelling and death. Halstead and Walter note that pediatric and teenage athletes tend to be at the greatest risk of this unusual disease. In certain cases, with simultaneous catecholamine-induced hypertension that leads to fatal malignant brain edema, concussions can cause death as a result of cerebrovascular dysautoregulation. Second-impact syndrome risk factors include 18 years of age or younger, previous concussion, and continuing postconcussive symptoms. Until the symptoms have healed, any patient fitting these conditions should not be allowed to return to sports.
| Conclusion|| |
In majority of cases, concussion, a type of MTBI, which occurred during sports activity is a self-limiting problem. In addition, appropriate management strategies are warranted for a better outcome from such injuries especially among young athletes. Concussion injuries if not attended properly might affect the normal functions of brain. Moreover, due to the occurrence of such injuries at a crucial stage of brain development, especially among athletes belonging to young people age-group, robust evaluation, intervention, and follow-up are required. In physical therapy management, by evaluating injured athletes using three-level concussion grading system, SACT5, SAC, and BESS, the therapist can accurately grade the injury and suggest an effective interventional strategy. Furthermore, recovery in such injuries is mainly based on removing or avoiding the impeding factors and it should be employed according to the person affected and type as well as extent of injury. In total, this article has summarized the various evaluation and interventional strategies, especially in the context of physical therapy, in sport activity-mediated concussion injuries, and their effectiveness among young people age-group.
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| References|| |
Halstead ME, Walter KD, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report – Sport-related concussion in children and adolescents. Pediatrics 2010;126:597-615.
Laker SR. Introduction. PM R 2011;3:S351-3.
Laker SR. Epidemiology of concussion and mild traumatic brain injury. PM R 2011;3:S354-8.
Signoretti S, Lazzarino G, Tavazzi B, Vagnozzi R. The pathophysiology of concussion. PM R 2011;3:S359-68.
Duff MC. Management of sports-related concussion in children and adolescents. ASHA Leader 2009;14:10-3.
Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, et al
. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2250-7.
Finnoff JT, Jelsing EJ, Smith J. Biomarkers, genetics, and risk factors for concussion. PM R 2011;3:S452-9.
Guskiewicz KM, Register-Mihalik JK. Postconcussive impairment differences across a multifaceted concussion assessment protocol. PM R 2011;3:S445-51.
Reddy CC. Postconcussion syndrome: A physiatrist's approach. PM R 2011;3:S396-405.
Putukian M. Neuropsychological testing as it relates to recovery from sports-related concussion. PM R 2011;3:S425-32.
Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al
. Sport concussion assessment tool for childrens ages 5 to 12 years. British J Sports Med 2017. doi:10.1136/bjsports-2017-097492childscat5 Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al
. Sport concussion assessment tool for childrens ages 5 to 12 years. British J Sports Med 2017;51:862-9.. doi:10.1136/bjsports-2017-097492childscat5
Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al
. The child sport concussion assessment tool 5th
Edition (Child SCAT5): Background and rationale. Br J Sports Med 2017;51:859-61.
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: A randomized controlled trial. Pediatrics 2015;135:213-23.
Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE, et al
. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010;34:87-93.
Cantu RC, Register-Mihalik JK. Considerations for return-to-play and retirement decisions after concussion. PM R 2011;3:S440-4.