A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes

Abstract

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10–14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

The Design and Development of MOVE-IT: A System for Remote Vestibular and Oculomotor Assessment in People with Concussion

“…Telehealth has been used as a tool to manage concussion in rural areas, although a commonly reported inhibiting factor is limitations in physical assessment [15]. Dizziness is one of the most common symptoms following concussion and requires objective assessments to view abnormal eye movement [2][3][4].…”

“…Although it is widely recognised that concussion is underdiagnosed, the projected global incidence lies between 40 and 55 million per year [1]. Most people with concussion recover within two weeks without requiring specialist input [2]. However, approximately 10-15% of individuals experience persistent symptoms 10-14 days after the impact [2].…”

“…Most people with concussion recover within two weeks without requiring specialist input [2]. However, approximately 10-15% of individuals experience persistent symptoms 10-14 days after the impact [2]. Dizziness is considered one of the most common symptoms following concussion and a risk factor for prolonged recovery [2][3][4].…”

“…However, approximately 10-15% of individuals experience persistent symptoms 10-14 days after the impact [2]. Dizziness is considered one of the most common symptoms following concussion and a risk factor for prolonged recovery [2][3][4]. A thorough vestibular assessment is required for these individuals, which involves identifying abnormal eye movements during vestibular testing [3,4].…”

Pre-frontal Cortex Oxygenation Changes During Aerobic Exercise in Elite Athletes Experiencing Sport-Related Concussion

“…Most recently, exertional exercise testing protocols, such as the Buffalo Concussion Treadmill and Bike Test have proven to be safe and efficacious (Leddy et al, 2016aHaider et al, 2019;Morissette et al, 2019) in evaluating the athletes post-concussion. These laboratory testing protocols have been designed with the intent to differentiate the type of concussion injury (i.e., physiologic, vestibulo-occular, cervicogenic;Ellis et al, 2014Ellis et al, , 2015Leddy et al, 2016a), and to discern the physiological mechanisms (cerebral autoregulation, cerebrovascular reactivity, neurovascular coupling; Ellis et al, 2015Ellis et al, , 2016Ellis et al, , 2018Neary et al, 2019). This research has added to our understanding of the pathophysiological changes that occur following a concussion (Len et al, 2011(Len et al, , 2013Giza and Hovda, 2014;Bishop and Neary, 2017;Bishop et al, 2017b;Worts et al, 2019), and has also provided a greater understanding of how we can apply exercise safely as a treatment strategy.…”