Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach

Abstract

Historically, patients with sports-related concussion (SRC) have been managed in a uniform fashion consisting mostly of prescribed physical and cognitive rest with the expectation that all symptoms will spontaneously resolve with time. Although this approach will result in successful return to school and sports activities in the majority of athletes, an important proportion will develop persistent concussion symptoms characteristic of post-concussion syndrome (PCS). Recent advances in exercise science, neuroimaging, and clinical research suggest that the clinical manifestations of PCS are mediated by unique pathophysiological processes that can be identified by features of the clinical history and physical examination as well as the use of graded aerobic treadmill testing. Athletes who develop PCS represent a unique population whose care must be individualized and must incorporate a rehabilitative strategy that promotes enhanced recovery of concussion-related symptoms while preventing physical deconditioning. In this review, we present our evolving evidence-based approach to evaluation and management of athletes with PCS that aims to identify the pathophysiological mechanisms mediating persistent concussion symptoms and guides the initiation of individually tailored rehabilitation programs that target these processes. In addition, we outline the important qualified roles that multi-disciplinary healthcare professionals can play in the management of this patient population, and discuss where future research efforts must be focused to further evaluate this evolving pathophysiological approach.

A Physiological Approach to Prolonged Recovery From Sport-Related Concussion

“…79 Identifying the source of symptoms allows the provider to prescribe specific active forms of therapy such as cervical physical therapy, 80 vision therapy, 23 or vestibular rehabilitation. 81 …”

Subsymptomatic Aerobic Exercise for Patients With Postconcussion Syndrome: A Critically Appraised Topic

“…In recent years, there has been a shift in clinical treatment approaches that bring a more active recovery to the forefront of concussion management. [5][6][7][8] These treatments vary based on the types of symptoms and deficits that persist after concussion.…”

“…In the standard Balke Treadmill Concussion test, the baseline is determined by the patient reporting symptoms or unable to achieve full incline. 5,9 In the studies included, there were minor variations in time and intensity utilized in the protocols. [10][11][12][13] These values are then used to develop active rehabilitation protocols for patients after concussion in which they complete aerobic activity at a subsymptomatic threshold of between 60% and 80% of the baseline threshold.…”

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

“…Recently there has been a focus on the management of the athlete post-concussion, including when it is safe for the athlete to return-to-learn and return-to-play so that the likelihood of re-injury is decreased (Aubry et al, 2002;Collins et al, 2002;McCrory et al, 2005McCrory et al, , 2009McCrory et al, , 2013McCrory et al, , 2017Ellis et al, 2016;Terwilliger et al, 2016). Traditionally, ''prescribed rest'' has been used to ensure the safety of the athlete (Moser et al, 2012;Elbin et al, 2014;Thomas et al, 2015;Buckley et al, 2016).…”

“…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.…”