Each year nearly 135,000 U.S. children and teens ages 5 to 18 visit an ED because of recreational and sports-related traumatic brain injuries, including concussion, according to the U.S. Centers for Disease Control and Prevention. Many more sports concussions that do not receive emergency treatment likely occur.

“A physical therapist needs to be aware of the signs and symptoms of concussion,” says John Doherty, PT, MS, ATC, a physical therapist and athletic trainer with the Midwest Center for Concussion Care in Des Plaines, Ill. “Especially for patients younger than high school age, a physical therapist may well be the one to identify concussion because there [usually] aren’t athletic trainers at the schools,” says Doherty, who also is head athletic trainer for Munster (Ind.) High School.

A concussion is defined as a condition of impaired brain functioning caused by a violent blow or impact. (Although concussion also goes by the name mild traumatic brain injury, its severity varies widely.)

Research shows that the developing brains of adolescents are more vulnerable to concussion than those of adults and may heal more slowly.

There is a mistaken idea that loss of consciousness must occur in the case of a concussion. However, studies show that less than 10% of concussions result in loss of consciousness.

Concussion symptoms can be subtle, such as headache or feeling sluggish. Also, symptoms may not surface until 48 to 72 hours after injury, and they may wax and wane, Doherty says.

“You can see when a bone is broken or a joint is dislocated, but you can’t see the brain,” says Dan Lorenz, DPT, ATC/L, a sports physical therapist and licensed athletic trainer at Providence Medical Center, Kansas City, Kan.

When concussed athletes continue to play sports, they put themselves at risk of “second-impact syndrome.” The term for a repeat concussion before symptoms of the first brain injury have resolved, second-impact syndrome is a serious condition that can cause permanent disabilities and even death if diffuse brain swelling occurs.

Furthermore, experts have realized that concussion can be less transient than previously thought. Although most patients with concussion heal within two weeks of the injury, about 10% experience postconcussion syndrome, medical literature reports. In this syndrome, headache, fatigue, difficulty in concentration and disturbances in equilibrium may last for weeks or months after the injury.

PTs must know whether an orthopedic patient has a concussion so they can plan appropriate treatment. “Rehab of neck and back injuries could interfere with recovery from concussion,” Doherty says.

Management is controversial. “But we’re better off than a few years ago,” Doherty says. Recovery depends on rest until symptoms resolve, including “cognitive rest,” meaning limited scholastic activities while symptomatic.

The decision to allow a concussed athlete to return to sports can be difficult, Lorenz says. To ensure a safe return to physical activity, rehab specialists gradually advance the patient’s activity level from light aerobic activity to return to full sports performance. Some states, such as Washington, require a physician’s written approval before someone under 18 with concussion symptoms can play sports again.

To evaluate the physical and cognitive function of a suspected concussion victim, sports medics often use “sideline cards.” Doherty recommends that physical therapists keep these assessment cards in the clinic.

The most commonly used of these tests, according to Lorenz, are the Standardized Assessment of Concussion and the Sport Concussion Assessment Tool 2.

A tester can give the SAC in less than five minutes and compare the results with published normative data for junior high and older athletes. This tool assesses orientation, memory and concentration. The SCAT2, for use in athletes age 10 and older, also measures concussion signs and symptoms, neurologic responses, balance and coordination.

Newer, computerized concussion tests allow individual baseline and postconcussion neurocognitive testing. Such tests include CogState Sport (cogsport.com/go/sport), HeadMinder Concussion Resolution Index (headminder.com), and Immediate Postconcussion Assessment and Cognitive Testing (impacttest.com). The most frequently used is ImPACT, according to the UPMC researchers who designed it. A six-part test that takes 20 to 25 minutes to complete, it is far more involved than a sideline test, Doherty says. Ideally, athletes take the baseline test every two years and the postconcussion test within 24 to 72 hours after injury, he explains.

ImPACT has been used at the high school level and above and provides information that can assist with return-to-play decisions, including reaction times. Disadvantages, according to Lorenz, are that ImPACT is expensive and requires training in how to administer it. •

Kathleen Louden is a contributing writer for Today in PT.