Interview: Concussions with Dr. Rob Landel
This week we sat down with Dr. Rob Landel, Director of the PT and residency programs at the University of Southern California to cover the new concussion clinical practice guidelines.
Concussions are hard to rehab because they present so different every time. In addition, concussions are unlike any musculoskeletal injury; concussions can affect cognitive processing, memory, the quality and speed of these processes, balance, and eyesight and can oftentimes cause persistent headaches, migraines, and neck pain.
What's more, each of these issues needs to be properly evaluated and assessed if they are going to be properly rehabbed, making it crucial that patients with concussions get an in-depth, thorough evaluation with a competent and experienced provider who can make sure every facet is properly evaluated and ruled in / ruled out.
Furthermore, oftentimes, not one provider will evaluate and treat ALL aspects of a concussion. Therefore your provider should always be well connected to competent providers in the area that can help with a full recovery (e.g., neurologist/neuro-ophthalmologist/neuropsychologist, ENT with vestibular focus.)
The Assessment:
So what comes first are red flags, of course, and making sure you know what aspects of the concussion can be treated and who you need to refer to for what facets of their recovery (if required.) We really need to identify what of the four major domains of concussion rehab this patient has symptoms in.
Determining Concussion Irritability is Crucial
The four main domains for determining concussion irritability are:
Cervical
Assess the neck. The amount of force required for a concussion is around 100Gs, and a neck sprain is about 4.5Gs... meaning if you have a concussion patient come in and you're not assessing the cervical spine, you're missing the boat off the bat. Furthermore, we know that early neck pain after a whiplash injury is a major factor for the development of chronic neck pain, so dealing with that early on is going to get your patient moving in the right direction. From there, looking at dizziness and headaches. Do they have these symptoms at rest, are they recreated with cervical mobilizations/soft tissue? Are they aggravated with isolated cervical movements? Assessing these issues is going to help figure out if the concussions symptoms have cervical contributions requiring cervical-oriented treatment or not. Next up:
Vestibular-Ocular Domain
Is this a vestibulo/ocular issue? Parsing out are saccadic abnormalities present, are smooth pursuits an issue? Do we see a vestibular hypo-function through our objective testing? Do they see double when their head is moving...this can be typical of a VOR issue. These issues need to be parsed out if we target them directly and intentionally with our treatment. Third, we have...
Autonomic Exertional Function Domiain
Do they have symptoms as a result of elevated heart rate? Here we bring in either treadmill or cycle testing, making sure to monitor vitals throughout the progressive increase in exertion along with symptom monitoring. Again, if our rehab in general, our results will be poor. Targeted isolation with rehab can only begin through a thorough and targeted evaluation.
Motor Function
Here, we're looking at balance and dual function and cognitive tasking issues, or more "functional" problems.
Concussions are quite challenging to evaluate properly, and oftentimes you can't get it all done in one or even two sessions. These domains make it more manageable to focus on rehabilitation strategies in a programmable, organized, and targeted fashion. Just looking at these 4 domains is not enough; we need to be strong with our cranial nerve exam, vestibular-ocular exam, picking up on BPPV, cervical exam testing, exertional testing (taking vitals while someone is exercising is not particularly easy,) and of course, we need to be able to evaluate irritability.
Determining Irritability
Determining irritability is crucial because it will tell you how aggressive you can be during your exam and treatment. Irritability needs to be targeted to each symptom, e.g., dizziness, headaches, nausea, etc....we need to ask our patients for each symptom the following:
What makes you worse?
When you get worse, how much worse do you get?
When you're worse, how long does that last?
When you're worse, what will ease your symptoms?
And how quickly will your symptoms ease when you've applied that easing factor?
For example, headaches and dizziness may come quickly and be able to be calmed down easily. If that's the case, I'm not too worried about bringing on their headaches. However, if someone gets nauseous and nauseous, they stay that way for 2-4 hours, and it won't calm down... So I'm going to be very wary of doing anything in my rehab that will make them nauseous. Without going through each symptom, however, and asking the patient these questions, I don't know where my boundaries are and which symptoms I need to be wary of aggravating.
Once you have that constellation of symptom aggravators and you know which should be challenged and which you need to be cautious of, the overarching goal is indeed similar to what we do elsewhere. We want to stress the system, load the system incrementally and progressively. Moving into concussion symptoms is a good thing and is helpful to the patient as long as they aren't getting overloaded, flared up, and worse off. Without that stimulus, the brain isn't getting the input needed to recalibrate and heal. With too much stimulus, you run into the same problem. However, since concussions aren't straightforward, you need always to balance what you're doing. As Dr. Landel explains, stressing the neck is important early on after a whiplash injury. Still, if cervical movement over-aggravates concussive symptoms, you may need to get creative so that you can progress your cervical rehab without over-stressing/flaring up the concussive symptoms.
As with most patients, education is important. The body "is a marvelous machine," Dr. Landel says and will heal well if given half the chance. Make sure to identify improvements in your patients. For example, after a couple of weeks, they may still have a 5/10 headache while driving, but they may be able to drive twice as long before that headache reaches a 5. It can be a long road, but marking objective improvement is necessary to ensure your plan of care is working and continue to motivate your patient.
What about rest?
Patients with concussions used to be put in a dark room to rest until their symptoms resolved. It's become clear that this approach doesn't really help a lot of people. Research shows that early activation is not harmful to patients. We can exercise patients early without any negative effects (as long as we're not over aggravating their symptoms.)
Conclusion
Concussion care is hard for providers because it's always changing. As hard as rehabilitation is for the provider, it's always significantly harder for the patient. Therefore, these patients must have their symptoms reassessed frequently to ensure the proper progression of their program.
