The “Invisible Injury”: concussion management and the role of physiotherapy
Suffering in silence.
A concussion is “an invisible injury “not easily seen or felt by others. There is no “cast or brace” worn to indicate a physical injury is present, yet it defines you.
This is how “Sarah” described the way she felt the first day she walked into my office. She was a national athlete, who was one year post-injury. Everyone was doing all they thought they could for her, however, she had never felt more alone.
I work with a physician-led, interdisciplinary team that focusses on concussion treatment. We are a group of caring professionals who practice in a collaborative manner to diagnosis and manage sports and exercise-related concussions. In clinic, we will see acutely injured patients, as well as others who have struggled with persistent symptoms for months and sometimes years. To us, Sarah’s story is not a unique one.
Many patients share their story and frustrations of a delayed concussion diagnosis and timely medical care, and difficulties connecting with the right practitioners who have experience managing concussions.
They suffer in private, continuing to look for the next new treatment or practitioner who may be able to help them in their recovery, with the hope that they may feel better one day.
The NHL, NFL and MLB take steps to ensure their athletes are receiving the best care. These organizations have rapid access to medical specialists and rehabilitation services and they have league protocols and guidelines.
However, when we reflect on who else experiences concussions, the following questions come to mind:
1. Who takes care of our student athletes, recreational adults and individuals who also get concussions?
2. How can we, as physiotherapists, provide the best care for this population and work within our scope of practice?
3. What guidelines should we follow?
4. Is there a standard of care for physiotherapists?
5. How can we help “Sarah” feel like she is not alone in this process?
The concussion debate
According to Brain Injury Canada, 160,000 Canadians sustain a brain injury each year . Many of these people under-report their true symptoms, for fear of being misunderstood or judged. Literature suggests that more than 30% of concussion patients have symptoms that persist longer than four weeks .
This statistic warrants the question: What is our role as physiotherapists in concussion management and how can we define practice-based competencies?
Concussion care has often been dubbed “the wild west”. Without a defined standard of care, health care providers and the public are not clear on when people should seek care, what type of care is needed, and by whom.
The government has responded and is taking action to propose legislation:
was just 17 years old when she died after suffering a second head injury within one week. Following the loss of this Ottawa athlete, and with strong advocacy and support from her family, the Ontario government implemented new legislation called “Rowan’s Law” to help patients get what they need to “power through” a concussion. It advocates and mandates medical clearance, concussion education, and immediate removal from play when a concussion is suspected.
This Ontario bill represents a strong position on concussion care, and other provinces such as Manitoba are also taking key steps towards legislation. However, there are limitations to Rowan’s Law. This bill does not cover community-based sports, or the general population, and does not define guidelines for practitioners on how to manage care.
To fill some of the gaps, the Ontario Neurotrauma Foundation (ONF) began its search in 2016 for clinicians and professionals in the field to implement its own guidelines for those that do not apply to school-aged children.
Ontario Neurotrauma Foundation Guidelines: a provincial approach
With the help of 65 concussion care providers, the ONF created guidelines to help deliver the right care, at the right time, by the right provider. I was thrilled to be included in these discussions. The document outlines optimal concussion care and services, and aims to empower patients with information about what they should expect and receive from their concussion management programs.
How does this translate into our physiotherapy practice?
The ONF outlines the term “concussion clinic” as a health care management team of interdisciplinary care (minimum three providers from different disciplines) that exists in one location (or in a close network that is accessible). When an individual requires care by a concussion clinic, a physician with experience in concussion care provides the diagnosis and directs treatment together within a multi-disciplinary team of health care practitioners, each with experience in brain injury.
The ONF states:
Each patient is required to have a diagnosis (by physician, Nurse Practitioner (NP), or neuropsychologist);
Each clinic is required to have access to a physician (with experience in concussion management);
Each patient should have access to: an assessment, education, and therapies/interventions;
Each practitioner involved in the management should be regulated under their health professional licensing body, and has sufficient knowledge of traumatic brain injury, experience in concussion management, and practices within their defined scope of practice.
Concussions Ontario lists the full 15 Standards, as well as accompanying tools and resources.
While the provincial approach outlined the need for concussion resources and provided clarity on the standards needed for concussion clinics and roles of practitioners involved in concussion care in Ontario, there remained a strong need for provincial and federal governments to collaborate on the development and implementation for national guidelines. The federal government and Public Health Agency of Canada initiated the formation of an expert subcommittee on concussions via Parachute Canada, a non-profit charity and national injury prevention organization, to create a national guideline for concussion in sport.
Parachute Canada was the nidus for this initiative and together with the collaboration of 54 national sport organizations, medical experts, clinicians and researchers created the following recommendations:
The Canadian Guideline on Concussion in Sport is aimed to educate athletes from educational institutes, and non-school based organized sports activity (including: athletes, coaches, parents, officials, teachers, trainers, and health care professionals).
The Guideline addresses seven key areas:
Pre-season education: Information on pathophysiology
Head injury recognition: All members should be informed on how to recognize a concussion, regardless of their role
Onsite medical assessment: Emergency/sideline medical assessment (Athletic therapist (AT), Physiotherapist (PT), Medical doctor (MD)
Medical assessment: Official Diagnosis (MD, NP)
Concussion Management: A team of multi-disciplinary practitioners specializing in steps for return to learn and return to play
Multidisciplinary Concussion care: Regulatory licensed practitioners
Return to sport: MD and NP prescribed based on recommendations from licensed practitioners
The guideline is based on the international statement released in Berlin in October 2016, which proposed a worldwide guide to concussion management that allows practitioners to play a supportive role in recovery.
This guideline informs us of the following:
Prolonged rest is not required! We need to educate our patients
Gradual return to cognitive activity- re-integrate our students slowly
Progress recovery guided through symptom reports. Continually re-assess the concussed patient; do not exacerbate symptoms
Baseline testing is not necessary; it is not recommended in clinic for adolescents and children based on evidence
Re-assessment is key; individualized treatment plans targeted for patients are essential for recovery.
How do we as physiotherapists transition our role into concussion management team members?
What does this mean for physiotherapists working with athletes and patients in a clinic setting? How can we practice within our scope of practice and provide high quality care?
We all have varying expertise, we practice within our own “specialties”; however, we can translate our educational knowledge, and clinical practice into the following areas of concussion management:
Dizziness and balance (vestibular retraining);
Visual changes (ocular motor dysfunction);
Tinnitus/ hearing impairments;
Orthopedic co morbidities;
Cervical spine dysfunction;
Return to learn/play/work.
Where do we go from here?
The key message in the Provincial/National/International guidelines and protocols is to protect the patient, apply key medical assessments, and continually follow symptomatology.
We as therapists are lucky enough to have neurological, physiological and orthopedic understanding, which enables us to manage these patients in a controlled setting.
We are a group of highly educated professionals that are able practice on the frontlines of concussion care, if we specialize and tailor our treatment to guideline and protocol recommendations.
If we are able to understand our limitations, and build on our strengths, we can all make massive contributions to the body of evidence on concussions and in advancing practice-based recovery.
Perhaps we may be the missing link that “Sarah” has been searching for, and our intervention strategies can allow her to feel and behave like the athlete she deserves to be.
For more information on concussion management and strategies, please visit the linked documents.
Carolyn is a proud physiotherapist at Concussion North, a multi-disciplinary concussion clinic in Barrie, Ontario. She has tailored her education to Vestibular and Advanced Vestibular based courses, with a focus on Central Neurological Dysfunction. She was also a proud participant in the ONF guideline creation and implementation.
She has kept her education current by completing her post-graduate education at McMaster University in Rehabilitation Science.
 Acquired Brain Injury. Retrieved from
 Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, et al. Clinical Risk Score for Persistent Post-Concussion Symptoms Among Children with Acute Concussion in the ED. JAMA. 2016 Mar 8;315(10):1014.