Most people know that a concussion is a serious injury, yet not everyone takes it seriously. Did you know that a concussion is actually classified as a mild traumatic brain injury (TBI)? Maybe that will grab your attention. It is the most underdiagnosed injury on the sports field. 5 – 9% of all sports injuries can be classified as a concussion and it is becoming a much too common type of injury to see, especially among youth athletes. Mainly because athletes want to stay on the field, it goes unreported. However, the after-effects of a concussion are enough to encourage anyone to rather have it looked at, than hoping for the best.

The skull

Your head acts as the house for your brain. The bone that makes your head so hard is called your skull. It’s a sturdy structure that forms a hard shell around your brain. Its main function is protection and there’s some truth behind the saying that someone “has a thick skull”. The bone structure of your skull is thick, strong, and immovable.

The meninges

Along the inside of the skull, several layers of membranes cover the brain. There is fluid, called cerebrospinal fluid, in between the membranes. In essence, your brain floats in this fluid. This fluid helps to provide nutrients to your brain and the membranes help to protect your brain by acting as a barrier.

The brain

Your brain is a soft organ that consists of billions of nerve cells. It communicates with the rest of your body through your spinal cord and a big network of nerves. It sends and receives signals that allow you to react to the environment around you (like making decisions and feeling different emotions). The way your brain functions is so complex, that all the research in the world is not enough to allow anyone to fully understand how it works. The important thing to remember is that different sections of your brain are responsible for different jobs. The brain can be divided into three basic sections: the cerebrum, the cerebellum, and the brainstem. The cerebrum is the largest part of the brain and it initiates movement and enables speech, judgement, thinking, reasoning, emotions, vision, hearing, and touch. Towards the back of your brain, you can find your cerebellum, which helps with coordination and balance. Your brainstem also sits at the back and connects your brain to your spinal cord. It is responsible for important functions like consciousness and breathing.

The neck

Even though your neck is not technically part of your brain’s anatomy, it’s important to remember that the head and the neck work together. Without your neck, you wouldn’t be able to move your head. It consists of spine bones (vertebrae) and multiple layers of muscles that control the movement of your head and support the weight of it.

Because a concussion is classified as a brain injury, people tend to forget that the neck always gets injured as well. If the impact is big enough to injure your brain, you can imagine that your neck takes a lot of strain at that moment as well.

Your brain is the control room of your entire nervous system. It is like the headquarters that interacts with almost all other parts of your body.

• Controls thought, memory, emotions, judgment, and decision-making.
• Forms your personality and social behaviors.
• Initiates movement (this includes anything from moving your body to blinking, chewing, swallowing, and facial expressions).
• Enables us to feel touch, temperature, pressure, and pain.
• Regulates hunger, thirst, sleep, body temperature, breathing and consciousness.
• Connects with your eyes, ears, mouth, and nose to give you the ability to see, hear, smell, and taste.
• Interacts with other organs to regulate breathing, oxygen levels, blood pressure, heart rate, digestion, and immune responses.
• Maintains body posture, coordination of movement and your sense of awareness in the space around you.
• Releases and regulates hormones.

In fact, this list is very condensed when it comes to what your brain does for you. This list can go on for much longer and into much more detail. You would be astonished. But, it serves to show you how many things can be affected and injured when you have a concussion.

It starts with a direct blow to your head. Whether you fell or your head was hit by something, what happens next is the serious part. This impact violently pushes your head in one direction, almost like a whiplash action. Your brain, which floats inside the fluid in your skull, will follow the same route. The shell of your skull absorbs most of the impact, but your brain hits the inside surface of the skull and then rebounds back into position. Think of it as your brain that is ‘shaken’ inside your skull (coup contrecoup injury). So, we often find signs of brain injury on the side of the impact as well as the opposite side.

Because your brain is soft, the impact of the concussion causes a contusion (bruise) type injury to the nerve cells in the area. The tricky part about this injury is that your skull might not be injured at all and you might not even have a wound that is visible on the outside. But, your brain takes the punch and causes a whole chain reaction of symptoms.

The inflammation reaction

The injured area of your brain will start to swell. Depending on the amount of swelling, this can be a problem. Your skull is rigid and won’t stretch or make space for the swelling. Thus, the pressure in your brain increases (intracranial pressure), with devastating consequences. The impact of the concussion can rip or tear the membranes (meninges) around your brain. These membranes help to provide oxygen and nutrients to your brain. So, the swelling and pressure cause a disruption of normal circulation to the nerve cells in your brain, leading to ‘suffocation’ of the cells and possible permanent damage.

In more severe cases of brain injury, there can be bleeding together with swelling in the brain. This increases the pressure even more and completely disrupts the ability of the nerve cells in that area to interpret and process information.

The chemical imbalance

Concussion initially results in what has been described as a ‘metabolic mismatch’. Our brains use glucose as fuel and glucose travels to your brain via blood vessels. However, with an injury like a concussion, the normal circulation to the brain is decreased, and the demand for glucose increases.  This is why it is called a mismatch or imbalance. Now, the normal behavior of nerve cells gets disrupted because of a lack of glucose fuel. A common sign of this is an inability to concentrate, focus, or execute a task.

The secondary brain injury

People tend to think that a concussion is only serious if you pass out (lose consciousness). While it is certainly serious to lose consciousness, what happens in the hours or days after a concussion is just as serious.

In the days after a concussion, your body produces less glucose at a slower rate. Magnesium and calcium levels change. More brain chemicals (neurotransmitters) are released. All these things affect the complex, yet normal way that your brain cells work. Your brain is now in crisis mode, recovering from this injury. These changes can either suppress your brain from functioning normally for a while, giving you a slower reaction time or memory loss. Or worse, it can cause permanent brain damage, especially if you don’t respect the injury. You wouldn’t expect a torn muscle to be as strong as before, so why expect everything to immediately go back to normal after a concussion?

• Direct blow to your head, face, or neck
• Motor vehicle or motorcycle accidents
• Whiplash injuries
• Falling from a ladder, the bed, the stairs, or the bathtub
• Contact sport (e.g. rugby tackles or being hit by a ball against your head)
• Wrestling or boxing

Concussions present very differently from person to person. The symptoms you experience will also greatly depend on the area of the brain that got injured. Here are a few things that we look at to determine the severity of your concussion injury:

Losing consciousness

To lose consciousness (pass out) after a concussion, is not always a good indicator of how severe your concussion is. It simply shows us that your brain and body tried to protect you by cutting off the connection for a moment while it responded to the trauma of the injury. If the impact was close to the section of your brain that manages your consciousness, breathing, and blood pressure, passing out might be the first symptom you experience. The greater question is how long did you lose consciousness? You will probably not remember, but your coach or family member can hopefully help with this. If someone struggles to regain consciousness after a few minutes or longer, it shows us that your brain function was injured to such a degree that it was being suppressed.

Neck injury/whiplash

Direct impact on your head will most definitely injure your neck as well. If a force is strong enough to ‘shake’ your brain inside your skull, it would have put severe strain on your neck as well. It’s a normal reaction for your neck muscles to ‘tense up’ to try and stabilize your head. So, that’s why you can also feel neck pain and stiffness in the days and weeks after a concussion. It will take much longer to feel like you have recovered from both a concussion and a whiplash.

When did the symptoms start?

It is normal for symptoms to only start in the hours or days after the concussion. Initially, your body goes through an adrenaline rush and you might feel perfectly fine. However, if the injury to the brain is very severe, you will experience the symptoms immediately and it could even get worse as time goes by.

How long have you had symptoms?

Your body takes time to heal from any injury. So, recovering from a concussion can take anything from a few days to a few weeks. However, it is a warning sign if your symptoms do not improve after several weeks or months. Some people even experience multiple or recurring head injuries, especially in certain sports. This can cause chronic concussion syndrome. Nerve and brain injuries can take much longer than other tissues to heal. But, if the injury is severe enough, it can lead to permanent nerve and brain damage.

Describe a sentence to give the patient confidence that we’re the equipped/best at diagnosing this problem.
“We can handle it” vs “Our knowledgable expert physiotherapists are well versed, confident, and experienced in their approach to diagnosing your…”

Important to note

Focal contusional (coup-contracoup bruising) brain injuries, which by their nature evolve over time, are often not evident on CT or MRI scans taken on the day of the injury. These injuries are more readily detectable on scans taken 2 to 5 days after the head injury.

We follow a structured plan to diagnose, classify the severity, and determine the hierarchy of priority that your knee needs. We stress, screen and scan all the possibilities that could be causing your pain. Identify any other injuries to surrounding structures. If there is an injury to the ligaments, meniscus, muscles or nerve, or cartilage we will find it.

We understand the physiological healing stages you’ll go through, and custom-fit your treatment program. By knowing the extent of the tissue damage we can guide you through a structured program to recover faster and safely return to the things you love doing. That’s why our physiotherapists are the best at diagnosing this type of problem.

Why is it crucial to get/understand a diagnosis? Does it mean anything? Or is it a death sentence? or will you treat it differently if you know what you’re dealing with?

Muscles cannot be seen on an x-ray, so it will not be effective to diagnose a muscle spasm. X-rays will however show the integrity and alignment of joints in your spine. This will enable us to see if something is wrong with the structure of the bones in your spine or if there is a loss of disc space.

What are you looking for on an X-ray? Cortical stress lines, Displacement measurements, What Classification is done via X-ray?

Your physiotherapist can refer you to get x-rays taken if necessary.

Diagnostic ultrasound can be used to show the presence of a muscle tear (muscle strains), inflammation, swelling or simply increased contraction of a muscle (muscle spasms).

If you need an ultrasound, your physio will refer you.

CT scan

CT (computerized tomographic) scans, which are computerized reconstructions of images obtained by conventional tomographic x-rays, are very good at identifying bone, air, water and collections of blood. In the acute phase of head injury, CT scans are therefore useful for detecting skull fractures, intracranial bleeding, localised swelling and/or shift of the brain.

MRI

MRI (magnetic resonance imaging) scans are very good at identifying soft tissues and the planes between different types of soft tissue. MRI scans are therefore best at detecting the gross structure of the brain, cerebral cortex, deep white matter, basal ganglia, ventricles, cerebellum, brain stem and cranial nerves, as well as distortions thereof.

An MRI scan can image all of the structures in your lower back, including soft tissue, discs, nerves and bones. However, for a muscle spasm an image like this is unnecessary and very expensive. If your physiotherapist suspects anything more than just a muscle spasm, you will be referred to the right specialist.

Is an MRI necessary for this diagnosis – if not when could it become a necessity?

Discuss why the pain does not improve –

• This section assumes that NO intervention/ treatment/ personal care/medical attention is applied….
• A patient that leaves his fracture untreated, undiagnosed, what will happen
• Without treatment “wait and see” approach. – what’s wrong with it and the problems they’ll face.
• There is a risk of more critical and possibly irreversible damage if you don’t take the warning signs seriously.
• What slows down your recovery period
• Discuss – Non-union, Malunion, Prolonged healing, Abnormal Calllus formation,ect.
• You become stuck in a cycle of pain, not knowing if it is safe to move or not
• Make sure you are getting the right treatment from the start
• Without intervention, or treatment why is the tissue state not improving?

Why will this condition NOT resolve or recover on it’s own

Complications (guaranteed, or high probability of developing with this problem/diagnosis/condition.

• One concept per paragraph. Explain What resistance or problems can you encounter during the treatment process. Stay to the core message.
• Speak to your patient as if each of these is happening to them.
• Explain the WHY it’s a problem, not only state “it’s a problem”, but why…
• Not bullets – they are only to guide your thoughts. Choose a few (not all), and explain why its more severe.
• E.g. Not staying in the sling for the recommended period, “Taking the sling off occasionally to drive” Explain why its a problem.
• Compensation expectations
• Reasons that delay recovery time

Pain medication (how long is normal/ acceptable)

Misconceptions about treatment

Please inspire confidence in your ability to test, identify, diagnose and treat/ deal with this.

Example:

Our priority is to determine the extent of the damage to your piriformis muscle. Then, we test the structures surrounding your hip and lower back to clear the nerve pathway and resolve the sciatic nerve pain. Avoiding nerve compression is crucial to prevent relapse and restore the sciatic nerve’s regular sliding. We must protect the muscle from overworking by differing forces away from the piriformis muscle, strengthen the surrounding muscles, correct the compensation, and retrain the correct firing pattern. This allows time for the piriformis muscle to adapt and heal. Our practitioners bring on a change and monitor the results until it’s working, and then we magnify the effects to get even better outcomes.

Patient asks you:
“So why should I come see you for … ?”
Your answer is…

• We can provide the best treatment for, provide guidance and answers., Implement a very effective and structured plan of action like
• Use the antonyms of the words the patient complains of. Instibility – stability/stable, Fear – confidence, worried – calm/carefree, anxiety – serenity
• And we will also look at (muscle strength, joint range of motion, flexibility, ligament stability, and nerve control.)
• Gradual strengthening, control, and conditioning.

Physio protocol time frame for healing (weeks/months)

Whereas the major portion of natural improvement following brain injuries occurs during the first 6 to 12 months, minimal further improvement can occur up to 2 years after the accident, while no further neurological improvement can be expected after 2 years.

In cases of childhood head injury it is common to find increasingly apparent mental disability as the child ages. In other words, despite being neurologically stable, the learning impairment becomes more apparent and more disabling in high school than in primary school.

Reasons for this phenomenon include :

The head injured child’s mental development proceeds at a slower rate than that of his or her uninjured peers, and at a slower rate than would have been the case in the absence of the head injury.

The role of the child’s frontal lobes becomes more heavily taxed in higher grades at school and in adult life, particularly in relation to the escalating needs for abstraction and independent execution of tasks.

• A full recovery and return to sport will take longer and should not be confused with the healing period.
• It takes about 3 to 4 months to return to exercise and sports.
• You will need physiotherapy treatment twice a week for the first two weeks.
• After this, your treatment sessions can be …
• Remember: “Non-operative Treatment” or Non- Surgical Not conservative

This section is about other treatments that can help the process services that can help – but we don’t provide.

• Your doctor (GP) will probably
• Pain meds, injections,
• Getting your back or neck ‘aligned’ or ‘clicked’ in the hopes of improving the … will not improve the state of the muscle or change your pain. It could even worsen or trigger a muscle spasm. You need to look at the bigger picture.
• A biokineticist will be able to help you in the final stages of your rehabilitation and get you back to training for your sport.
• Wearing a back brace won’t be the solution to your problem.
• Stretching or foam-rolling might ease your pain temporarily, but

Surgery is necessary when …

• These are the surgical checkboxes that must be ticked before surgery is even considered.
• Surgery is only Halfway mark for a successful surgery, the rest is the reintegration, strengthening and adapting your body to the change.
• Types of surgeries that can be done.
• Why is rehab important after surgery?

Vertigo (BPPV)

A concussion may lead to the octonia (crystals in the inner ear) to dislodge and move in the semicircular canals. This will cause severe vertigo (spinning of yourself or the room) with head movements.

Whiplash

The delicate structures in the neck may also be injured with a concussion. Neck pain, decreased movements and headaches will be present.

• Synonyms
• List key phrases (careful – start each bullet with different word)