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.

Your head acts as a house for your brain. It is a vital organ that controls nearly everything you do, from breathing, speaking, listening, seeing, moving, and feeling.

The skull

Your skull is a sturdy structure that consists of different bones fused together to form 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 protects it.

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 whole 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. Different parts of your brain are responsible for different things like sensation, movement, thoughts, memory, sight, or sound. Towards the back of your brain, you can find your cerebellum, which helps to control movement and balance. As well as your brain stem, which controls things like consciousness and breathing.

The neck

Without your neck, you wouldn’t be able to move your head. It consists of spine bones (vertebrae) and lots of muscles that control the movements of your head as well as support the weight of your head.

The brain is the control room of your entire nervous system. Different parts of the brain are responsible for different functions. Your ability to breathe when necessary, move and remember are all controlled by your brain. Your brain is HQ for your body.

The brain is a complex soft structure. It contains nerve cells that are grouped into regions. In simple terms there is a layer of grey matter (nerve cell bodies) over the surface of the brain, with white matter (nerve cell fibers) beneath the grey matter, and basal ganglia (nerve cell bodies) that are beneath the white matter.

What is this structure’s Main function/ then is it dependent on: (Isolated function)

• Stability, Protective, Move, Hold, Static Stability, Mobilizer, Brace, Guard
• How it normally should work if everything is ok. (Use an example to say what kind of movement it involves)
• This section is supposed to be about the function of the patella. It’s not so much about how it functions. You can rather discuss that under the anatomy section.  In this paragraph, you want to discuss which things and movements it is going to help out with and discuss it in a practical way)
• Keep it short and sweet, this section is background information for the patient to understand what they loose or lost. Strength – weakness, Stability – unstable “It’s not there anymore”
• Good place to underpin the relationship working in harmony with surrounding structures to produce, stabilize, absorb, and generate force.
• Please don’t use the work ‘function’ E.g. As a mechanic we use our skills and knowledge to help your car function normally. VS As a mechanic we use our skills and knowledge to keep you car on the road. ~The second line is much more relatable.
  Please don’t use the word ‘function’, if there’s no other way to say it – don’t say it.

What is this structure’s Mian function/ then is it dependent on: (Isolated function)

Stability, Protective, Move, Hold, Static Stability, Mobilizer

Players who sustain concussion injuries are often not the best witnesses of their own condition, and in many cases their perceptions are misleading. It is usually observed best by a mother, teacher or coach. It must not be taken lightly. The consequences of a concussion injury may only appear a week after the actual injury and can get worse from there.

A concussion occurs when you get a direct blow to the head. This can be either from a ball / another player / a fall. Off of the sports field a concussion can also be caused by your head slamming onto the dashboard in a car accident, or during a fight. Concussion can also occur indirectly when you receive a blow to your chest / back.

This impact will cause your head to violently move in one direction within a split second. Your brain  (suspended in fluid) will follow the same route, but with a slight delay. The shell of your skull absorbs most of the impact but the brain, hits the inside surface of the skull. The brain rebounds and hit the opposite side as it moves back into position. This follows Newton’s 3rd Law, that every action has a reaction. So we often find signs of brain injury in the two opposing hemispheres, depending on the force and direction of impact.

The brain will swell after impact. Because the skull does not give way, the swelling will increase the pressure within the skull (intracranial pressure), with devastating consequences. In broad terms concussion is described according to the time of onset of injury, and in terms of the distribution of injury within the brain. Both of these should be taken into account in classifying any traumatic brain injury.

This impact to the brain may cause a shearing force that can rip or tear the membranes of your brain called the Duramater, Archnoid mater and Subarachnoid mater. These membranes are embedded on the inside surface of the skull, and if suddenly ripped into a direction it may tear lose from its anchors. These membranes supply oxygen and nutrients to your brain tissues, therefore any interruption of circulation of these membranes will cause the cells to suffocate and lead to permanent damage to the brain.

In most cases there is no bleeding with a concussion and therefore no neurological symptoms. Neurological symptoms is the umbrella term used to describe any symptoms that are caused by an injury to the nerves. This can include pins and needles, numbness, weakness or the inability to move.

It is rare to find that the blood vessels or arteries rupture with an concussion. The most damage is due to the injury to the actual grey matter nerves  in the brain where most of the information gets interpreted and processed.

Like with any bruise, your body sends cells to the tissue to repair it. This causes a rush of cells to the injured site, almost like all the traffic after an accident, the ambulance, tow trucks and police. This is localized swelling, but you can imagine the effect when a lot of cells rush into the confined space of your skull.  The skull does not “give way”, and therefore swelling leads to an increase the normal pressure within the skull, resulting on pressure on the brain tissue (increased intracranial pressure).

Primary brain injury: occurs at the moment of impact

Secondary brain injury: occurs after the moment of impact

Secondary brain injury happens after impact (hours or days ), due to increase in intracranial pressure because of the primary brain injury.

Diffuse brain injury:
affecting the whole of the brain.

Focal injury:
affecting a single (unifocal) or number  (multifocal) of specific regions in the brain.

Concussion initially results in what has been described as a ‘metabolic mismatch,’ during which cerebral blood flow significantly decreases, while the demand for glucose increases. Our brains use glucose as fuel. A concussion will disrupt the circulation to your brain cells, reducing the delivery of glucose, in turn this will decrease the normal behavior of  the nerves in your brain. The most common signs is the inability to concentrate, focus, or execute a task.

Although glucose metabolism initially increases post injury, a period of hypometabolism soon follows, which has been shown to persist for up to 10 days in animal studies and for up to one month in PET (positron emission tomography) studies of TBI. Mild traumatic brain injury has been linked to decreased magnesium levels, diffuse axonal injury, persistent calcium accumulation and alterations in neurotransmitter activity. Research has established that, in some instances of mTBI, both cellular and ultrastructural damage may occur.

Nerve impulses are transferred to your processing centers in your brain, these connections between nerves are called neurotransmitters. Neurotransmission is altered when the circulation is compromised. Neurotransmitters are released in higher amounts than usual. This will cause the nerve cells to go into overdrive. This leads to imbalances in chemicals in the brain.

What was the even, or buildup that lead to this __________ (condition)?

Choose one mechanism of injury and take the patient through a Slow motion event that describes the pathology.

• The circumstances that lead up to the point of failure, the order of dominos that must fail one after the other to end up with this.
• Slow motion description how the structures fail under pressure, force, tension, angular force,
• The condition of the tissue, pre-event and as it deteriorates into this condition state.
• Why the tissue damage takes place – Rotational force, Pressure force, sudden twisting, e.g. sideways pressure along the length of the bone is like stomping on a toothpick, the bone will break.
• It’s your responsibility to highlight the secondary fallout that they might not even consider.
• Example: the physiological breakdown of the structures, failure of one system, then the next, then the next. Muscle tension to the max, then tears, then the passive structures are the backup system (ligaments) that takes up the slack, but then rips through it, splits the ligament, and pry through any resistance, this all occurs in a split-second, in the blink on an eye.
• Pathophysiology
  EXPLAIN on a cellular level what goes wrong – Friction, Pressure, Bleeding, Forces, Tension
• Explain the defect & bring it back to function
  • Backward, regression of a chemical irritant, nociception leading into chaos, damage, destruction, loss of function, loss of _____

  This is not a bullet section, this is the explanation part – the “causes section” is for listing the bullet points

This is the primary factors determine the likelihood of developing ….

Predisposing factors that leads to, directly or indirectly can be linked to this type of problem,

meaning the activities, movements, and positions, systemic underlying conditions that directly flares-up, worsen and keep on causing the problem to get worse

Primary brain injury

These injuries occur at the moment of impact, as a result of acceleration-deceleration forces that are transmitted to the head (skull and brain). The forces may be linear- and/or rotational. These forces injure the entire brain. The brain is literally displaced, shaken and rotated within the skull. These injuries may occur without any direct impact to the head.

Because the physical characteristics of grey and white matter differ (density ect.)  the forces that are applied to the head cause regions of grey matter and white matter to accelerate at different rates. This typically results in shear injuries (tearing of tissue).

Loss of Consciousness (Blackout)

Depending on the magnitude and direction of forces, injuries may include a variety of symptoms. This may include permanent destruction of nerve cells (diffuse axonal injury). These injuries are usually characterized by immediate loss of consciousness, followed by variable forms and durations of neurological impairment. In certain cases neurological impairment may occur despite no loss of consciousness.

Secondary brain injury

These injuries typically occur hours or days after the primary injury. The injured brain is more vulnerable than the healthy brain to deprivation of blood supply. Extracranial risk factors such as hypoxia, fat embolism often occur as a result of co-existing orthopaedic-, chest-, abdominal- and/or vascular injuries. These extracranial risk factors often aggravate the effects of the primary brain injury, by hampering recovery of damaged nerve cells and/or by causing further damage to nerve cells.

These injuries are often not detected in the acute phase. They typically make themselves known at a later stage, at the time of resumption of normal daily activities, study and/or work. These injuries are best visualised on CT brain scans taken 2 to 5 days after the injury.

Symptoms are the words your patient will use – in a subjective assessment.

Following a blow to the head, you may lose consciousness. You may “pass out” for a few seconds or longer. Your brain suffers a temporary overload of firing nerves in your brain, that may cause it to shutdown and reboot.

Your short term memory will be altered, like what the score of the game is. You may suffer from retrograde amnesia (what happened just before your injury) or post traumatic amnesia (what happened after your injury). The duration of the amnesia does not indicate how severe the concussion is.

Your ability to think clearly and focus on tasks may be decreased. Something simple, like unlocking a door, may take you longer than usual. Simple and complex task may take longer to execute. Problem solving will be affected, like  finding the solution to a puzzle.

Serious injury has to be excluded immediately. Rather be safe than sorry. Players who have received a blow to the head will be taken off the field on a spinal board, then evaluated to exclude a brain or spinal cord injury. Our first step is to determine the extent of the brain injury by doing a battery of test.

These are signs that you can pick up by observing how a person reacts and behaves in a certain way that may be out of the ordinary.

• Amnesia (memory loss)
• Disorientation (looking confused and ‘lost)’
• Blurred / double vision – Seeing double or difficulty to make out the shape of objects, miss judging how far away an object.
• Sensitivity to light / sound – Covering eyes, squinting, wearing sunglasses inside.
• Incomprehensive speech – Unable to follow a conversation, delayed response to a question
• Nausea / vomiting – Also loss of appetite due to nausea is much more common.
• Headache – Aching pressure around their head, not limited to a specific area
• Imbalance / dizziness – Missing a step, leaning while walking, unable to walk a relative straight line.
• Decreased concentration – Longer time to reply to a question / difficulty to focus in classroom situations
• Changes in mood (sad, anxious, depressed)
• Lethargy / fatigue – Slow motion movements, to do a simple task like picking up a cup, as if in a ‘drunken state’
• Slowed reaction time to catch a ball or object.
• Sleep disturbances – Sleepiness, suddenly sleep for 12 hours a day, returning to sleep after only a few hour of being awake.
• Seizures – Sort sercuting of the nerves in the brain.

Difficulty with short-term or long-term memory

Short term: What day is it today? What’s the score? What you had for breakfast

Long term memory:  What’s your address? When is your birthday?

• Confusion: Difficulty following a train of thought, or following a conversation.
• Slowed “processing” (eg, a decreased ability to think through problems)
• “Fogginess”- Where’s my keys? Where did you put the file/ document.
• Difficulty concentrating
• Worsening grades in school – Especially Maths and Science where a process of scientific thinking must be applied with regards to background knowledge.

These are emotional cues that may be observed when interacting with a person that sustained a concussion. It is usually observed as out of the ordinary by someone that knows you well, like a parent, close friend or teacher.

• Irritability
• Restlessness – fidgeting,
• Anxiety – unreasonable reaction in a situation that would not normally be fearful
• Depression – Overbearing feeling of sadness, regret, negativity
• Mood swings – Changes from manic to depressive behaviour
• Aggression – Abnormal response of overly defensive
• Decreased tolerance of stress – Inability to cope under a reasonable stressful situation.
• Change in personality or behavior – Seems like a totally different person, or a response like: That doesn’t sound like something that he/she will normally do.

The different areas (lobes) of the brain have different functions. An injury to the specific area will lead to problems with that specific task. Thefrontal lobe (forehead) is responsible for decision making (taking consequence of decisions into account), memory, regulating behaviour. An injury to the frontal lobe may cause difficulty in planning, sequencing tasks, self correction. School work in subjects like maths and science will be impaired.

The occipital lobe (back of the skull) is responsible for the interpretation of your visual field. Injury will lead to visual disturbances, like difficulty to focus on a object or double vision.

The temporal lobe (just above your ear) is responsible for sensory interpretation. That is connecting an image to a memory, understanding language and emotional association. An injury to the temporal lobe may lead to personality changes in the sense that a person does not connect the same meaning to something than before the injury.

Self-test your … at home with these modified tests and see if you might have a ….

Use your key phrases abundantly here, if you need a few more.

1. Load progression in your tests.
2. Do not use “try to..” – keep to clear instructions. It’s an ‘must do’ instruction. These are tests, must be clear and simple, and avoid words like: “attempt” “try”
   “attempt to cross your painful leg”, “attempt to bend”, “try and twist”.

Describe at least:

• Weight-bearing
• Loaded
• Unloaded
• Stretch/ End of Range

Choose 4/6 of the below signs and DISCUSS that you (as a professional) use to identify and classify as more severe than another person with the same diagnosis.

Meaning: Imagine there’s a group of 20 patients, all with this same diagnosis and you must rank them from ‘less severe’ to ‘more severe’ ~ What markers/ signs will you look for to make your hierarchy and group them?

• Frequency – Intermittent/Constant/ re-occuring
• Movement or static positions (rest) flare pain.
• Duration – Days, Weeks, Sudden, Short burst, change position of your … eases the pain.
• Size – Radiate – Shoulder, Upper back, Head…
• Intensity (pain) – bearable, pain doesn’t stop you, hesitant to
• Colour: Bruising, Blue, Red,
• Loading: Contraction, Low load required to bring on pain, High load (jump)
• ROM: Limitation? Less than 10 degrees limitation (not a  problem) vs completely locked up.
• Stiffness
• Swelling
• Intensity: Discomfort – Painful – Sharp sting

WHY is it a serious type of injury?

On a scale from 0-10 describe a picture of Regression.

• Ligament tear Gr 1 – 3
• Muscle strain, micro tear – complete separation split in fibers
• Tendon phase of degeneration
• Cartilage erosion, plugging, tears

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)