Physiotherapy management of concussion can be a challenging area of practice. I’ve talked to a lot of physios, and concussion care can sometimes see overwhelming - with good reason. But it’s also incredibly rewarding, and very, VERY valuable for the patients who need it. To convince you that the rewards outweigh the challenges, I’ve compiled the most common challenges of concussion rehab for physios in private practice, with my best advice to get around these challenges.
1: “Concussions are complex injuries, and there seems to be a lot of gray area. For example, I know acute injuries are different than chronic symptoms, but I’m not confident in my skills. I’m not sure I have anything to offer this patient population.”
So, so true - these injuries are complex. But most of what we treat is not straightforward. Even so-called “simple” MSK conditions can be complicated by a variety of patient-related factors. As far as concussions go, it’s true that acute concussions should be managed differently than prolonged post-concussion symptoms. Understanding this is the first step in taking your concussion practice to the next level, so if this is your concern, you’re well on your way.
There are a couple of things to remember when caring for patients who have had concussions. First of all, the evidence shows that most patients get better on their own, and are symptom-free in a matter of weeks (depending on age) (McCrory). But these patients generally aren’t the ones that show up in your clinic. So when we’re talking about the complexity of concussion care, we’re generally talking about people with prolonged post-concussion symptoms. In these cases, management is complex for the same reason that managing chronic pain is complex - it affects ALL aspects of a patient’s life.
The good news is that you have the skills for this. The biopsychosocial model you’ve used to understand chronic pain can be applied to understanding chronic concussion symptoms too. All those so-called “soft skills” you’ve practiced with every patient you’ve ever treated? They make all the difference in the world with these patients.
2: “The advice for how to manage concussion seems to be always changing. I don’t know what to tell people.”
“I didn’t learn anything about this in school, and there’s lots of conflicting advice out there. Rest? Exercise? Let them sleep? Wake them every hour? I don’t know what to tell people.”
Let’s break this down. From lots of concussion research, we know the advice we used to give people isn’t supported by current evidence. We don’t tell people they need to wake up every hour the night after a concussion. We don’t tell every patient that they have to rest in a dark room for a set period of time anymore.
Maybe you didn’t learn about concussion rehab in physio school, but in school and afterward you’ve been developing excellent clinical reasoning skills. Concussion is just another clinical reasoning problem. You assess to look for impairments, provide interventions to address those impairments, and re-assess to see if your interventions had the desired effect. The only difference from your patient with an MSK injury is a change of context. After an MSK injury, you’re looking for impairments in things like strength or range of motion. In a patient with post-concussion symptoms, you’re looking for impairments in, among other things, vestibular function or exercise tolerance.
Get educated to learn how to assess concussion-specific impairments, and you’ll be on your way. But just accept that concussion education is not a “one-and-done” process. The advice we give patients will continue to change as research is done and our knowledge grows, so be prepared to brush up on your education every few years, or when big advances in knowledge are made.
3: “Patients with persistent post-concussion symptoms are complex, and some of them require expertise I don’t have.”
Again, I agree. Most of these patients will present with more than one impairment. For example, one of my former patients had vestibular symptoms, but also debilitating anxiety about exacerbating her symptoms. I provided a vestibular treatment plan, but I’m not a mental health professional. Dealing with anxiety is not within not my scope of practice. Instead of trying to stretch outside of your scope of practice (always a bad idea), you need a network of professionals that can provide these services.
This is not unique to concussion. Patients with many types of complex injuries or chronic symptoms generally require a team approach to their care. Chronic post-concussion symptoms are no different. Be prepared to liaise with physicians, nurses, optometrists, occupational therapists, speech-language pathologists, psychologists, social workers, teachers, coaches, case managers, and many other professionals. You don’t have to provide every aspect of a patient’s care - nor should you. Do what you do best, and coordinate with the rest of the team.
The flip side of this is when the patient doesn’t have a team in place. You may be asked to help build it, especially if the primary care physician doesn’t have experience managing a patient with prolonged concussion symptoms. It’s a good idea to know how persistent concussion symptoms present in ways outside of your scope of practice, and be able to screen for a few of them, like depression, vision problems, or communication difficulties. You shouldn’t try to treat these, but have a network of professionals in your area who you can recommend patients be referred to. When I started seeing patients with chronic post-concussion symptoms, I didn’t have a ready-made network. I built it slowly, calling OTs when I had a patient who needed one until I found an OT who would see my patient. I kept that name handy, and slowly added mental health professionals, speech-language pathologists, and others until I had a list of people who saw patients similar to the ones I kept seeing.
I hope I’ve convinced you that adding concussion rehab into your private practice is possible, if you’re interested in it. It’s an emerging practice area, with the rewards and the challenges that brings. It’s also an underserved area in medicine and rehab right now, and becoming a skilled provider will allow you to reach patients who are in need of expert intervention. Like most good things, it might not be easy, but it will be worth it!
This blog post was written by Meaghan Adams, an Embodia continuing education instructor
PT, BSc, MSc(PT), PhD(Neuroscience)
Meaghan earned her physiotherapy degree from Queen’s University, and completed Fowler-Kennedy’s Sport Physiotherapy Fellowship before earning a Certificate in Sport Physiotherapy from Sport Physiotherapy Canada. She also holds a Certificate in Vestibular Rehabilitation from Emory University. Meaghan completed her PhD in neuroscience at the University of Waterloo, studying how concussions affect brain function and sensory integration, and is currently a post-doctoral fellow at York University studying the integration of cognition, motor function, and sensory inputs after concussion, with a special focus on women with persistent symptoms.
Meaghan serves as the vice-chair of the Neurosciences Division of the Canadian Physiotherapy Association, and is an Assistant Clinical Professor (Adjunct) at McMaster University’s School of Rehabilitation Science.