As a healthcare provider, treating concussions can be challenging. There are a lot of different interacting systems that can manifest a variety of different symptoms in your patients, and that can leave you not knowing where to start. Having the right tools in your clinic will not only allow you to have an organized and comprehensive list of options to include in your patient’s treatment plan, but it will ensure that your patient and the other members of their support system are also integrated into the concussion recovery process. This will lead to the best possible care for your patient.
There are many different concussion management tools on the market today, with some being more established in the management of concussion patients and others still well within the experimental stages.
When we were coming up with a list of our favorite concussion tools, we wanted to include tools that were:
Before diving into our favorite tools, we are going to review the pathophysiology of a concussion, which will justify which tools we have picked.
A concussion occurs from an acceleration-deceleration of the brain within the skull cavity after an impact to the head or body. This acceleration-deceleration injury leads to a functional brain injury secondary to a neurometabolic cascade within neurons. This manifests as widespread activation and subsequent energy deprivation throughout various brain areas.
In addition to functional neuronal damage, there can also be associated cervical spine injury, psychological challenges, impact on school and sporting activities, and other person-wide changes after minor head trauma.
In most cases, the brain will recover and repair the effects of the neurometabolic cascade over a span of approximately 30 days. Current research-based treatment recommendations include patient education, prevention of second head injuries, a gradual return to work and school, and various rehabilitation protocols (visual, vestibular, etc.) based on your patient’s symptom profile.
With that in mind, here is the list of our current 3 favorite concussion management tools and an honorable mention.
A heart rate monitor is a critical concussion assessment tool when diagnosing and treating a mild traumatic brain injury because it can give you an objective measure of how your patient is coping with increasing physical demands and what worsening symptoms they may or may not be experiencing as a result.
Diagnostically, heart rate monitors are used in the initial evaluation of a suspected concussion during the Buffalo Concussion Treadmill Test (BCTT).
The BCTT is a standardized test that uses increasing slope, and potentially speed, of a treadmill to tax the cardiovascular system of your patient to learn if increasing cardiometabolic demands make their symptoms worse. During this test, a heart rate monitor gives you an objective measurement of how high the relative demand of a given exercise is on the cardiorespiratory system and gives you the ability to correlate their subjective symptoms to their objective workload.
If a patient experiences concussion symptoms within increasing physical activity during the test before they reach 85-90% of their age-adjusted maximum heart rate, or approximately >17 RPE on the Borg 6-20 scale, you have confirmation that they have indeed sustained a concussion and that increasing physiologic demands is a trigger for their symptoms.
After you have completed the BCTT, the heart rate monitor can help track the recovery of your patient over time and can help guide you in how hard you can push that patient’s rehabilitation.
For example, let’s say on the initial visit their exercise capacity was limited by concussion symptoms at 165 bpm. If, after two weeks of rehabilitation, they can now reach 180 bpm before symptom onset, you know that they are recovering nicely and just need a little more time to fully recover before going back to sporting activities.
Or, let’s say your patient is still having dizziness when swimming but can reach their age-adjusted maximum heart rate during the BCTT without seeing symptoms increase. This may point you toward looking at the cervical spine or vestibular systems for the cause of dizziness with swimming, as their symptoms are not coming from a dysfunction in their cardiometabolic system.
Heart rate monitors are also important in correctly scaling a patient’s rehabilitation program when returning to physical activity. It is well established that cardiovascular exercise is a recommended treatment after 48 hours of initial rest in acute concussions, provided that symptoms are minimal (1). Therefore, exercise protocols have been developed for graded return to physical activity via monitoring heart rate data.
For the average person, it is safe and recommended to complete cardiovascular exercise at 80% of the symptom-limited heart rate achieved on the BCTT. Athletes can increase to 90% of symptom-limited HR on BCTT. In both athletes and non-athletes, it is recommended that symptoms stay below a 2/10 increase from baseline and resolve back to baseline within an hour. After one week, you can conduct a new BCTT, find a new symptom-limited maximum heart rate, and increase their exercise intensity accordingly until they are back to their full capacity and are symptom-free.
There are two main clinic-based heart rate monitors: chest-worn and wrist-worn.
For patients, we generally recommend wrist-worn devices for at-home use because they are integrated into smartwatches and other tech they likely already own.
This is something like an Apple watch or a Garmin running watch that uses LED lights to sense changes in the light absorption of the skin with changes in blood flow. While fairly accurate, they can be susceptible to movement artifacts, and they must be worn on the correct wrist location for accurate data. Wrist-worn heart rate monitors should be worn just proximal to the ulnar styloid process and should be tight enough that it does not move with quick wrist movements.
In the clinic, it is recommended that you use a chest-strap style heart rate monitor because it is more accurate and less likely to have movement artifacts or give false or absent heart rate data.
Chest-worn heart rate monitors actually measure the electrical activity of the heart via electrodes in the chest strap. This makes them more accurate as they are less sensitive to movement artifacts, and they are a direct measure of heart activity. However, to function properly, the electrodes need a moisture layer between the sensor and the skin to read accurately, so wetting the sensors before use is recommended. Correct placement of the chest-worn heart rate monitors is just below the sternum, with the electrodes on either side of the sternum, and tight enough that it does not slide down with movement.
A treadmill is another tool that is used in the assessment and treatment of every head injury patient. It is used during the assessment of the patient during the BCTT and in the patient’s rehabilitation as a way of giving them progressive symptom-limited cardiovascular exercise in a safe, yet challenging method.
To conduct the BCTT correctly, you need a treadmill capable of speeds of at least 12 mph or 19 kmph, and a treadmill that can increase the slope/incline to at least 15 degrees. Both the speed and the incline are used during the test to increase the cardiometabolic demand for the patient during the BCTT and to determine if there is a physiologic cause of some or all of their concussion symptoms. As mentioned above, the results of this test are used in both the diagnosis and rehabilitation of concussion patients, particularly if there is a history of sports injuries, such as in student-athletes.
The treadmill is also used to determine an athlete’s ability to safely return to non-contact sporting activities such as sport-specific exercises. After an athlete has sustained a concussion, there are several stages of return- to- sport protocol they must pass to be cleared to safely return to sporting activities. For a deep dive into the return-to-sport protocol, please see our other post here.
In short, there are 6 stages of return- to- sport: light physical activity at home, light aerobic exercise, sport-specific exercise with no contact, sport training drills with no contact, full contact practice, and following clearance by an appropriate healthcare provider, back to full sport participation.
To progress to sport-specific exercise with no contact (Stage 3), your patient must be able to reach at least 90% of their age-predicted maximum heart rate, or 80% of their age-predicted maximum heart rate with an RPE >17, during the Buffalo treadmill test with no exacerbation of concussion symptoms.
The Concussion Tracker app is an invaluable, and arguably the most important, sports concussion assessment tool on the list because it provides you, your patient, and your patient’s support system (healthcare practitioners, coaches, parents, teachers, etc.) with an integrated platform for comprehensive care of a concussed athlete. It is exclusive to patients and practitioners who are registered through Complete Concussions and is a game changer when it comes to the thorough management of concussions.
The single biggest priority for a patient or athlete who has sustained a brain injury is making sure that they do not sustain a second head injury during the healing process. As healthcare providers, we want to do everything in our power to prevent acute concussions from evolving into more serious and complicated conditions such as post-concussion syndrome or even second-impact syndrome. This is especially important in sports-related head injuries, as not recognizing when a concussion has occurred or not waiting until the concussion has fully resolved before returning to play are two major risk factors for more severe brain injuries and symptoms.
The Concussion Tracker App allows everyone involved with patient management to be fully informed about the progress and recovery stage of a person in real-time. Athletes, parents, coaches, and healthcare practitioners can all have separate accounts through the app that allows them access to information regarding baseline test scores, date of initial injury, recovery status, symptom burden, clearance letters from medical professionals, history of repeat concussions, and more. They can also give updates on how your patient is doing in various aspects of their recovery journey, such as teachers’ updates on return-to-school progress or athletic trainers’ updates on how they felt during their return to non-contact practice.
In addition, if a patient needs a referral to another healthcare practitioner, such as for psychological counseling, in-depth visual or vestibular rehabilitation, occupational therapy, etc- all referrals within the multidisciplinary team can be conducted through the concussion tracker app.
As mentioned above, all of these benefits are for the exclusive use of the Complete Concussions Clinical Network, so if you are passionate about the care of your concussion patients, become a clinic and join the Complete Concussions Clinical Care Network now!
For more information on the concussion tracker app, click here or find the app in the app store for Apple or Android.
Education is an indispensable part of the recovery process for every patient that comes into your clinic and is arguably the most important part of an evidence-based rehabilitation plan for both acute and chronic brain injuries.
In our clinics, we spend a significant portion of every visit at our whiteboard educating patients about various topics, including the pathophysiology of concussion, where we are in their management plan, goal setting, return to work and/or sport timelines, etc.
The reason why education is such an important feature of a good concussion management program is that there can be a lot of stress, anxiety, and worry that your patient is experiencing after sustaining a head injury. Accurate, easily digestible information can be difficult to find.
When will my symptoms resolve? Is physical rest helpful or harmful? Can I participate in my regular physical activities? What are the common symptoms of a concussion? Do I need to go to the emergency department? What are the red-flag symptoms of concussion? Is there a structural injury present?
These are all questions that your patient likely has. As healthcare professionals, it is important to remember that there is a person who also needs help and support beyond the physical symptoms they are experiencing.
Giving patients and their support system current, evidence-based information on concussion management, will ensure that outside of the clinic, your patients are active participants in their concussion recovery process and will increase the efficacy of the treatment plan you have provided.
In conclusion, there are many different tools, apps, and protocols that you can utilize in your practice to optimize the management of concussion patients. Heart rate monitors, treadmills, and the concussion tracker app will give you the most bang for your buck and allow you to effectively implement evidence-based concussion treatment protocols into your practice.
If you would like more information on current evidence-based guidelines, treatment protocols, or information for patients, please check out our other blog posts or consider taking one of the many courses that Complete Concussions offers, such as the newly updated 2024 course, Concussion Management for Physical Therapists (PT, DC, AT, OT, etc).
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