As part of concussion education, I often explain to patients that a good concussion program is like a table. You need all 4 legs to be in place for the program to work well. However, in reality not all aspects of treatments have equal importance or evidence. Rather than a table, a better analogy for concussion treatment is the hierarchy of a pyramid; with a good foundation being the most important part. To best facilitate recovery, in my opinion a good program’s components, and the order they are delivered, should be as follows:
In traditional physiotherapists we are used to treatments that focus on hands-on mobilizations, exercises, modalities and education. In concussion & Post-Concussion Syndrome (PCS) the priority needs to shift. Because we are treating a brain rather than say a joint or a muscle, education and managing the patient’s emotional state (as far as are allowed within our profession) are of primary importance.
It is now acknowledged that concussion symptoms (due to inflammation and its effect on the mitochondria) are in great part initially caused by an energy crisis within the brain. Getting the patient to understand their condition and manage their energy is therefore crucial to their recovery. Settling the brain that is in an elevated “fight or flight” state is also very important. Dr Leddy research around the Buffalo Concussion Treadmill Test (BCTT) & treatment protocol have some of the best evidence for efficacy. The other remedial therapies we as PTs use have growing evidence, but still require much more research.
Don’t shy away from this; you will help your patient with this aspect of treatment almost more than with anything else you do. Though time consuming, informing/guiding/reassuring, is “real treatment,” not just a nice add-on. So, spend the time you need right at the beginning to establish this crucially important foundation.