Post-Concussion Syndrome Treatment: PT and OT to Keep Patients Sharp

There are plenty of conditions that seem, on the surface, to be completely unrelated to your work as a physical or occupational therapist (PT or OT). After all, concussions? That seems squarely within the purview of neurologists and emergency and primary care physicians. But, as it turns out, there’s a lot that rehab therapy can do for the treatment of neurological conditions, like post-concussion syndrome.

So, when it comes to treating patients with post-concussion syndrome, what do you and your staff need to know? Is there anything you can do to not just provide high-quality care for these patients when they are sent to you, but to become a destination for treating these kinds of cases? We’re going to cover everything you need to understand to prep your clinic fully for post-concussion syndrome treatment… and maybe even other neurological disorders as well.

What Is Post-Concussion Syndrome Treatment?

Post-concussion syndrome treatment isn’t necessarily a specific specialty or even type of physical or occupational therapy—like sports rehab or pediatric—but it does pull from general neurological treatment strategies. But neurological conditions can vary widely, just like injuries and surgical recovery can. The treatment you might apply for stroke recovery could help inform some specific exercises you’d use for post-concussion syndrome treatment, but the goals of the two will be very different.

To understand how you’ll approach treating a patient with post-concussion syndrome, you first need to understand the underlying causes of post-concussion syndrome and, in turn, the causes and symptoms of concussions themselves.

What Are Concussions?

Concussion is a brain injury caused by trauma, whether a hit or a significant jolt. This force can cause the brain to impact the skull, which can then cause the brain to swell or bruise, nerve strain, or torn blood vessels. Not all concussions cause a loss of consciousness, but, depending on the initial injury, it can be a warning sign of the initial concussion. The main sign that a concussion has occurred is abnormal neurological function.

That can be vague, so some common signs of abnormal neurological function include:

• Pain, especially constant or recurring
• Confusion
• Vision problems, like blurriness
• Nausea or vomiting
• Inability to maintain balance
• Memory loss
• Difficulty concentrating
• Light sensitivity
• Disruption of motor function

While some concussions can be successfully treated at home, any concussion that causes a loss of consciousness, slurred speech, increasing pain, or generally worsening symptoms should be seen by a physician.

How Concussions Heal

There’s a lot going on in the brain while it’s healing, but it’s all important to understand post-concussion syndrome. So, what’s happening inside the skull while the concussion is healing?

The Energy Crisis

All of the damage caused to the brain by the traumatic brain injury (TBI) can trigger an “energy crisis” as the brain tries to heal. This is because, just like other injuries, the brain requires more energy and more resources to heal from trauma. The crisis forms because the injury to the brain lowers the total energy available, so the brain lacks enough energy just when it needs it the most to successfully heal.

The only way for the energy crisis to subside is with time. After a period of time, depending on the severity of the injury, cardiovascular exercise that does not put strain on the injury—which may depend on the individual’s tolerance and discomfort—has been shown to help increase the speed of recovery but should be assessed on a case-by-case basis. Within a few days, taking a short walk with the dog or similar activities should be manageable, but this should be discussed directly with a physician.

Cell Turnover

At the cellular level, when most injuries heal, white blood cells arrive and eat the dying cells, foreign material, and microorganisms that are causing the damage to the body. This is true of the brain during the healing process following a concussion as well. However, researchers discovered a problem here.

When conducting a study to understand why drugs that had been developed to treat TBIs were not very effective, a team of researchers found that this recycling effect was dampened in the brain. That means cell turnover is less effective and the immune and neuron responses are suppressed, leading to a slower recovery. The team didn’t find a drug to speed up the process (yet), but they did conclude that this cell recycling is critical to the healing of brain injuries like concussions.

Return to Activity

Proper healing requires adequate blood flow, which is one of the main drivers of the newer push for patients to return to activities sooner than traditional methods recommend. Historically, recommendations have been to rest as much as possible, avoid lights and screens, and reduce or eliminate mentally intensive tasks.

New research, however, indicates that, as seen with the energy crisis, a return to light activity can not only help with recovery immediately, but also reduce the risk of long-term concussion symptoms. Longer-term symptoms can be a risk factor in sustaining another concussion before the first has been able to fully heal, leaving the patient at risk for permanent and serious complications.

Who Treats Concussions?

Concussions, especially severe concussions or those in patients who are athletes, can have an interdisciplinary team working together to help the patient return to normal function. While these practitioners might never officially collaborate on the patient’s treatment, it’s important to remember what role they play in the healing process overall.

A patient with a concussion may see any grouping of:

• Emergency medicine physician
• Primary care or general practitioner
• Neurologist
• Psychiatrist
• Physical therapist
• Occupational therapist

Depending on the severity of the injury, a patient might start their treatment at the hospital emergency department, an urgent care facility, or with their primary care physician. For severe concussions or for some professionals, a neurologist might be the next step. They can help with additional complications or more complex treatment methods. If the patient is experiencing psychiatric symptoms, which may happen if the damage to the brain impacts certain areas, a psychiatrist may see a concussion patient. And physical and occupational therapists may be involved in recovery—like the reintroduction of activity—especially for patients who are athletes or have to pass physicals for their job.

Post-Concussion Syndrome Treatment Options

So, now that we’ve discussed what concussions and their treatments are like, it’s time to dig into post-concussion syndrome.

What Is Post-Concussion Syndrome?

Post-concussion syndrome (PCS) is a condition in which concussion symptoms last much longer than the normal healing timeframe of a few weeks. Because concussions may prompt a variety of symptoms, enduring symptoms can massively disrupt everyday life.

About 15% of concussions may result in PCS, but not only might that be an underestimate due to patients not seeking care for persistent symptoms, there may also be an innate component resulting in a predisposition to concussions. Some research is looking into a blood test that may be able to diagnose this predisposition before concussions occur.

Because a history of concussion or head injuries, complications from concussions, other brain-related conditions, behavioral conditions, a wide range of concussion symptoms, or severe concussion symptoms can all be risk factors for PCS, understanding whether your patient has a predisposition to concussion can be helpful in knowing how to approach their PCS. Until a blood test is available, it’s best to treat PCS as a risk factor for further trauma to the brain.

How Can PTs and OTs Treat Post-Concussion Syndrome?

There is a wide range of activities that PTs and OTs can perform to help treat patients with concussion and PCS.

• Slow return to cardiovascular activity: We’ve discussed the importance of a return to cardiovascular exercise for healing from concussion, and the same is true for post-concussion syndrome
• Balance and gait training: Because PCS can affect vision and thus balance, OTs can be a crucial part of relearning how to perform daily activities while balance is impaired
• Vertigo treatment: Although less common, vertigo is a possible symptom of PCS, and PTs and OTs often have specific exercises designed to improve and successfully treat vertigo in patients
• Cooperation with other specialists: For patients with PCS, multiple practitioners may be involved in their treatment, so working well with other specialties is key for rehab therapists

Common PCS CPT Codes for Rehab Therapists

Current Procedural Terminology (CPT) codes are how you let insurance providers know what treatment you’re providing patients—and we know it can be a pain. But understanding CPT codes, how they work, and how best to code is critical for a smooth practice for both you and your patients.

Here are a few CPT codes that you might need to know for the proper treatment of PCS and concussion symptoms.

• 97110: A timed code covering therapeutic exercise in 15-minute intervals, which can cover cardiovascular exercise used to treat concussions
• 97116: Covers gait training, an approach that can be used to treat balance- and stability-related symptoms
• 97112: This code is used for neuromuscular re-education, which can be used for some vestibular and vertigo treatment

How Can Clinics Be Ready for PCS Patients?

The good news is, most of the treatments that would be helpful for concussion treatment and PCS are already services you perform in one way or another for the treatment of other conditions. You likely already have the equipment you’d need to perform successful PCS treatment. All you need to do is make sure your staff understands the specific approach to PCS treatment and how it differs from other uses of the same techniques.

Make sure your staff is up to date on:

• Progressive increases in cardiovascular exercise for concussions
• Vestibular rehab therapy
• Balance and stability exercises
• Working in conjunction with other clinicians for a patient’s treatment
• Rehab therapy for sports

PTs, OTs, and Post-Concussion Syndrome Treatment

Concussions are very common, especially for athletes and people with physical jobs, and many don’t seek treatment for their injury. Concussions have long been thought of as a mild condition, though medical understanding of how concussions truly affect the brain and body is continuing to expand. The most up-to-date research shows that not only are concussion symptoms that last for a few months or more, known as post-concussion syndrome, relatively common, the traditional wisdom of complete rest until symptoms subside may be delaying recovery from concussion and PCS.

With the wider adoption of treatment options that include incorporating physical activity much earlier and an increased push to continue treatment when symptoms continue past a few weeks, PTs and OTs are likely to see more PCS patients on their docket. It’s important to understand how to develop a plan to best treat PCS and help patients return to their normal quality of life—whether that’s on the job, on the field, or simply back on their feet at home.