To the Editor:

I was very pleased to read the recent Special Interest article "Concussion: Current Concepts in Diagnosis and Management" (Borich et al1), which presents an excellent introduction to concussion for physical therapists. I found the discussion on diagnosis particularly interesting as this is a great dilemma faced by all caregivers who may run across, or specialize in, concussion management. The authors noted the lack of reliable, valid assessments of concussion, and did an excellent job of identifying current screens in use, as well as some of the trending scientific horizons that hope to improve the diagnosis of concussion. I thank the authors for their excellent discussion as well as their courage in introducing the enormous body of current concussion science to print. Thank you for taking that big step. It appears that diagnosis of concussion is a significant bottleneck in the progress of concussion science.

Beyond the scope of sports injuries, it is important that physical therapists stay abreast of developing knowledge related to concussion. The 4th International Consensus statement on concussion in sport, Zurich 2012, noted that "concussion can result from a direct blow to the head, face, neck or elsewhere on the body with an 'impulsive' force translated to the head."2 Because concussion can occur as a result of direct or indirect force that translates to the skull causing trauma to the brain that is within, I feel it is possible that physical therapists, in their "everyday" practice, may see people with undiagnosed concussion that co-occur with injuries that physical therapists routinely treat. Such patients may have concussion ruled out by now-obsolete criteria such as no loss of consciousness, normal findings on CT/MRI, and no specific blow to the head, but who knew? Some "neuroscreens" used by physical therapists in musculoskeletal evaluations are not sensitive to concussion but rather to reflexes, dermatomes/myotomes, and focal injury such as cranial nerve nucleus injury. Concussion, however, is currently conceptualized as a diffuse rather than focal injury, with physiologic/functional, rather than structural consequences, as noted in the JNPT article. Perhaps there is a knowledge gap that together we can bridge.

Borich et al1 note that educating our fellow physical therapists about concussion and its management is imperative, and I wholeheartedly agree. I suggest that with more concussion education physical therapists might play a significant role in concussion identification, management of concussion within physical therapist scope of practice, and referral of patients to additional, specialized concussion experts and programs. Further research to address if and how concussion presents in the physical therapy setting is indicated.

Susan W. Halloran, PT, DPT,

Nominating Chair, TBI SIG, Neurology Section

Craig Hospital: 1983-2003

University of Colorado Physical Therapy Program 2008-2011

Mother of concussed soccer playing daughter: 2007

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