T-Concussions and Other Mixed Martial Arts Injuries

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES
Case Report
Presented to
The Faculty of the College of Health Professions and Social Work
Florida Gulf Coast University
In Partial Fulfillment
Of the Requirement for the Degree of
Doctorate of Physical Therapy
By
Jason L. Burns
2015
APPROVAL SHEET
This case report is submitted in partial fulfillment
of the requirements for the degree of
Doctorate of Physical Therapy
______________________________________
Jason L. Burns
Approved: May 2015
______________________________________
Dr. Stephen Black, DSc, PT, ATC, CSCS
Committee Chair
______________________________________
Dr. Russell Hogg, PhD.
Committee Member
The final copy of this case report has been examined by the signatories, and we find that both
the content and the form meet acceptable presentation standards of scholarly work in the
above mentioned discipline.

Acknowledgements
I would like to express sincere gratitude to the following individuals who assisted
in the completion of this independent study: Dr. Steven Black who served as my
committee chair and provided guidance and support along the way; Dr. Russell Hogg
who was my committee member, a mentor, and a consummate professional. This study
would not have been completed without their wisdom, direction, and insight. I would
also like to thank my fellow classmates and most of all my family for their endless
support
CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES 2
Table of Contents
Abstract ..................................................................................................................................... 4
Introduction ........................................................................................................................... 6
Injuries .................................................................................................................................. 7
Wrestling ............................................................................................................................... 9
Traditional Martial Arts ...................................................................................................... 10
Informal Search of MMA Injuries ...................................................................................... 12
The Case Study ....................................................................................................................... 14
Introduction ......................................................................................................................... 14
Literature Review: Identification ........................................................................................ 20
Literature Review: Management......................................................................................... 25
Literature Review: Physical Activity Tolerance ................................................................. 27
Literature Review: Return to play....................................................................................... 29
Literature Review: Dual Task Activities ............................................................................ 30
Literature Review: Long-term Consequences .................................................................... 31
Future Research .................................................................................................................. 31
Case Description: ................................................................................................................ 32
The Examination: ............................................................................................................ 34
The Assessment: ............................................................................................................. 35
The Plan of Care ............................................................................................................. 36
Outcomes: ....................................................................................................................... 42
Future Recommendations: Team Approach to Management ............................................. 44

References ............................................................................................................................... 45
Appendix: Tables .................................................................................................................... 49

List of Tables
Table 1 .....................................................................................................................................46
Table 2 .................................................................................................................................... 48
Table 3 .................................................................................................................................... 49
Table 4 .................................................................................................................................... 50
Table 5 .................................................................................................................................... 51
Table 6 .................................................................................................................................... 52
Abstract
Mixed Martial Arts is in its relative infancy as an official sport, however, the
various components of the MMA athletic competition have been in use throughout
human history. Mixed Marital Arts is a conglomerate of virtually every form of unarmed
combat sport utilizing: punches, kicks, knees, elbows, throws, takedowns, spinning,
jumping, and other movements. The competitors will utilize a combination of strength,
power, speed, and endurance throughout their matches. The early results of recorded
injuries during these sporting events indicate that any physical therapist interested in
working with mixed martial arts athletes or clients who prefer to exercise in a similar
fashion will need to be well versed in several different areas such as; concussions, neck
and back injuries, as well as upper and lower limb disorders. Therefore they will best
serve their patients through an evidence-based “best practices” approach to treating these
injuries
Introduction
On November 12, 1993 eight-men entered an arena in Denver, Colorado to
participate in an event that would change the world of sports dramatically over the next
two decades. This was the first Ultimate Fighting Championship. While hand-to hand
combat has been around essentially since man’s beginnings here on earth, it first became
a sport in 648 B.C. during the Greek Olympiad games. Fighters of that time participated
in the Pankratian combat style which was essentially a mixture of boxing and wrestling.
Over the centuries styles have branched out and evolved according to regional traditions
and teachings. However, with the introduction of Mixed Martial Arts, those fighting
styles have once again been brought back together and blended into a conglomeration of
techniques which build a more rounded athlete. In a mixed martial arts competition, the
contestants obtain victory by: concussing the opposing fighter until he or she is
defenselessness through blunt head trauma; or disabling an opponent through joint
subluxation, dislocation, or soft tissue trauma. The opponent at that point may choose to
either forfeit the fight by “tapping out” or suffer injury (Buse, 2006).
Over the years, numerous studies have shed light on the varying types of injuries
common to each specific style of martial arts. These injuries are the result of a
combination of techniques coming from styles such as; boxing, wrestling, Judo, Karate,
and Jiu-jitsu. With Mixed Martial Arts (MMA) being so new to the scene, the science
specifically targeting the discovery of MMA injuries is in the early stages. There are
approximately 18 million people in the United States who practice some form of martial
arts. While this is merely an estimate that is currently unverifiable, it does provide an
idea of how wide spread the field of combat sports is.

Additionally, professional mixed martial arts have become an industry that
generates hundreds of millions of dollars of revenue each year. Owners, fighters,
trainers, and even fans have a vested interest in the health of the athletes. With this in
mind, it seems prudent to research the training for and injuries resulting from such a
physical sport, and to determine where physical therapists will find their place in this
emerging market. With a deeper grasp of the types of incidents of injuries and a full
understanding of the training regimen of these athletes, physical therapists will be better
equipped to implement preventative measures and best-practice therapy techniques for
those athletes and solidify the importance of their practice in this field of sports
rehabilitation.
Injuries
With Mixed Martial arts being a relatively new sport, there is a shortage of
recorded data regarding the prevalence of injuries occurring during mixed martial arts
bouts. More research needs to be conducted on the types of injuries and the long term
repercussions that arise from them. In the few studies that did catalogue these injuries,
the statistics showed a variety of injuries common to combat sports. For example, in one
study done in 2010, 232 rounds of fighting were observed; during this time 55 injuries
were recorded. They consisted of: 28 abrasions and lacerations, 11 concussions, 5 facial
injuries, and 11 orthopedic injuries (3 metacarpal injuries, with 1 confirmed fracture; 1
acromioclavicular separation; 1 traumatic olecranon bursitis; 1 elbow subluxation; 1
midfoot sprain; 1 aggravation of elbow medial collateral ligament sprain; 1 elbow lateral
collateral ligament strain; 1 trapezius strain; and 1 Achilles tendon contusion (Shadgan,
Feldman & Jafari 2010). Elsewhere in Buse’s research on mixed martial arts, 642
matches were studied; of those: 182 resulted in head-impact trauma, 106 showed
musculoskeletal stresses to the participants resulting in a stoppage, and 91 fights were
won by neck chokes. The degree to which orthopedic trauma was sustained was not
determined in this study; however, joint-locks were noted as the primary cause for match
stoppage when musculoskeletal stress was cited (Buse, 2006). For fighters of this genre,
the risk of successive joint degeneration could be related to factors such as: intensity of
the joint loading during the submission move, articular incongruence after healing, lack
of or improper therapy post-injury leading to joint instability, and various other factors
such as the fighter’s age, co-morbidities, lifestyle, etc. This is a prime reason for physical
therapists to step in and introduce themselves into this up and coming sports platform.
While the classification of injuries in MMA may be in its infancy, physical
therapists may be able to have a solid understanding of the types of injuries they will
likely treat by systematically breaking apart the components of the combat into
researchable categories. Concurrently, the development of probable prevention strategies
and exercises requires classification of injured patients as well as evaluations of the
patterns of injuries sustained (McPhearson & Pickett, 2010).
The mixed martial arts contest can be fragmented into several different modules;
wrestling or “grappling” (which includes submissions), boxing and kickboxing, and
traditional martial arts Each style has its own tactical strategies and therefore each lend
more to the use of specific biomechanical movements which would, in turn, lead to
varying injuries of the different styles.
Wrestling
Wrestling is the form of competition involving techniques such as clinch fighting,

throws and takedowns, and joint locks. There are several well-documented injuries that
are frequent to grappling and wrestling including; lacerations, strains, sprains, fractures,
and dislocations. Head and neck injuries are also a major source of damage when
involved in this segment of the fight-game and are commonly a result of an impact with
the ground. Injuries seen from these movements could be; open wounds, pulled neck
muscles, concussions, etc. (McPhearson & Pickett, 2010).
To have some understanding about how these head and neck injuries occur,
therapists can observe the more common maneuvers seen in a mixed martial arts contest.
First, the hip throw, is a skill where one fighter positions the hip under the abdomen of
the other and raises the opponent’s body off of the ground. The individual then rotates
both bodies in the transverse plane while driving the opposition to the ground. One
article identifies the first point of impact to be located at T2/T3 in the thoracic region of
the spine (Kochhar, Back, Mann & Skinner, 2005). Another throw, the Suplex, is
performed by having the fighter grab the opponent around the waist in order to lift him up
over his shoulder. As their combined center of gravity moves, the fighter falls backwards
on to the back, preserving the hold on the opponent, who falls forward, on to the face
(Kochhar et al., 2005). This puts hyper-extensive strain on the neck/cervical region of
the spine. Lastly, the Souplesse, is initiated when one fighter lifts his challenger from the
waist, and swings him over his shoulder. At the last moment, the opponent is rotated over
his upper chest and slammed down on to his back. The initial point of impact is, again,
the T2/T3 region (Kochhar et al., 2005). Moves such as these often lead to debilitating
injuries of the spine. While these methods are commonplace within the ring, there is not
much statistical data ranking the resultant injuries amongst others. In terms of statistical
rankings of injuries, there are some differing opinions as to which are the most frequently
occurring in the sport of wrestling. In one study done by Shadgan et. al., the authors
show that, recorded injuries resulted in; 19 skin lacerations (59.4%), 4 nose bleeds
(12.5%), 8 sprains (25%), and 1 muscle strain (3.1%). The most common sites of injuries
were the face and head (68.7%), followed by the upper limb (18.7%) and the lower limb
(12.5%). They go on to say that their research shows similar results to some studies, but
that the results differ from the findings of the International Olympic Committee Medical
Commission and others who produced data aligned with the IOCMC (Shadgan et al.,
2010).
Traditional Martial Arts
The term “Traditional Martial Arts can be considered a combination of several
genres of combat including; Karate, Taekwondo, Akido, Kenpo, Kung Fu, and many
others. Within this category we find that lower limb injuries were the most frequently
occurring; and of the lower limb injuries McPherson and Pickett noted in their research
that athletes were most likely to incur fracture injuries. The authors cite in their article
that more injuries occurred in Karate than in the other forms of marital arts; in fact of the
189 fractures reported, approximately half occurred in Karate. (McPhearson & Pickett,
2010) They noted that falls, throws and jumps are the predominant cause of injury in
most styles as opposed to karate kickboxing and taekwondo, in which kicks and foot
strikes are the sources of the greatest morbidity, but where twisted ankles and lower limb
fractures are still common (McPhearson & Pickett, 2010).
Kickboxing
Kickboxing also plays a crucial role in the world of MMA fighters and accounts
for its fair share of injuries as well. Results of injury evaluations of this form of combat
revealed a summation of 382 injuries from 3481 fighters, which yielded an injury rate of
109.7 for every 1000 fight participants; the most common region of the body was the
head/neck/face which accounted for 52.6% (Zazryn, Finch, & McCrory. (2003).
This can be explained by the fact that the head, neck, and face are the primary
targets of striking. Lower extremity injuries were the second most common (39.8% of all
injuries), which can be attributed to the focus of this discipline on the use of the legs as
weapons and the lower limbs as a scoring zone in some competitions. Despite the
prominence of punches that take place during a kickboxing match, fewer than 3% of
injuries in the ring involved the upper extremities. Concurrently, there were a low
number of injuries to the trunk area as well, only 2.1% were recorded (Zazryn et al.,
2003).
Informal Search of MMA Injuries
While records are almost certainly being documented and scrutinized by the
owners of major mixed martial arts organizations in order to protect their investments,
these incidents often go unpublished. With no official source to pull from, it was
necessary to conduct an informal search of professional mixed martial arts injuries in an
attempt to categorize the variety of dysfunctions resulting from this sport.
Interestingly, of the 101 injuries documented in professional Mixed Marital Arts
in 2013, 66 of them were reported as “undisclosed injuries”. This means that 65% of the
injuries that took place over the course of the year were not identified. The reason for
this lack of reporting stems from the injured fighter not wanting a future opponent to be
aware of a potential weakness. Fighters are very protective of their medical privacy in
situations like these. Any information an opponent has is likely to be used for their
benefit in the upcoming fight. For example, if “Fighter A” knows that “Fighter B” has
recently recovered from an MCL injury of the knee, he is likely to target that knee with
kicks.
This can have negative effects both physically and psychologically for the
previously injured individual. He or she may not fully trust in the recovery of their
injury. If their opponent is specifically targeting that area, the fighter may end up
changing his or her strategy in order to protect the effected body part. This could lead to
them leaving openings in their defense that would not otherwise be available. Physical
disadvantages may become prominent as well. Often athletes are faced with tough
decisions to make about when to return to sport. Financial demands, opportunity for
advancement, pride, and many other factors could lead a fighter to return to the ring
before they are fully recovered.
In recent years, medical professionals have put more emphasis on cataloging
MMA injuries, and learning what are the best evidenced-based approaches to treating
these injuries. However, these motives have created a culture of secrecy when it comes
to injuries, making it difficult to track exactly how many mixed martial arts athletes are
injured each year, and what types of injuries they experience. Below is a table (See Table
2) charting the 35 injuries that were reported in the year 2013, and the percentages of
each category of injury. This summary is a snap-shot compiled to assist any medical
professional interested in working with this subpopulation in understanding the types of
injuries they are likely to encounter in their patients.
The literature review of injuries occurring during combat sports leads to a

realization that any physical therapist interested in working with mixed martial arts
athletes or clients who prefer to exercise in a similar fashion will need to be well versed
in several different areas such as; concussions, neck and back injuries, as well as lower
limb disorders. Authors indicate that more than half of the injuries reported during
tournaments affect the lower extremity (Shadgan et al., 2010). The physical therapist
providing care for these fighters will need to be able to distinguish between strains,
sprains, fractures, etc. in the knee and ankle, and determines the most fitting course of
rehabilitation when treating the injury. With the increasing influence of jiu-jitsu and
other grappling techniques in the sport of mixed martial arts, upper extremity submission
locks are responsible for more musculoskeletal injuries such as shoulder subluxations and
dislocations. The physical therapist choosing to go into this field will no doubt treat
numerous rotator cuff injuries, and so he or she will need to have an evidence-based “best
practices” approach to treating the shoulder as well as numerous other musculoskeletal
disorders.
The Case Study
When investigating the various injuries associated with the sport of mixed martial
arts, there is no doubt that as stated above researchers will discover an array of
dysfunctions. While lower extremity injuries seem to be at the top of the list as far as
sheer numbers of incidents go, in terms of greatest potential for fatalities concussions are
the foremost concerning to fighters and medical personnel.
Concussions, which are referred to as commotio cerebri in European and most
other countries, make up 6 – 10% of all sports-related injuries, and can be considered a
brain injury which is a complex pathophysiological process brought on by biomechanical

forces (McCrory et. al., 2012). They are defined as, “A traumatically induced alteration
in mental status” (American Academy of Neurology 1997). Concussions generally
present with rapid onset of short-lived interruptions in neurologic function that resolve
spontaneously. In some instances, symptoms could develop over a number of minutes to
hours. These incidents may or may not involve a loss of consciousness which is
particularly concerning to fighters because most Knock Out stoppages occur when the
fighter becomes unconscious due to blows to the head, however, as stated fighters may
experience head injuries without realizing it and continue to participate in their matches.
In fact, loss of consciousness was recorded in less than 10% of athletes diagnosed with
concussions (Broglio et. al., 2014). It is important for athletes, coaches, parents, and
medical professionals alike to realize that it is not always the big hits that lead to trauma;
concussions have been recorded even on “light contact” days!
Rationale
It is no secret that discussions regarding concussions have now come to the
forefront of full-contact sports. The National Football League’s Player’s Union recently
settled a class action lawsuit on behalf of retired players for $765 million (Curry, 2013).
High school and collegiate coaches are under more scrutiny than ever to make sure they
do not send players who’ve received a head injury back into the game. However, the
problem is that not everyone has been fully educated on what to look for in suspected
concussion cases. Players themselves have reported that 61% of high school athletes
could not correctly identify concussion symptoms and 25% believed that loss of
consciousness was required in order for a concussion to take place (Broglio et al., 2014).
Additionally, 70% of collegiate athletes and 50% of high school athletes did not report
the concussions they suffered that took place during football games. These statistics are
important for pointing out shortfalls in the reporting of concussions.
It is imperative that occurrences of concussion symptoms be conveyed
immediately by athletes, coaches, physicians, and family members to avoid
underdiagnoses and the potential for more serious damage. Statistics show 75% of repeat
concussions happen within seven days of the first concussion, and 92% of repeat
concussions happen within 10 days of the first concussion (Guskiewicz, 2007).
Additionally, players with 1 previous concussion are 1.5 times more likely to receive
another, and those players suffering 2 previous concussions are 2.8 times more likely to
incur a third (Guskiewicz, 2007). Furthermore, it is not just enough to have a report of
symptoms, rather a trained medical professional is paramount in the diagnosis of
suspected concussions as 33% of players with concussions who were permitted to return
to play on the same day were allowed to continue because of a delay in the onset of their
symptoms as long as three hours post-incident. Cases have also been recorded where
individuals who initially appeared symptom free for the first 15 minutes post-injury, still
faced memory deficits as long as 36 hours later (Guskiewicz, 2007).
The latter situations are examples of the types of dangerous situations that could
potentially lead to the development of Second Concussion Syndrome (SCS). This occurs
when the athlete receives a second concussion before the symptoms of the first
concussion have resolved, and can have major implications in terms of injury severity.
The damage incurred from Second Concussion Syndrome likely stems from the body’s
inability to auto-regulate blood flow within the brain. When this happens, venous flow
gets backed up allowing blood to pool in the brain and can lead to a hemorrhage. With
recent attention shedding light on the seriousness of these brain injuries, cases of SCS are
now being studied and have shown; 100% morbidity (meaning long-term permanent
damage), and worse 50% mortality rates (Guskiewicz, 2007).
Literature Review: Etiology
Concussions are categorized as mild Traumatic Brain Injuries (TBIs) which are
brought on by biomechanical insults to the brain. Sheering forces to the vascular supply
can cause damage to the vessels, and Cerebrospinal fluid (CSF) volume increases may be
the result of blockage of outflow pathways or interference with reabsorption (Goodman,
2009). The implications of the vascular changes that take place include a decreased
ability of the cerebral vessels to maintain a level of homeostatic blood pressure and blood
gas composition. Within the first few hours the injury, a decreased level of cerebral
blood flow can cause ischemia. Normally neurotransmitters in the brain such as
acetylcholine will cause a dilation of the vessels when they release and endothelium-
derived releasing factor. This will allow relaxation of the smooth muscle in the vessel
wall. In contrast, this reaction is interrupted in the concussed brain, resulting in abnormal
vasoconstriction (Goodman, Boissonnault, & Fuller 2009).
The rise in neurotransmitters, and an increase in potassium, leads to unregulated
depolarization in the injured brain along with disturbances in postsynaptic functions
resulting from imbalances in the interactions between neurotransmitters and amino acids
(Goodman et al., 2009). Glutamate, a neurotransmitter with excitatory properties, rises to
abnormal amounts during TBI’s, and when levels are increased the glutamate becomes
neurotoxic (Goodman et al., 2009). The depolarization brought on by the injury creates
nonselective openings of the voltage-sensitive calcium channels and an abnormal

accumulation of calcium within neurons and glia.
The neurometabolic chain of changes within the brain including the release of
excitatory neurotransmitters results in changes to cellular membranes and ionic
imbalances as well (Mjersek et. al., 2008). Changes at the level of the endothelium result
in a disturbed blood-brain barrier in the injured brain. There is an initial increase in
glucose metabolism and then a period of decreased abilities of the cells to “uptake” the
glucose for use as energy. This reduced uptake stage may last anywhere from one to nine
months (Majersek et. al., 2008). Additionally, researchers have noted an increase in the
quantities of adenosine triphosphate (ATP) within the brain. It is thought that the ATP
increases are the body’s attempt to counteract the ionic imbalances caused by free radical
formation. The increased glucose metabolism, and initial decrease in cerebral blood
flow due to acute swelling, results in an incongruity between the energy required by the
cells of the brain and the amount of energy available (Majersek et. al., 2008).
Concussions occur in one of three ways. A Rotational Concussion stems from
pivoting around the axis of the neck left to right or right to left such as those incurred
from a roundhouse kick to the head. Compression Concussions are those that take place
in a top to bottom fashion as might be experienced if a fighter landed on their head from
an opponent’s throw. Finally, Tensile Concussions, the most common form, are those
caused by a sudden movement from back to front or front to back, and can be caused by
straight punches, kicks, elbows, etc. to the head (Guskiewicz, 2010).
Symptoms of concussions are considered to be functional and not necessarily
structural (McCrory 2012). They can be classified into three categories; somatic,
neurobehavioral, and cognitive. The somatic concussion symptoms will present in ways
such as; headaches, nausea, vomiting, paresthesia, disturbances in balance, sensitivity to
sound and/or light. The neurobehavioral symptoms often include; fatigue, drowsiness,
increased sleep, nervousness and trouble sleeping. The cognitive symptoms of
concussions are; feeling slowed down or “foggy”, difficulty concentrating, and lapses in
memory. Medical personnel attending MMA practices and matches should be alert for
these symptoms, but research shows that symptoms may not always be observable. In
fact, as many as 38% of athletes who experienced a concussion reported no symptoms
however, they may still have neurological deficits (Guskiewicz, 2010).
Often times athletes individuals suffering from concussions will experience
dizziness. This symptom can be the result of many pathological conditions (e.g., benign
paroxysmal positional vertigo, labyrinthine concussion, and/or perilymphatic fistula),
central nervous system disorders such as post-traumatic migraine, brainstem concussion,
autonomic dysregulation/postural hypotension, and oculomotor dysfunctions as well as
other causes including psychological and/or musculoskeletal disorders (Stewart,
McQueen-Borden, Bell, Barr, & Juengling 2012). It is important to correctly identify the
underlying source so that appropriate interventions may be prescribed.
Headaches are listed as the most common post-concussive symptom of sport-
related concussions. There are numerous reasons that people experience headaches
including; cervical spine injury, sensitivity to light and loud noises, impaired sleep,
increased intracranial pressure, and others. If headaches are severe enough, they may
have an impact on other normal body functions including energy levels, motivation,
sleep, focus and attention, control of emotions, higher level cognition, exercise tolerance,
and appetite (Stewart et. al., 2012). Physical therapists should take care to complete a
comprehensive assessment of the neuromusculoskeletal system to determine if these
dysfunctions are the reason for the athlete’s headache. If so, interventions can be
properly administered to the individual. While sleep and rest are traditionally
recommended it has been discovered that too much inactivity can be counterproductive.
Stewart et. al., 2012)., found that three to six days of bed rest can result in an athlete’s
complaint of headache, restlessness, and difficulty sleeping, which may complicate the
treatment of the patient with persistent post-concussion symptoms. (See Table 3 for list of
post-concussion symptoms):
There are numerous aspects to consider in the prognosis of concussion recovery
potential for athletes. See Table 4 for implicating factors that may have a bearing on; the
risks of injury, symptom severity, and length of recovery.
Literature Review: Identification
When time is of the essence to an athlete and their coaching staff, a rapid
assessment tool that is reliable and valid should be used. The Standardized Assessment
of Concussions (SAC), the Sports Concussion Assessment Tool (SCAT3), or even the
King-Devic test have all been researched and found to be effective. These tests should
not be done alone however; concussion evaluations need to incorporate many facets of
examination which will be discussed hereafter. Furthermore, it is important to point out
that the traditional line of identification questioning such as orientation to; time, place,
and person have been shown to be unreliable when compared with the current use of
more thorough assessments (McCrory et. al., 2012). For this reason, there is a vital need
for trained medical personnel to administer on-site assessments and become involved in
follow up care. The attending medical staff will be able to more accurately diagnose the
concussion and progression or resolution through the use of; a comprehensive history a
detailed neurological exam that focuses on evaluation of the patient’s mental status,
cranial nerve testing, cognitive functioning, gait, and balance tests as well as the
determination of the clinical status of the patient. This clinical status will include
observations as whether or not there has been progress or deterioration in the individual’s
condition since the time of injury. Often this will involve seeking additional information
from parents and/or coaches (McCrory et. al., 2012).
Medical professionals responsible for monitoring the safety of athletes
participating in mixed martial arts competitions or training will need to be extremely well
acquainted with the red flag signs that may indicate a detrimental decline in a fighter’s
condition. The signs include; extensive loss of consciousness greater than one minute or
a decreasing level of consciousness, amnesia, deterioration over time instead of progress,
increasing confusion or irritability, numbness in the arms or legs, pupils that are uneven
in size, repeated vomiting, seizures, slurred speech or inability to articulate, inability to
recognize people or places, and a headache that becomes progressively worse over time
(Harmon, Drezner & Gammons 2013). These are signs that are grounds for an immediate
trip to the Emergency Room for further testing and observation (see Table 5).
In addition to the Red Flag signs indicated here, the on-site medical professional
should be trained to observe and/or administer several other evaluations to ensure the
safety of the participants. These include items like; nystagmus which could indicate a
cerebellar problem, changes in breathing: which may be the result of autonomic
instability, check pulse and blood pressure, palpate the head and neck to feel for painful
or tender areas, swelling, or crepitus, administer range of motion tests of the neck (only
on athletes who are able to stand up and move around), and grip, strength (Guskiewicz,
2010). To determine if the intracranial pressure is building athletes should be given
special tests for cognition, coordination, and cranial nerves. The Cognitive tests may
include drawing a clock with numbers, a 3 word recall, verbalizing the days of the week
in reverse order. For coordination testing, the athlete may be asked to perform tests like;
fingers-to-nose touches, heel-to-shin rubs, heel/toe balancing, or alternating
pronation/supination hand flips. Furthermore, cranial nerves tests including: eye
tracking, blinking, hearing, sticking out the tongue, smiling/frowning, etc. should be
performed during the evaluation as well.
With the recent incorporation of computerized diagnostic testing in the field of
concussions, identification of cognitive and reaction time testing is becoming fairly
standardized. However, these types of diagnostic tools fail to utilize a balance
component. Recent research shows the increased accuracy of concussion diagnosis when
integrating a balance and gait test such as the Berg, DGI, BESS, etc. The inclusion of
these tests has been shown to add up to 37% more sensitivity to the detection of these
problems even when athletes are reporting they experience no symptoms (Guskiewicz,
2010). Additional research into the co-occurrence of concussions with balance deficits
has revealed that; individuals with headaches and/or migraines report more balance
problems and that athletes who have experienced two or more concussions are more
likely to have balance problems (Guskiewicz, 2010). This may be helpful in ascertaining
the repeat concussions in competitors have not been forthcoming with their prior history,
which could lead to the prevention of long term consequences. Finally, balance tends to
be more effected in instances where amnesia is present; however, this is not exclusive to
in amnesia patients.
The deficits listed above could be due in part to the impaired postural control
commonly seen in athletes experiencing with post-concussion symptoms. Postural
stability testing therefore should be used when objectively assessing the motor domain of
neurologic functioning. A likely source of postural dysfunction is an interruption in the
body’s capacity to process vestibular information (Stewart et. al., 2012). The human
body utilizes the vestibular system, proprioception, mobility and strength in the joints and
muscles respectively to control postural stability and balance. Any disruption in; afferent
or efferent coordination of these components would potentially have adverse effects on
an athlete’s posture which could then lead to a change in the center of gravity disrupting
their stability.
The resultant cognitive symptoms associated with a concussive blow to the head
typically include; difficulty concentrating, lack of extended focus, memory problems,
decrease in executive functions such as organization, planning and problem solving as
well as slowed mental processing. The application of neuropsychological (NP) testing
has shown clinical value by adding significant information to the results of the
concussion evaluation (Stewart et. al., 2012). Athletes presenting with these symptoms
are more likely to fall into the category of a positive identification of a concussion. Most
acute concussion measurement evaluations will contain a cognitive portion in their exam.
For example, the SCAT3 contains a section for an immediate word recall, a delayed word
recall, and a concentration task where the athlete will list a set of numbers in reverse
order. Medical professionals charged with the determination of the presence of
concussions should include a structured interview with the athlete to uncover any
cognitive deficits they may be experiencing in the days following the incident. The
athlete may report findings such as; difficulty with completing regular daily activities,
difficulty driving, forgetfulness, trouble recalling conversations, decreased tolerance to
distractions, slowness or “fogginess”, and errors in academics or the workplace as well as
mental fatigue (Stewart et. al., 2012).
Along with cognitive symptoms, psychological conditions and behavioral changes
may be noted in post-concussion patients. Medical staff should address this with the
athlete to make them aware that they may experience abnormal feelings such as
depression and anxiety. These symptoms are common in almost all types of traumatic
brain injuries, and armed with this information, the athlete may feel more comfortable
discussing such a sensitive topic (McCrory et. al., 2012).
The use of imaging as a whole for the identification of persons with concussions
is generally not recommended. Computerized Tomography (CT) and magnetic resonance
imaging [MRI]) adds very little to concussion evaluations. However, it may be helpful to
incorporate these techniques if suspicion of an intracerebral hemorrhage or structural
lesion such as a fracture exists (McCrory 2012). In these situations, indicators such as;
prolonged unconsciousness, focal neurological deficits, or symptoms which are
worsening rather than regressing are likely to be experienced by the athlete.
In summation of the diagnostic process, it is important to note a few items in
regards to working specifically with athletes that have not yet been mentioned. First, it is
critical to ensure the competitors are well hydrated at the time of evaluation, as moderate
to severe dehydration may present with similar symptoms which could negatively
influence the outcome of the clinical measures (Berkoff, Cairns, Sanchez & Moorman.
2007). Next, the significance of baseline testing cannot be overstated. The intent of
baseline testing is to give the medical professional data for an accurate comparison to the
athlete’s pre-injury functional levels. For example, if an individual had deficiencies in an
area such as poor tandem balance or a learning disability that were not previously
recorded; they may inadvertently be scored as a false positive in those specific categories
of the concussion diagnostic evaluation. Finally, having a timeline of when to conduct
follow-up evaluations is fundamentally important. At the APTA’s annual meeting on
traumatic brain injury, Dr. Kevin Guiskewitz proposes that athletes should be tested; at
the time of injury, then between one and three hours after the initial incident the
symptoms checklist should be re-administered, and 24 hours post-injury a full re-
evaluation should be completed. Once athlete is asymptomatic screeners should allow 24
more hours of rest before final testing is completed, or if symptoms do not resolve after 7
days, a full functional test including; balance, cognition, coordination, and symptoms
checklist should be performed and the athlete referred to a neurological specialist
(Guiskewitz, 2012).
Literature Review: Management
The traditional theory of thinking dictated that patients suffering from
concussions should be prescribed bed rest. However, prolonged inactivity has been
shown to lead to several co-morbidities associated with concussion; vestibular disorders,
depression, posttraumatic stress disorder, chronic fatigue, and pain disorders are among
the list (Stewart et. al., 2012). Patients who underwent between three and six days of bed
rest reported complaints of headache, restlessness, and difficulty sleeping, which may
complicate the treatments. For this reason, bed rest for longer than three days is counter-
indicated (Stewart et. al., 2012).
During the acute phase of post-concussion healing, the athlete should avoid all
sports-related physical activities and only engage in actions that require mild to moderate
physical effort. Initially, cognitive tasks such as; school, work, video games or other
cognitively demanding events should be avoided. The current theory of pathological
implications of a mild TBI’s are that the sympathetic nervous system activity is increased
which raises heart-rate. This along with the interruption in cerebral blood flow can give
rise to a re-surfacing or exacerbation of post-concussion symptoms with physical exertion
and a potential increase in blood pressure (Goodman, 2009). This knowledge lends to the
thought that sub-symptom threshold exercise can be applied to target disrupted blood
flow and alleviate the dysfunctional sympathetic nervous activity. Once concussion
symptoms have resolved, the complete assessment should be administered again and the
results compared to the previous test and to the baseline numbers.
Approximately 80% to 90% of concussions resolve in 7–10 days, in some
instances persistent symptoms of more than 10 days are reported (McCrory, 2012). In
this latter group; patients often experience prolonged, physical, behavioral,
neuropsychological, and personality changes which have been termed post-concussive
syndrome (PCS) (Stewart et. al., 2012). Even when patients are asymptomatic, up to
40% percent have shown cognitive deficits, suggesting that a cognitive component be
included in the therapy process and the Return-to-Play protocols.
After the initial prescribed rest period, the therapeutic program should include;
motor, vestibular, cognitive, and if necessary psychological therapies. Then, according to

patient tolerance a graded exercise program can be introduced along with an assessment
of any lingering, prolonged symptoms that need to be addressed. The patient will need to
be closely monitored to avoid exacerbation of symptoms. The program will need to be
individually tailored to the athlete’s level of fitness as athletes engaging in high levels of
activity after experiencing mild TBI’s have shown worse neurocognitive performance.
However, those who participated in a more moderate level of activity demonstrated the
better performance on these tasks (Majerske et. al., 2008).
Finally, additional therapy techniques may include components such as; treatment
for those patients who present with cervical spine or vestibular dysfunction, interventions
to improve postural stability, sensory integration exercises, balance training, oculomotor
training, eye-head coordination training, visual motion sensitivity training,
neuromuscular control, and patient education on proper body mechanics. Pharmacologic
therapy in the management of concussion-related dysfunctions could include the
management of specific or prolonged symptoms like headaches, depression, anxiety, and
sleep disturbances through appropriate medications (Stewart et. al., 2012).
Literature Review: Physical Activity Tolerance
At the latter end of rehabilitative therapy, prior to administering return-to-play
activities, an athlete will need to be assessed to determine their readiness to partake in an
exercise program of more moderate intensity than that which addresses the initial
symptoms and recovery. This is referred to as physical activity tolerance. One
recommended protocol for the activity tolerance assessment includes the use of the Balke
treadmill test. The Balke test uses a graded application of treadmill running and ratings
of perceived exertion (RPE) to monitor the individual’s response (Stewart et. al., 2012).
The Balke protocol is varied for males and females. Male participants will begin with the
treadmill set at 3.3 MPH at a grade of 0%. After one minute the grade is raised to 2%.
Each minute following the grade is increased by 1%. When the participant is no longer
able to carry on, either from symptoms or from fatigue, the test is concluded. Females
athletes start at a setting of 3.0 MPH and a grade of 0%. The grade is increased 2.5%
every 3 minutes, and again the test will be terminated when the participant can no longer
continue (Stewart et. al., 2012). The medical professional conducting the test should
keep a log of the speed, grade, and heart rate associated with symptom exacerbation
and/or fatigue. By keeping a detailed record the heart rate at which symptoms or fatigue
were experienced can be noted and used as a guide to create an individualized exercise
program for that athlete.
The heart rate at which symptom exacerbation or fatigue is associated is
considered the athlete’s heart rate threshold (HRT). In the article by Stewart and
colleagues, the authors suggest that exercise intensity should begin at a level less than
70% of the HRT for no longer than 15 minutes. Progression of the exercise will be in 5
minute increments each session until the participant reaches a 30 minutes. After the goal
of 30 minutes has been accomplished, the intensity of the treadmill activity can be
increased by adjusting the speed or grade so that the athlete has about a 5% increase in
their heart rate (Stewart et. al., 2012). This protocol represents one method for
monitoring and prescribing exercise tolerance, and these are general guidelines. It is
important to mention that if symptoms are experienced during the testing, it should be
halted for that day. It may begin again the following day at the same intensity.
Progression should not be made while symptoms are present and the author believes that
a regression in the protocol should be incorporated if symptoms are greater than those
experienced during baseline testing. It is also is interesting to note that alternative
exercise protocols other than continuous cardiovascular exercise can be utilized as well.
Some athletes may tolerate other forms of training such as interval training better than a
strictly cardiovascular approach. Although, in this author’s opinion clinician’s should
utilize resistance training with caution initially as it has the potential to impact blood
pressure which may be problematic especially within the injured brain, and there is
limited evidence to support the use of resistance training in obtaining beneficial outcomes
with post-concussion rehabilitation (Stewart et. al., 2012).
As with each stage of concussion therapy, the patient will need to be monitored
closely, but even more so during the incorporation of exercise due to the fact that glucose
uptake in the brain is interrupted, and cortisol levels are increased both of which have the
ability to negatively affect the neuronal energy mismatch that occurs post-concussion
(Majerske et. al., 2008).
Literature Review: Return to play
For athletes to participate in a Return-to-Play program, evidence suggests that
they be symptom free for 24 to 48 hours, perform at levels consistent with baseline
testing for all aspects of diagnosis, and pass a clinical medical examination (Stewart et.
al., 2012). Each individual will respond in an independent fashion to symptom recovery
and tolerance to rehabilitation, but the typical athlete is withheld from sport for
approximately one week. This time frame can be adjusted by the medical professional,
but athletes experiencing concussion-like symptoms should never return the same day.
Athletes whose symptoms last longer than the 7 to 10 day period are considered to have
Post-concussion Syndrome; these individuals can expect a longer recovery process with
an extended Return-to-Play protocol that takes into account their decline in physical
conditioning (Stewart et. al., 2012). Return-to-Play protocols developed by the National
Athletic Trainer’s Association in conjunction with the American Academy of Neurology
show a progression of activities, or stages, the athlete should participate in during the
recovery process. Each stage will be separated by a 24 hour period after successful
completion that includes no reports of concussion-related symptoms (Stewart et.al.,
2012). If at any stage during therapy, the participant experiences symptoms; the activity
should be stopped immediately and a 24 hour rest period should be implemented before
resuming the graduated protocol. (See Table 4 for a suggested Return-to-Play program)
Literature Review: Dual Task Activities
One area showing promising results in concussion management is the use of dual-
task activities. This method for addressing problematic symptoms is particularly
pertinent to the field of physical therapy because of the association between concussions
and gait abnormalities as well as various other functional limitations. Dual-task activities
are those that require the athlete to perform multiple activities across varying categories
at the same time (Stewart et. al., 2012). For example, a patient may be asked to perform
balance and cognitive activities simultaneously such as standing on a wobble board while
counting to 100 by 3’s. Simultaneously conducting attention-oriented activities and
balance training has been found to be especially effective in treating post-concussion
athletes with dizziness, balance and visual disturbances. The deficiencies seen when
performing dual-task activities are hypothesized to be a result of the impaired ability of
the executive functions of the brain to share attention between the demands of the two
tasks (Stewart et. al., 2012). In the article written by Stewart and colleagues, it is
suggested that therapists appropriately level the types of dual-task activities they are
asking patients to perform whether it is for motor, visual, cognitive deficits, etc. so that
the tasks are feasible for patients to perform as a single-task intervention. Outcomes such
as balance errors, correct number of counting sequences, words read per minute, etc. can
be used to monitor progress.
Literature Review: Long-term Consequences
As of yet, the impact of concussions on a patient’s long-term physical and
cognitive health have not been clearly defined. Early reports show changes to motor
control, neuroelectical activity, and neurocognitive abilities (Harmon 2013). Professional
athletes participating in high-impact sports have indicated via self-report survey methods
an increase in late-life cognitive impairments, depression, anxiety, lack of impulse
control, and chronic traumatic encephalopathy. While current studies may lead to the
likely conclusion that repetitive concussive and sub-concussive impacts have a direct
correlation with the symptoms listed above, variables such as genetic predisposition,
comorbidities, lifestyle risk factors, and normal decline through the aging process have
not been extracted so the reliability of such studies remains uncertain.
Future Research
Research in many areas of identification and management are growing and
evolving as science delves deeper into understanding these brain injuries. One new
experimental advancement that may have some future merit is that of gene marker
identification. New studies are looking into the significance of apolipoprotein (Apo) E4,
ApoE promotor gene, tau polymerase, and other genetic markers in the identification,
management, and benefits to outcomes of rehabilitation. At the present time, no solid
evidence has been uncovered. However, evidence from human and animal studies in
more severe traumatic brain injuries are showing variant levels of genetic and cytokine
factors, such as insulin-like growth factor-1 (IGF-1), IGF binding protein-2, fibroblast
growth factor, Cu-Zn superoxide dismutase, superoxide dismutase-1 (SOD-1), nerve
growth factor, glial fibrillary acidic protein (GFAP), and S-100 associated with
concussion injuries (McCrory 2012). Additionally, electrophysiological recording
techniques such as; evoked response potential, cortical magnetic stimulation, and
electroencephalography are, at least in the early stages of research displaying
reproducible abnormalities for subjects in the post-concussive state. Unfortunately,
results are mixed with some studies revealing no significant difference between
concussed players and control groups. These methods are in the developmental stages
and continued research is being done to determine the validity of their use as
identification tools (McCrory 2012).
Case Description:
The following is a fictitious case study based on the author’s experience with
working with an actual client, but one who did not fit the criteria of being a mixed martial
arts fighter. The patient is a 27 year old male who reports he received an insult to the left
temporo-parietal area of the cranium during a mixed martial arts fight on 8/30/15.
Headaches started shortly after on the right forehead region. Symptoms of vertigo began
in September. The patient was under the care of a D.O. and was receiving stretching and
soft tissue treatments from the cranium down to the sacrum, but no thrust maneuvers
were performed.
There are no reports of tingling, numbness, cracking or popping. He currently
presents with pain; in the right temporal region, the right cervical region, and the right
trapezius however, occasionally the pain will be located on the left side as well. He
describes his discomfort as a pressure and heaviness at those points. The patient reports
his pain level is currently 5/10, at its best it has been 3/10, and at its worst an 8/10.
Symptoms of dizziness and spinning wake him at night when turning onto his right side;
they generally subside within a minute or two. Cervical extension and forward bending
initiate the vertigo which is associated with nausea. He reports fatigue that comes on
rapidly and exacerbates the symptoms. He states that he is even fatigued by taking a
shower, and is having difficulties remembering “normal things”. Sensitivities to sound
and light also provoke headache symptoms. He reports barriers to his activities of daily
living (ADL’s) such as; the inability to drive, not being able to read due to headache and
neck pain, and an intolerance for activities that require a lot of movement. He also
described feeling “not so steady” on his feet and claims he has been very irritable and
emotional since the incident.
The patient states that he had neurological tests and imaging; he was told that
there were no fractures and that he had a concussion. He felt that he was not progressing
in his treatment; his primary physician referred him to physical therapy. He does not
have any scheduled follow-up appointments at this time.
His past medical history is significant for a right knee arthroscopy on 9/12/11 and
a kidney stone on 12/18/13. He denies taking any prescription medication, illegal drugs
and drinks 6-8 alcoholic beverages per week. His goals for physical therapy were to be
independent with driving and to return to working out and mixed martial arts.
The Examination:
• Postural Examination:
- Mild subcranial side-bend to the left
- Slight forward head, with protracted shoulders
- Right should slightly elevated
- ASIS, PSIS indicate nothing remarkable
• Range of motion:
- Cervical flexion within normal limits but brings onset of
headache symptoms
- Cervical extension is limited due to dizziness
- Cervical lateral bending within normal limit
- Cervical rotation within normal limit
• Dermatomes: - C1 – C8 all within normal limits
• Reflexes: C5-6, C6-7 bilateral 2+
• Myotomes: - Bilateral upper extremities and lower extremities 5/5
• Special tests:
- Static Stabilization (-)
- Gaze Stabilization (-)
- VOR (-)
- Bilateral Head Thrust (-)
- Smooth pursuit (-)

- Hallpike-Dix (+): patient presents with tortional upbeat nastagmus with a
right Hallpike-Dix test. A right Eply’s maneuver was
performed and the patient experienced extreme sense of
dizziness, spinning and nausea that subsided after 3
minutes and 30 seconds. The patient was sat back up and
experienced a mild relapse of dizziness during which he
had a mild counterclockwise sway when seating
unsupported. This quickly went away. The maneuver was
repeated, patient reported feeling 60-70% less dizzy; no
nystagmus was present.
- Alar Ligament and Transverse Ligament Tests: (-)
• Neck Flexor Muscle Endurance Test: 11 seconds with associated neck and
headache pain and dizziness
• Neck Disability Index (NDI): 68/100
• Berg Balance Test: 32/56
The Assessment:
Findings are indicative of BBPV in the right, posterior semi-circular canal with
co-occurring post-concussion syndrome as confirmed by the torsional, up-beating
nystagmus, the presentation of severe dizziness with specific directional movements, as
well as memory loss, exaggerated emotional responses, increased susceptibility to
fatigue, decreased tolerance to fatigue, sensitivity to light and sound, a high risk Berg
Balance test. Additionally, he may be encountering cervicogenic headaches as a result
of soft tissue cervical and subcranial reactivity in relation to Wiplash Associated Disorder
(WAD). These results are evidenced by tenderness to palpation in the upper cervical and
subcranial regions, the unilateral headaches, postural imbalances including forward head
posture and protracted shoulders, as well as a below average Neck Flexor Muscle
Endurance Test time.
The Plan of Care:
The patient is expected to attend physical therapy sessions 3x’s per week for 4
weeks with an application for an extension if it is deemed medically necessary.
Treatments are to include additional canolith repositioning maneuvers, AROM, PROM,
and soft tissue manual therapy to the subcranial, upper and lower cervical regions,
vestibular habituation exercises, postural education and strength exercises, dual-task
activities that include cognitive interventions in conjunction with balance, coordination,
or motor control activities, and cardiovascular endurance activities. The following is the
4 week intervention plan initiated with the post-concussion client:
Week 1 – 2
Day 1-3 (Acute Phase):
- Mild to moderate activities of daily living.
- No activities that require stressful cognitive demands like
school or work.
Day 4-7:
- Recumbent bike (5 mins.)
- Cervical spine AROM/PROM, stretching, and manual therapy
techniques
- Vestibular Habituation exercises:

1. Brandt-Daroff Vestibular Habituation Exercise: Side-lying w/ 45
degree opposite rotation (dizziness +30 seconds) 5x’s
2. Corrective Saccades: 2 fingers – 12 in. apart, Eyes look right. Head
turns right. Eyes look left. Head turns left. (10x)
3. VOR X1: One sticker in the middle of card. Head moves L/R card
stays stable.
4. VOR X2: One sticker in middle of card. Head moves L/R, eyes
stable, card moves horizontally opposite of head while eyes track.
Then repeat vertically. (1 minute each).
- Postural Education and maintaining posture during static balance
1. Tandem stance: (3x’s 30 seconds ea.)
2. Feet together: EO/EC (3x’s 30 seconds ea.)
3. Standing on foam pad: EO/EC, turn head R/L (2x’s 30 seconds)
- Coordination exercises:
1. Alternating pronation–supination hands: (2 sets 20x’s)
2. Sobriety test: Finger to nose R/L (2 sets 10x’s)
3. Bounce ball: one hand, opposite hand, floor to wall, dribble
(10x’s ea.)
Day 8-14:
- Airdyne bike (5 mins.)
techniques
- Review postural education and begin dynamic balance activities:

1. Toe taps on steps: (2x’s 10 ea.)
2. Turn 90 degrees: R/C/L/C (3sets of 3 ea.)
3. DGI activities: walk turn head R/L, U/D
4. Side-stepping: over half-bolsters
- Vestibular Intervention:
Laser pointer tracking: patient in dark room, seated in chair that rotates,
approximately 4.5 feet from the wall. Track laser on wall w/ fixed head
position (Clockwise/Counter-clockwise Circles, figure 8’s, “H’s”,
Diagonals). Progress to turning chair R/L as patient tracks
- Coordination and Cognition activities:
1. Star-stepping: 8 Post-its placed in semi-circle around patient
approximately 24 inches from center. Post-its are labeled 1-8.
Patient stands feet together in center. Therapist calls out foot
R/L and number. Patient responds by stepping to the number
and back with the correct foot. (2 sets of 8 each leg)
2. Tandem Cities: Patient stands arm’s length from wall. 4 rows
of 3 post-its are placed on wall each labeled with a different
letter of the alphabet. Therapist calls out a letter, patient
reaches out and touches the post-it with that letter on it and
then names a city that begins with that letter. (activity can be
progressed by beginning each turn by verbally recalling the

cities that have been recited so far before picking a new letter).
(1 complete round of 12)
3. Stack and Add Dice: Patient is given 3 dice. Patient rolls dice,
calls out the numbers represented on each dice, then adds those
three numbers. Next the patient stacks the 3 dice on top of
each other. Repeat using non-dominant hand as well. (10x’s
each hand)
Week 3:
Day 15-21
- Airdyne bike (8 minutes)
techniques.
- Vestibular Habituation exercises:
1. Laser pointer tracking: patient in dark room, seated in chair
that rotates, approximately 4.5 feet from the wall. Track laser
on wall w/ fixed head position (Clockwise/Counter-clockwise
Circles, figure 8’s, “H’s”, Diagonals). Progress to turning
chair R/L as patient tracks
- Motor control and dynamic balance exercises:
2. Balance a ball on clipboard: Patient balances a ball on a
clipboard, tennis racket, etc. Then, patient walks down the hall
trying not to let the ball drop. Repeat with other hand. (3 sets
down and back with each hand)
3. Rolling ball under 1 foot: Patient stands with 1 foot on top of a
ball, the other foot flat on the floor. Patient makes 10
clockwise and 10 counter-clockwise circles with the ball.
Repeat with other foot (2x’s each foot.
4. Weave between cones and step over: 5 cones are placed
approximately 24 inches apart in a straight line. Patient
weaves in between the cones, then on the return trip he/she
steps over the cones. Repeat with side-stepping each side as
well. (3x’s each direction).
5. BOSU marches and bounces: Patient sits with good posture on
BOSU ball and flexes one hip at a time, raising the knee and
lifting the foot off of the ground. (3 sets of 15x’s with each
leg). Next, patient engages the core and completes 20 seconds
of bouncing (3 sets of 20 seconds)
- Coordination and cognitive activities:
1. Catch and reverse: Patient stands approximately 10 feet from
therapist. Therapist will throw the ball and say a sequence of 3
numbers. Patient catches the ball, repeats the numbers in
reverse order, and then throws the ball back. (2 sets of 10)
2. Comprehension questions “and”: Patient is given a newspaper
or magazine article and asked to read it. At the same time, they
are also asked to count the number of times the word “and”
appears in the story. When they are finished reading, they will
tell how many “ands” they counted, and answer 3
comprehension questions based on the article.
- Cardiovascular endurance activity: 5 minute walk on treadmill at
< 70% HR max
Week 4:
Day (22-30)
- Posture and core stability exercises:
1. TA Contractions and bridges: 2 sets of 15
2. Standing rows: with shoulder blade pinching 2 sets of 15
3. Elbows on table Donkey Kicks: 2 sets of 15 each
4. Standing shoulder horizontal abduction and extensions:
2 sets of 15 each w/ theraband
5. Side-stepping with weighted resistance: 2 sets of 3
repetitions 10 steps down and 10 steps back on each side.
- Cardiovascular endurance activity: 10-15 minute walk on treadmill
at < 70% HR max

Outcomes:
The patient progresses slowly over the course of the 4 week treatment plan. He
initially displayed a decreased tolerance to cervical end range activities due to an increase
in symptoms of headache and dizziness. Balance was moderately affected and was quite
problematic for him initially; memory deficits were troubling to the patient also.
Initially, the Eply test was repeated on the second visit and did not result in nystagmus,
although he continued to experience a moderate level of dizziness of 3/10. The patient
was given Eply exercises to complete as his HEP, and on the third visit symptoms of
dizziness were no longer existent. The Berg Balance Score increased from 27% to 44%
putting the participant back into the independent category.
Through 12 physical therapy sessions, the patient improved cervical flexion and
extension to within normal limits without provocation of symptoms, and was able to
complete full flexion as well. Cervical headaches persisted until the 8th physical therapy
session when the patient reported a 0/10 on the pain scale for headaches and neck pain.
His 30 day NDI score was 32% which is considered a statistically significant difference.
The patient has shown independence in his awareness of proper posture and body
mechanics. His forward head posture is reduced but still present; shoulder blades
appeared mildly more retracted with no signs of winging, and his score on the Neck
Flexor Muscle Endurance test increased to > 30 seconds.
The quality of the patient’s coordination improved and his movements were
performed in a smooth controlled manner. His increased susceptibility to fatigue and
decreased tolerance to activity improved but still need to be addressed before taking part
in a Return-to-Play program. When performing the Balke Treadmill test in week 4, the
patient was forced to stop at 9 minutes due to onset of headache and dizziness, and
shortness of breath. The patient self-reports not feeling as “foggy” as he used to. The
patient discussed ongoing occasional bouts of anxiety and lethargy. A referral was
provided to him for a neuropsychologist to address these issues.
It is this researcher’s recommendation that the patient take part in an additional 4
weeks of physical therapy working on strategies that were targeted in the 4th week of the
program; posture and core strengthening as well as cardiovascular endurance training. At
the end of the 2nd week, the patient should be reassessed, and if he is found fit to
participate, a Return-to-Play protocol should be followed and monitored by a medical
professional before participating in competitive fighting again.
Future Recommendations: Team Approach to Management
As evidenced-based concussion management gains momentum, the standard of
care is moving toward an individualized approach to assessment and treatment. Patients
suffering from post-concussion syndrome are better served through access to a wide
range of health care professionals including; the primary physician, nursing staff,
physical therapists, athletic trainers, and neuropsychologists to provide care and advocacy
as the medical team. In addition to the principal medical team, academic and
employment personnel are fundamental to concussion management as well. Social
workers, school guidance counselors, numerous teachers, coaches, and family members
could all play an essential part in the recovery process. (Stewart et. al., 2012)
Even when symptoms of concussions appear mild, they could greatly detract from
the athlete’s ability to function physically, cognitively, and psychosocially.
Academically, it may be necessary to review the prior functioning levels of a student

athlete to determine if there were previous learning disabilities, any history of problems
with social behavior in the classroom, with peers, and with authority figures. For adult
patients the same should be done to look into work history, any history of concomitant
substance abuse, and the athlete’s level of job performance and independence prior to the
injury (Stewart et. al., 2012). Finally, a truly comprehensive assessment designed to best
help the patient should consist of not only a functional assessment, but also an evaluation
of that patient’s family and peer support system resources, namely, repeat physician visits
and additional diagnostic tests (American Academy of Neurology 2013). It is the
author’s opinion that in consideration of the wide array of services necessary for optimal
care, and knowing the cognitive deficits that can accompany post-concussion syndrome;
a medical professional designated to be a Concussion Care Coordinator would be a
beneficial addition to the health care system. In addition to the myriad of necessary
appointments, the Concussion Care Coordinator would be able to provide patients with a
list of both signs and symptoms that may indicate a decline in the patient’s status that
would warrant emergency medical care, as well cataloguing the daily intensity, duration,
and number of symptoms through phone conferences and providing that information to
the primary care physician or physical therapist.

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Appendix: Tables
Table 1: Compilation of the classification of reported injuries in 2013
Fighter’s Injury Date Notes

Name
Cat Zingano Rt. ACL and May 2013 Occurred in training during
meniscus tear plyometric jumps 6-9 months
rehab post-surgery
Roger Hollett Bicep Tear January 2013 Injured in training
Anderson Silva Lft. broken tibia December Occurred in competition while
and fibula 2013 checking an opponent’s leg
kick
Manny Gamburian Thumb and February Injured in training
Elbow 2013
Rory McDonald Neck February Injured in training
2013
Johnny Eduardo Shoulder March 2013 Injured in training
Alistar Ovareen Quad tear March 2013 Injured in training
Santiago Broken hand March 2013 Injured in training
Ponzinibbio
Dan Hardy Heart Condition March 2013 Discovered while training
Alexander Cut on face March 2013 Injured in training
Gustavson
Gunner Nelson Knee March 2013 Injured in training
Eric Perez Knee infection April 2013 Injured in training
Nick Catone Dehydration April 2013 Rapid weight loss prior to fight
Constantinos Cut on face April 2013 Injured in training
Philippou
Renan Barao Foot May 2013 Injured in training
Isaac Vallie-Flagg Back May 2013 Injured in training
Antonio Rogerio Back May 2013 Injured in training
Nogueira
Anthony Pettis Knee Meniscus June 2013 Injured in training
Robert Drysdale Staff infection July 2013 Contracted it while training
Clinton Hester Broken Ribs July 2013 Injured in training
Phil Harris Broken Orbital July 2013 Injured in training
bone
Stephan Struve Heart condition: August 2013 discovered while training
Leaking aortic
valve
Table 1 (Continued): Compilation of the classification of reported injuries in 2013
Fighter’s Injury Date Notes

Name
Broken orbital August 2013 Occurred in competition
Chan Sung Jung bone and
dislocated
shoulder
Connor McGregor ACL August 2013 Occurred during competition
Wanderlei Sylva Back August 2013 Injured in training

TJ Grant Concussion September Injured in training
2013
Luke Rockhold Knee September Injured in training
2013
Michael Bisping Eye September Inured in training
2013
Charles Olivera Strained thigh October 2013 Injured in training
muscle
Rodrigo Damm Kidney failure October 2013 Rapid weight loss prior to fight
Cain Velasquez Shoulder surgery November Occurred in competition
2013
Anthony Pettis Knee November Re-injured in training
2013
Jake Ellenburger Hamstring November Injured in training
2013
Erick Silva Elbow and January 2013 Injured in training
infection in leg
Buddy Roberts Mouth January 2013 Injured in training
Table 2: Category, number and percentages of recorded injuries in 2013
Category Number of Injuries Percent of Injuries

Reported
Head/Face 5 14%
(including lacerations,
broken bones, etc.)
Concussions 1 3%
Neck and Back 4 11%
Shoulder (GH) 3 9%
Upper Extremity Broken 3 9%
Bones
Upper Extremity 1 3%
Musculotendinous
Lower Extremity Broken 2 6%
Bones
Lower Extremity 3 9%
Musculotendinous
Knee 7 20%
(ACL, PCL, Meniscus,
MCL, LCL)
Other: 6 17%
Includes; infections, heart,
and other organ-associated
dysfunctions
Table 3: Common Symptoms Associated with Concussions
▸ Physical
– Headache – Balance problems
– Nausea – Vomiting
– Fatigue – Dizziness
– Visual problems – Sensitivity to light
– Sensitivity to noise – Dazed
– Numbness/tingling – Stunned
▸ Cognitive
– Feeling mentally ‘foggy’ – Repeats questions
– Feeling slowed down – Answers questions slowly
– Difficulty concentrating – Confused about recent events
– Difficulty remembering – Forgetful of recent information and
conversations
▸ Emotional
– Irritable – More emotional
– Sadness – Nervousness
▸ Sleep
– Drowsiness
– Sleep more than usual
– Sleep less than usual
– Difficulty falling asleep
Table 4: Influences that Impact Risk of Concussion and Duration of Recovery
Factors Variables
Symptoms Number of symptoms
Duration of symptoms (<,>,=) 10 days
Signs Amnesia
Loss of consciousness (LOC) > 1 minute
Sequelae Seizures
Convulsions
Temporal Frequency of incidents
Time since last concussion
Threshold Successive events tend to require less
impact and show a longer recovery period
Age Women > recovery time than men
Children < 18 years old
Comorbidities Pre-existing; migraines, headaches,
depression, anxiety, sleep disorders, and
other learning disabilities such as ADHD
Medications Anticoagulants
Psychoactive medications
Behaviors Dangerous or risky behaviors including
heightened aggressiveness without
consideration of bodily harm while
participating in sport
Sports Collision and high-contact sports
High-risk or “Extreme” sports
Table 5: Red Flag Signs: Requiring Immediate Medical Attention
• Extensive loss of consciousness greater than one minute
• Decreasing level of consciousness
• Amnesia
• Deterioration over time instead of progress
• Increasing confusion or irritability
• Numbness in the arms or legs
• Pupils that are uneven in size
• Repeated vomiting
• Seizures
• Slurred speech or inability to articulate
• Inability to recognize people or places
• A headache that becomes progressively worse over time

Table 6: Return-to-Play Protocol
Stage Recommended Exercises

Mild to moderate activities of daily living
1. No Activity No activities that require stressful cognitive
demands like school or work
Light aerobic activities such as walking,
2. Light Aerobic Activity jogging, etc. that are performed at < 70%
of the calculated Heart Rate Maximum.
Running, skating, swimming with rapid
3. Sport-specific Exercise turns and jumps at increasing intensities
but do not require contact.
Incorporation of more complex training
4. Non-contact Drills (sport-specific) drills that require the inclusion of fine and
gross motor skills without demanding
contact (Ex: passing routes in football,
puck-handling and shooting drills in
hockey, resistance weight training)
Normal practice activities (should be
5. Full Contact Practice monitored) and only after receiving
medical clearance
No limitations
6. Return to sport

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CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

The Faculty of the College of Health Professions and Social Work

Florida Gulf Coast University

Of the Requirement for the Degree of

Doctorate of Physical Therapy

This case report is submitted in partial fulfillment

of the requirements for the degree of

Doctorate of Physical Therapy

Approved: May 2015

Dr. Stephen Black, DSc, PT, ATC, CSCS

Dr. Russell Hogg, PhD.

above mentioned discipline.

Traditional Martial Arts ...................................................................................................... 10

Informal Search of MMA Injuries ...................................................................................... 12

The Case Study ....................................................................................................................... 14

Literature Review: Identification ........................................................................................ 20

Literature Review: Management......................................................................................... 25

Literature Review: Physical Activity Tolerance ................................................................. 27

Literature Review: Return to play....................................................................................... 29

Literature Review: Dual Task Activities ............................................................................ 30

Literature Review: Long-term Consequences .................................................................... 31

Future Research .................................................................................................................. 31

Case Description: ................................................................................................................ 32

The Examination: ............................................................................................................ 34

The Assessment: ............................................................................................................. 35

The Plan of Care ............................................................................................................. 36

Future Recommendations: Team Approach to Management ............................................. 44

Appendix: Tables .................................................................................................................... 49

On November 12, 1993 eight-men entered an arena in Denver, Colorado to

defenselessness through blunt head trauma; or disabling an opponent through joint

idea of how wide spread the field of combat sports is.

Additionally, professional mixed martial arts have become an industry that

generates hundreds of millions of dollars of revenue each year. Owners, fighters,

equipped to implement preventative measures and best-practice therapy techniques for

injuries, and 11 orthopedic injuries (3 metacarpal injuries, with 1 confirmed fracture; 1

acromioclavicular separation; 1 traumatic olecranon bursitis; 1 elbow subluxation; 1

musculoskeletal stresses to the participants resulting in a stoppage, and 91 fights were

While the classification of injuries in MMA may be in its infancy, physical

researchable categories. Concurrently, the development of probable prevention strategies

and exercises requires classification of injured patients as well as evaluations of the

patterns of injuries sustained (McPhearson & Pickett, 2010).

wrestling or “grappling” (which includes submissions), boxing and kickboxing, and

varying injuries of the different styles.

Wrestling is the form of competition involving techniques such as clinch fighting,

muscles, concussions, etc. (McPhearson & Pickett, 2010).

Traditional Martial Arts

The term “Traditional Martial Arts can be considered a combination of several

fractures are still common (McPhearson & Pickett, 2010).

Informal Search of MMA Injuries

necessary to conduct an informal search of professional mixed martial arts injuries in an

attempt to categorize the variety of dysfunctions resulting from this sport.

Interestingly, of the 101 injuries documented in professional Mixed Marital Arts

before they are fully recovered.

In recent years, medical professionals have put more emphasis on cataloging

professional interested in working with this subpopulation in understanding the types of

injuries they are likely to encounter in their patients.

The literature review of injuries occurring during combat sports leads to a

practices” approach to treating the shoulder as well as numerous other musculoskeletal

The Case Study

the foremost concerning to fighters and medical personnel.

Concussions, which are referred to as commotio cerebri in European and most

brain injury which is a complex pathophysiological process brought on by biomechanical

in mental status” (American Academy of Neurology 1997). Concussions generally