22 Apr What To Do After A Concussion?
A concussion is a mild form of traumatic brain injury (TBI). It is considered part of the mild spectrum because there is no observable pathology; meaning that on standard imaging, you cannot see a concussion injury. Concussion rather is an injury that results in changes to how the brain functions – it is a functional injury. Concussions don’t necessarily come from hits to the head. Concussions are due to the acceleration of the brain inside the skull. Although a hit to the head is the most likely cause, you can also sustain a concussion – this acceleration of the brain – from a hit to the body, or a fall, or a whiplash-type mechanism. A concussion is treatable; in this article @Concussion_Doc will break down the science behind a concussion in addition to effective treatments for persistent concussion symptoms!
What is a Concussion?
The following video from Complete Concussion Management describes how a concussion happens and how it affects your brain function:
Rest is no longer best!
In the early stages of concussion recovery, we used to tell people that the best thing to do was rest. Shut your brain off, lock yourself in a dark room, and don’t even think of looking at a screen! Well, the times, they are a changin’.
Recent research has found that people who engage in earlier cognitive and physical activity actually do better than people who take the old-school approach of rest. In fact, a number of recent studies have determined that exercise is possibly protective against post-concussion syndrome (PCS) (AKA persistent concussion symptoms), whereas rest is potentially detrimental.
The concern about rest is that it:
- medicalizes the condition – makes people think that the injury is more serious and damaging than it actually is;
- creates fear avoidance – if you’re afraid to do things because you might ‘flare’ your symptoms, you are going to continue to decline, as activities are important for both your cognitive and physical health;
- creates social isolation – this opens the door for anxiety and depression which are known to contribute to delayed recovery;
- creates physical deconditioning – one of the main causes of persistent post-concussion symptoms has been attributed to abnormal blood flow, and rest alone – for as little as 12 hours – has been shown to create alterations in blood flow; and
- causes people to fall behind in their work or school – once you fall behind, the stress and anxiety begin to mount, which can lead to further decreases in productivity, which often gets misattributed to problems focusing or concentrating.
What To Do After A Concussion?
In the first few days following a concussion, take it easy, but don’t shut down every aspect of your life. Go for walks, get outside, try reading. You’re allowed to do anything that:
- does not increase your symptoms; and
- does not put you at risk for suffering another concussion (for example, sports, skiing, bicycling, etc.).
Most importantly, coordinate your care through a trained concussion clinician. Most healthcare professionals are not well trained when it comes to concussion, as it is very much a specialty field. Your clinician may be a physician, physical therapist, chiropractor, athletic trainer, or something else entirely. What matters most is that your clinician has additional training and experience in the management of concussion injuries and that they practice in an evidence-based manner. A good place to start is to visit completeconcussions.com/find-a-clinic to find a list of clinics that have received extensive training and certification on the assessment, diagnosis, management, and treatment of concussion and persistent concussion symptoms.
Persistent concussion symptoms (AKA PCS)
Concussion symptoms generally dissipate within the first 10 to 14 days in adults and within the first four weeks for children/adolescents. If you have symptoms that last longer, these are termed Persistent Post-Concussion Symptoms (PPCS). Although we don’t have a definitive answer for why some people recover quickly and why others develop PPCS, the current understanding is that it can occur for many different reasons.
Now, let’s cover the five main causes for PPCS as well as some examples of assessments and treatments.
1. Blood flow/autonomic nervous system
After a concussion, both animal and human studies have found that there can be significant alterations in blood flow to the brain. For the most part, these abnormalities generally dissipate within the first two weeks after injury; however, in some, particularly those with persistent symptoms, these abnormalities can linger. These patients are typically intolerant to exercise.
Funny enough, the treatment for this condition is exercise. These patients first need to be tested using a specific testing protocol to establish their threshold heart rate. Once that has been established, loads of scientific evidence support the use of subthreshold exercise as the go-to treatment for this type of PPCS.
2. Metabolic/inflammatory/hormone Imbalance
These three I have lumped together because even though they are not the same, they are typically treated with dietary or supplement interventions. I typically encourage all of my concussion patients to avoid any foods which are considered ‘pro-inflammatory’ – this includes refined sugars, dairy, low-quality red meats, gluten, processed foods, etc.
A concussion can result in inflammation, not only to the brain but potentially to other areas of the body too. Recent research has found that brain injury can also affect the microbiome of the gut and increase the permeability of the digestive tract. This can lead to increased systemic inflammation, which can lead to headaches, fogginess, and a host of other concussion-like symptoms. By eating clean after a concussion, the thought is that we may be able to mitigate some of this gut-brain axis influence and improve the outcomes of our patients.
I have had many patients over the years that within a week of changing their diet, have experienced their symptoms all but disappear.
Please note, a lot more research is needed in this field of study and before undertaking any dietary changes, it is important to do this in concert with a licensed healthcare professional. For more information on how diet can impact concussion recovery, be sure to check out this video of Dr. Paul Hrkal on the Ask Concussion Doc podcast: https://www.youtube.com/watch?v=iBpL_72SVpk
3. Visual/vestibular dysfunction
About 30% of your brain is devoted to vision and visual processing. It is therefore very common to have visual disturbances following a concussion. The vestibular system is your main balance center, which is mostly controlled by little sensors in the inner ears.
I put visual and vestibular together because often times the symptoms can look very similar. Sometimes what seems like a problem with vision, ends up being a vestibular problem, and sometimes dizziness is actually a problem with vision. It is important that clinicians understand how each system works and are able to separate the two to determine the dysfunction and the appropriate course of action.
One key clinical test that can be done to assess these systems is the Vestibular-Oculomotor Screen (VOMS). This battery of tests is based on the patient self-reporting whether any of the tests increase their symptoms to any significant degree. If they do, then this can be where you start your rehab protocols. The clinician is also looking for abnormal signs during the test. See the VOMS test below
4. Cervical spine (neck)
Concussion requires a fair amount of acceleration to occur. Studies examining football helmets using accelerometers find that the highest predictive occurrence of concussion happens around 96 G (where “G” = the force of gravity). Whiplash or mild strain injury of the cervical spine happens with as little as 4.5 G. Given the fact that concussion is acceleration/deceleration of the brain and whiplash is acceleration/deceleration of the head and neck, it is safe to assume that these injuries often occur simultaneously. Previous studies have proven this fact.
The symptoms of concussion and whiplash are identical! Both can cause headaches, confusion, mental fogginess, dizziness, trouble focusing, ocular/visual disturbances, and more. So, although you may have originally had a concussion, you may now be dealing with the lingering effects of a whiplash injury; even though the symptoms are the same. A clinician who is an expert in manual therapy and rehabilitation of the neck may be able to determine if your symptoms are coming from your neck. In my experience, the neck is the most overlooked and most underappreciated issue with respect to its influence on persistent concussion symptoms.
I have included some interesting videos for testing, assessing and treating some basic neck-related conditions. Click here for some neck Prehab Exercises.
The neck and head are intimately connected. Sometimes when the neck is injured or the muscles are tight, you don’t feel this as neck pain, but rather as a headache. You think it’s coming from your head, or your brain…but it’s not! The patient in the following video only needed two treatments (a combination of soft tissue release and spinal manipulation) and she was discharged with no recurrence of symptoms.
Your neck also tells your brain a lot about where you are in space. If certain muscles and joints are strained or not sitting quite right, then the signals to your brain can be off. This will create the sensation of dizziness. The trick is figuring out whether this is a visual problem, a vestibular problem, or a neck problem. Below are two clinical tests that may help you to sort it out!
Smooth Pursuit Neck Torsion Test
Rotatory Chair Test
If the cervical spine seems to be involved, take a look at this neck pain program.
One of the highest predictors of persistent concussion symptoms is having a pre-injury history of mental health issues; particularly anxiety and depression. The symptoms of anxiety and the symptoms of depression can look and feel very similar to those of concussion: feeling overwhelmed, chronic fatigue, unable to think clearly, dizziness, etc. This makes it sometimes difficult to determine what is physical and what is mental.
Another part of the mental health picture is the potential misattribution of symptoms – meaning that you think you’re feeling a certain way due to your concussion – when in fact, it is either normal, or due to something else entirely. As an example, I will use light sensitivity. This is a common symptom following concussion and historically, patients were told to wear sunglasses and stay in a dark room to reduce discomfort during the early phases following injury. The very act of spending much of your time in darkness or always wearing sunglasses, however, can actually prolong your light sensitivity. But this has nothing to do with a concussion. Rather, it’s the fact that your eyes have become so used to minimal light, that when you expose yourself to light, everything seems too bright. This is what we refer to as an iatrogenic disability, meaning that the condition itself was caused by the improper medical advice that you received.
Finally, mental health issues can come up after concussion occurrence and this can also be due to how healthcare providers have historically dealt with concussion patients – social isolation, time off school, time off work, and no physical activity. Having no social outlets, no vocational purpose, and no exercise is a recipe for anxiety and depression which, as previously mentioned, can result in many of the same cognitive problems and symptoms as a concussion.
In fact, a recent study found that in concussion patients with cognitive problems (memory and concentration), putting them through six to 10 sessions of cognitive behavioral therapy with a psychologist was far superior in improving their cognitive abilities than six to 10 sessions of cognitive rehabilitation. This study indicates that often times, cognitive problems may be a sign of underlying mental health issues. It is very important that practitioners recognize the role and importance of mental health in concussion and concussion recovery. It is equally important that patients consider this as a potential contributor to their symptoms.
Due to ongoing, but fading stigma surrounding mental health, patients are often reluctant to accept the suggestion that their symptoms may be psychologically driven. Often times, this is the piece of the puzzle that is holding back recovery.
So, there you have it. That is my basic explanation of what a concussion is and some of the main causes of persistent symptoms. The most effective treatments for persistent concussion symptoms are rehabilitation, diet, and psychological interventions. Concussion IS TREATABLE; you just need a very knowledgeable and well-trained clinician/clinical team. For more information, please visit completeconcussions.com.
About the Author
Dr. Cameron Marshall, AKA @Concussion_Doc is a published concussion researcher and the founder of Complete Concussion Management Inc. (CCMI), the largest clinical network of concussion clinics in the world. With over 300 certified clinic locations in five different countries, CCMI provides clinics with the training and tools to develop an effective concussion management program within their clinic. By providing innovative technology, continuous education, and marketing support, CCMI-trained clinicians continue to stay a cut above the rest and provide effective evidence-based treatment to all those impacted by concussions.