Estimated reading time: ~8-10 minutes
Concussion has been a hot topic over the last decade. Changes have been made in sport and Hollywood even got in on the action. During this time there has been a great deal of information learned, myths have swirled, and culture has shifted.
One of the hardest parts about this injury is that it can appear to be invisible. We can see the limp from the knee injury along with the changes during the recovery process. Alternatively, when viewed from the outside someone who has sustained a concussion looks like nothing happened.
Appropriate management after a concussion reduces the odds of prolonged symptoms or chances of second concussion. Understanding some of the basics of the recovery is incredibly empowering and allows you be much more active in the process.
So you know where are headed with this article:
1) What a concussion actually is
2) Understanding what the scientific literature says about rest and return to sport/activity
3) What to do if you have experienced persistent concussive symptoms
*Disclaimer*: This article is not meant to be a substitute for seeking appropriate medical care. Its purpose to act as a guide allowing you to ask better questions and take ownership in your recovery.
What it concussion?
First, we need to know what a concussion is. There are numerous definitions out in the world, but basically it is:
Direct or indirect bump, blow, or jolt causing rapid acceleration and deceleration of the brain
This results in a change in physiology in the brain. These include changes in blood flow, altered metabolism, and changes in ion balances among other things. People can experience a wide range of symptoms that can vary in intensity. Common symptoms include headache, dizziness, nausea, neck pain, sensitivity to light, sensitivity to sound, difficulty focusing, fogginess, and changes in balance.
Also, for the sake of understanding we need to dispel a couple of myth. For a long time people believed that you had to lose consciousness in order to have had a concussion, which is not the case. Another myth is that a concussion will be able to be seen on advanced imaging. This is not the case for an average concussion. On the other hand, more serious brain injuries can be observed on these images.
It is important to note that most people recovery well from concussion. The research tells us that about eight out of ten adults will have symptom resolution over the of seven to ten days. This does mean that a small percentage of people will have persistent symptoms. It is important to note that adults and adolescents will have symptom resolution at different rates. This results in different timelines for classification of having a prolonged recovery. For an adult this duration is ten to fourteen days. For an adolescent this duration is greater than four weeks.
Treatment can look pretty similar if someone is classified as either in the acute phase or having persistent symptoms.This ends up being very individualized to the person and what they are experiencing.For simplicity I am going to split these two groups for the rest of the article.
ACUTE RECOVERY
When some someone as just experienced a concussion the most important things to consider is how much to rest and following a return to sport strategy. Again, the vast majority 8 out of 10 people will have symptom resolution in about 7-10 days.
Is rest the right answer?
I’m often asked how much should I limit activity or rest after a concussion. My answer might surprise you and runs counter to what the majority of people believe. The majority thinks that 5 days of strict rest after concussion is better than 1-2 days. Luckily for us some researchers tested this thought. What they found is that those resting only 1-2 days and then following a return to sport protocol did much better than those who rested for 5 days. The group with 1-2 days rest had symptom resolution on average 3 days sooner and had less symptoms during the follow up. By working to our tolerances we are showing the body what it needs to tolerate and providing a stimulus to help the healing process. We don’t want to rush the process. We want to go through a return to sport protocol.
Return to sport protocol
A return to sport protocol is a graded exposure approach to making sure you are ready to return to sport. This is much easier on your system than just jumping straight back into sport after resting for too many days. Return to sport is completed in distinct stages and the rate of progressing through stages is one per day. The ability to progress to the next stage is based on symptoms. If a stages activity provokes symptoms you return to the previous stage and can try that stage again after 24 hours. Below is a table from a research article that lays out each step.
PERSISTENT SYMPTOMS
What happens if my symptoms have remained?
I often get asked this question. People sometimes think that their symptoms are their new normal and that they destine to remain. This is NOT the case. The body has a beautifully innate ability to heal if the right stresses are placed upon it. There can be many different systems that concussion can affect, some of which can be addressed by physical therapy.
Domains of Concussion
In the scientific literature, they discuss six different clinical trajectories of concussion. These include cognitive, anxiety/mood, oculomotor, vestibular(dizziness), headache, and neck pain. Physical therapy can address vestibular, headache, neck pain, and along with some of the simpler oculomotor problems.
Headache, vestibular, and neck pain are very common in those with persistent concussion symptoms. What is interesting is that vestibular problems and headache can be linked together. This is due to the influence of the upper cervical spine. I'll dive into how this area can affect each of these areas and expand a little bit further on neck pain.
Headache
The type of headache that is associated with a concussion is called a cervicogenic headache. Cervicogenic essentially means of origin from the cervical spine. It is normally one-sided. It usually starts around the base of the skull and wraps around the head to behind the eye. The reason that this particular type of headache refers to the head is due to a structure called the trigeminocervical nucleus. This structure holds some of the nerves that are responsible for sensation in the head and face and is located in the upper cervical spine. The great thing about this type of headache is that it can be treated can be successful and have pretty quick results. It is common to have a 50% reduction of sx's within 2 visits. Interventions that yield really good results are targeted at restoring joint mobility of the upper cervical spine, addressing the of the small musculature, and improving muscular coordination/endurance.
Dr. Jordan Berry, a great friend, out of Onward Charlotte wrote a great article in which he covers 3 self-performed techniques to address cervicogenic headache. Check it out here “MIGRAINE HEADACHES: WHY IT’S NOT ALL IN YOUR HEAD”
Vestibular
The vestibular system can contribute to dizziness, unsteadiness, and a whole host of other symptoms. Often most people think of the funny-shaped snail-looking like structure in our inner ear for the vestibular system. What is often forgotten is the many reflexes that are part of our upper cervical spine. Just like we had cervicogenic headache, we can have cervicogenic dizziness. This just means the dizziness has the root origin coming from the upper neck. The upper neck has reflex loops that link your eyes and your vestibular system. The reason why they are located in your upper neck is so that when you move your head your eyes can maintain focus on a target. If your inputs from your eyes, vestibular system, and upper neck don't match for some reason, dizziness can be the result. For treatment, we address problems by finding the particular activities that make you dizzy and practicing them. This teaches the body the proper way to process this information.
Neck Pain
It is a common thing to experience whiplash-like symptoms after a concussion. Often these are experienced as upper back stiffness, neck pain as a result of prolonged postures, and feeling like your head is heavy. After a whiplash incident, the discomfort can alter the coordination of our muscles and the way we move. Our two focuses for treatment is to make sure stiff areas are moving well and work on the endurance of our deep neck muscles.
If you have been suffering with symptoms for a long time there is hope. I have worked with individuals that have had issues for 10+ years and they have had significant improvements in quality of life.
I hope you found this informative and now have even deeper questions. If you have any questions at all please don’t hesitate to reach out. My email is dan@arrowptseattle.com
References:
1.Mccrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017.
2.Thomas DG, Apps JN, Hoffmann RG, Mccrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-23.
3.Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports TraumatolArthrosc. 2014;22(2):235-46.
4.Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Inj. 2015;29(2):238-48.
5.Schneider KJ. Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice. J Orthop Sports Phys Ther. 2016;46(8):613-6.
6.Schneider KJ, Meeuwisse WH, Nettel-aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-8.
7.Yorke AM, Littleton S, Alsalaheen BA. Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists. Phys Ther. 2016;96(7):1018-28.