Let’s Talk about Concussion

Summary of a presentation at VGH on April 4, 2018 by Registered Physiotherapist Tori Etheridge (Arca) BKin MPT, and Registered Kinesiologist Nicole Strachan BHK, MSc. From The Balance Sheet: Quarterly BC Balance and Dizziness Newsletter. Learn more about concussions, maintaining wellness and treatment tips. Read the issue in full here.

What is a concussion?

A concussion is a force to the head, either direct (for example, a blow to the head) or indirect (for example, a force transferred from the body to the head). You do not have to hit your head to have a concussion.

This force to the head moves the brain within the skull. It typically causes brain tissue to change at a cellular level, leading to a rapid onset of neurological changes. These usually resolve spontaneously. All concussions are traumatic brain injuries – they need to be recognized as serious events.

How is a concussion diagnosed?

Unlike measuring heart rate or blood pressure, there is no device that measures a concussion objectively. Concussions must be diagnosed based on symptoms reported by the individual as well as the history of the precipitating event. Symptoms might not be immediate – it may take few days before they start to show up. Standardized imaging, such as CT scanning or MRI, often does not show a concussion.

What are some of the challenges in diagnosing concussions?

Many people still think you need to have lost consciousness to have a concussion. This is not true and can be a diagnostic stumbling block. The lack of an objective way to measure the symptoms associated with a concussion is also a challenge. Health care practitioners may differ in opinion as to what they consider a concussion and how it is diagnosed. Encountering these different approaches is an extra challenge for those experiencing concussion symptoms. In addition, concussion research is proceeding rapidly and new information sometimes does not quickly reach health care practitioners.

What to do initially after a concussion?

Recommendations of what to do immediately after a concussion have changed considerably in the past few years. What follows is based on the 2016 Berlin Consensus Statement.

A period of real rest for 24 to 48 hours immediately after the injury is recommended. Real rest means napping in a quiet, low-stimulus environment. Normal activities should be put on hold – real rest does not include going to work, school, using technology or doing chores. As long as your level of consciousness is not deteriorating, being awakened every few hours after a concussion is unnecessary – sleep after a concussion is good for the brain.

It is also important to seek medical attention by visiting a primary care physician to make sure you are medically stable. If the concussion took place at work or in a motor vehicle accident it is especially important to have your symptoms documented by a physician; this documentation is critical for any insurance claim and monitoring your history.

What to do after 48 hours after a concussion:

After the period of real rest, recommendations based on the 2016 Berlin Consensus Statement are to reintroduce cognitive and physical activity slowly while staying below symptom-exacerbation thresholds (that is, we want to challenge symptoms but we don’t want to pass the threshold). Challenging the threshold means allowing symptoms to increase overall slightly, but ensuring the symptoms return back to baseline level within 30 minutes to an hour of rest. If symptoms remain high after this hour, it is likely you have pushed it too far. Slow resumption of physical activity means gradually reintroducing activities of daily living such as light housework and simple grocery shopping. It does NOT include more vigorous activities such as hiking or running. In one to two weeks, visit your primary care physician for reassessment.

Brain rest is a crucial part of concussion recovery. Resting your brain can be a tough concept to adhere to in our fast and connected world. Brain rest in the initial stages of recovery includes activities such as: meditating, mindfulness or breathing exercises; listening to quiet music; lying down, napping or sleeping; having a bath; and taking a slow walk. It does NOT include activities such as:

• using a computer for two hours straight;
• multi-person conversations;
• using a cell phone;
• going to the mall, busy grocery stores or movie theatres;
• watching TV;
• driving; or
• exercising.

Predisposing factors that might lengthen recovery

Some factors may begin to cross over with concussion symptoms or make your symptoms worse. If you have already had several concussions, for example, it is not unusual for recovery to take longer. Discuss these factors with your healthcare professional to make sure that you are on the right trajectory towards recovery. These factors include: previous concussion; history of migraines; learning disabilities or ADHD; depression or anxiety; age; visual and vestibular abnormalities; sleep abnormalities.

Post Concussion Syndrome (PCS)

Most concussions resolve within the first three months. About 15–30% of concussions do not resolve spontaneously, however, and result in PCS. These individuals experience persistent ongoing concussion symptoms.
PCS may include the previously listed emotional, mental, physical and sleep disturbance symptoms as well as:

• Social withdrawal/isolation
• Erratic emotional responses out of proportion to the situation, including intense fearfulness, anxiety and worrying
• Balance problems
• Difficulty in busy environments (for example malls, grocery stores, big-box retailers)
• Difficulties with patterns or visually busy scenes (for example patterned carpets, windshield wipers or moving hands)
• Poor memory
• Speech difficulties
• Dysregulation of heart rate, blood pressure (exercise intolerance)

Different types of concussion presentation

Not all concussions present in the same way and can present with primarily one of the main presentations:

• Physiologic – returning to activity or exercise causes significant problems. Anything that changes the heart rate or blood pressure, from walking or running to bending over and getting up off the ground, may cause concussion symptoms to increase. Exertion therapy done with a kinesiologist, exercise rehabilitation specialist or physiotherapist may be helpful. Physiatrists, physicians who specialize in physical medicine and rehabilitation, may also be of help.
• Cervicogenic (neck-related) – changes to the neck muscles as a result of injury can cause many of the concussion symptoms. Stiffness in the neck, difficulty moving or rotating the neck and/or ongoing neck pain may occur. Hands-on work on the neck including massage therapy, chiropractic treatments and/or physiotherapy may be beneficial. Retraining the perception system in the neck, for example through laser-beam training, may help reteach the neck where it is in space.
• Migraine –migraine symptoms and triggers need to be under control and well managed.
• Affective –psychological and emotional components, such as depression, need to be considered.
• Vestibular – a concussion can cause direct injury to the vestibular apparatus in the inner ear. Or it can disrupt the brain’s ability to integrate signals from three main sensor systems: vestibular (balance portion of inner ear); visual; and proprioceptive (limb position) sensations. Working with a certified vestibular therapist may be beneficial.
• Ocular (visual) – visual issues, such as taking in information, light sensitivity, or sensitivity to motion near the face, cause problems. A vestibular therapist, neuro-ophthalmologist or a behavioural optometrist may be able to help.

Tips and tools for living with a concussion

• Pacing and planning your week to space out activities you know are challenging
• Breaking up challenging activities during the day so you do not have too many
• Taking brain breaks
• Dimming brightness on mobile phones or using an app to change the light (blue or red light)
• Using timers to limit activities
• Setting up a buddy system so you are checking in on symptoms
• Using earplugs, headphones and sunglasses – but in moderation
• Using relaxation/mindfulness apps