“A concussion is a traumatic brain injury induced by biomechanical forces” – Concussion in Sport Group – Berlin Consensus Statement 2016.
What does that mean? A concussion is an acceleration/deceleration injury, in other words, a concussion is caused by a whiplash injury. The head must speed up (accelerate) and slow down (decelerate) quickly in order to sustain a concussion. That means you do not actually need to be hit in the head to cause a concussion – of course, the easiest way to impart acceleration to the head is an impact, however it is not necessary. If a hit to a body is forceful enough to accelerate the head to a critical concussion level you can sustain a concussion as well.
Fun Fact: You can have a whiplash injury without a concussion. However, you cannot have a concussion without a whiplash injury
- Excitatory Phase: When the head is accelerated/decelerated to a certain threshold the nerve cells within the brain are physically stretched; this physical stretching causes the nerves to send off millions of signals at once causing an electrical storm within the brain, the brain is unable to process all this information which is why people often show a variety of symptoms upon impact (dazed and confused, loss of consciousness etc) – this is the first phase of a concussion called the Excitatory Phase, it is short in duration.
- Spreading Depression Phase: All of this nerve firing burns a lot of our body’s energy known as ATP (Adenosine triphosphate), and causes an increased production of chemicals within the cells that make it difficult to create more energy (ATP) – this causes a massive energy crisis, which is known as the second phase of concussion the Spreading Depression Phase – this usually occurs over the next few hours to days
Conclusion: concussion is a metabolic (energy) injury more than a structural injury – the nerve cells are in an energy crisis but are not significantly physically damaged.
How long does an acute concussion last for?
- Our cellular energy stores, or in other words our cells’ gas tanks, take 22-30 days to fully recover (i.e. it takes 22-30 days to fully recover from a concussion)
- 85-90% of concussions resolve SYMPTOMATICALLY within 7-10 days (that means most people who have sustained a concussion feel back to normal within that time frame)
It takes 7-10 days to feel better but it takes 22-30 days to recover…….what does that mean? It means that SYMPTOMS DO NOT CORRELATE OR MATCH UP TO RECOVERY with this type of condition.
Myth: your brain will be permanently damaged following a concussion.
Fact: actually if you fully recover from a concussion there are no long lasting effects (from what research has shown so far!) – the issue is not allowing yourself enough time to recover or not rehabilitating the concussion properly initially.
Quick access to healthcare leads to improved recovery!
Why do some people have symptoms for months or years?
10-15% of people who get a concussion will go on to have long term symptoms or deficits in balance, reaction time, neurocognitive function, etc. (beyond 22-30 days) – this is termed Post-Concussion Syndrome (symptoms beyond 1-3 months).
Beyond a 22-30 day period post-injury, there is no real explanation, within the brain itself, for Post-Concussion Syndrome
The exact cause of post-concussion syndrome is UNKNOWN, but here are six theories:
- Continued metabolic dysfunction (cellular gas tanks are still low) – has the person not rested at all? Are they unable to restore their cellular energy?
- On-going Inflammation – the theory is that the initial injury/microstructural cell damage causes an inflammatory response that is not under control
- Blood flow issue – the inability of the blood flow within the brain to respond to variations in blood pressure within the body (this should resolve in 2 weeks); OR maybe there are on-going issues/overdrive of the sympathetic nervous system (fight or flight system) causing a constant high heart rate and reduced exercise intolerance (these people often have an increase in symptoms whenever they get their heart rate up or exercise)
- Cervicogenic dysfunction – whiplash or neck related symptoms
- Vestibular (inner ear) and/or visual issues
- Psychological distress – anxiety and depression can occur or become amplified after a concussion and can physically manifest as symptoms similar to a concussion
How can we treat Acute Concussion/Post-Concussion Syndrome?
- Education: as with all injuries, understanding the condition itself allows you to rehabilitate it properly
- Relative Rest: hiding in a dark room until your symptoms disappear is a MYTH; I recommend relative rest – ie light chores, slow walks around the neighbourhood, short talks with a friend, listening to podcasts or movies (the eyes take up a major portion of your brain so activities that don’t put a lot of strain on your eyes is best)
- Return-to-Work and School/Return-to-Play protocol: understanding how to progress yourself to normal work/school activities/duties and sport WITHOUT exacerbating symptoms
- Treadmill/Bike Test: to see if you can get your heart rate up without symptoms – can we begin exercising; exercising is not encouraged during the first two weeks because of the above blood flow issue that occurs initially post-concussion; however, exercise is actually very important when it is safe to do – it actually helps with brain healing!
Often for acute concussions, education and guidance is the main form of treatment needed to get back to your activities symptom-free within 30 days.
If you are still having symptoms 7-10 days post-concussion (remember 85-90% of people are symptom-free at this point), there may be something else going on! At which point, I treat these people the same way I would someone with Post-Concussion Syndrome.
Post-Concussion Syndrome Treatment
- Rest: for those people who have been “go go go” since their injury
- Referral to Naturopath: if we suspect that there is still an issue with metabolic recovery and inflammation, diet and supplements can have a big impact!
- Neck treatment: sometimes reduced strength and stability, or injury to a specific muscle or ligament can be causing long term symptoms
- Visual Rehabilitation: physiotherapists who are trained in concussion rehabilitation have the skills to test your ocular movement and function and can give you exercises to work on at home
- Neuro-Optometrist Referral: if we don’t think you are progressing as much as we like we can refer you to a specialist in the field for continued assessment and rehabilitation as well as lenses prescription
- Vestibular treatment: vertigo and dizziness is a common symptom for concussion patients, again physiotherapists trained in concussion or vestibular rehabilitation can assess and give you exercises to help
- Psychological Distress: as a health care professional you always need to know if a patient fits within your scope of practice; as a physiotherapist I can offer some general guidance when it comes to breathing and mindfulness, but sometimes a referral to a counsellor, social worker or psychiatrist can be beneficial
So the next time you or someone you know is experiencing symptoms following a hit to the head or body – don’t put on sunglasses and hide; find a physiotherapist or other health care professional trained in concussion rehabilitation and seek treatment immediately for the best outcome and quickest recovery.
Written by: Karen Boyle, Registered Physiotherapist
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