Concussion

What is concussion: 

Concussion is the ‘stretching and sheering’ of neurons that causes a temporary ‘electrical storm’ in the brain which depletes ‘energy resources’. The electrical storm and depletion of energy/energy mismatch explains symptoms in the initial 30 days post injury. Peak reduction in brain energy stores is at 3-5 days post injury, so sometimes people do not feel the full extent of their injuries until this time. 

Figure 1: Levels of energy sources against time course following concussion.

 

     Signs of concussion immediately following the injury include any of the following:

     1. Decreased level of consciousness, for less than 30 min.

     2. Any lack of memory for events immediately before or after the injury (post-traumatic amnesia), less than 24       

     hours.

     3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking,     

     alteration of consciousness/mental state).

     4. Physical Symptoms (e.g., vestibular, headache, weakness, loss of balance, change in vision, auditory sensitivity,      dizziness).

     5. Note: No evidence of Intracranial lesion on standard imaging (if present, suggestive of more severe brain injury).

 

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     What should I be doing in the meantime, before my assessment, to assist in my recovery?

• Relative rest- not complete bedrest by any means.

• Your body will crave more sleep to help with recovery, so allow yourself some rest times during the day in the very acute phases. If day naps are affecting your sleep at night, these should be limited. See Sleep Hygiene Handout for more information.

• Stay relatively mobile and active, as symptoms allow. Walking is ok, however do not do strenuous cardio-vascular exercise or resistance training if this makes your symptoms worse (until your therapist allows this).

• Do avoid activities that cause a large increase in symptoms in the initial two weeks.

• If work or school is aggravating symptoms, then time off from these activities are supported. You may need to discuss a gradual return to school and work program if you are symptomatic. Your GP may be able to help you with this. Your therapist at VertiGO Physio and Rehab will give you a clearer understanding of which ‘phase’ of return to activity you fit after your assessment.

• Eat well and sleep well. See ‘Brain Recovery Diet’ handouts for more information. Please seek support form nutritionist/dietician as required for more detailed recommendations.

• Avoid tasks that aggravate headaches you may be having for the mean time.

• If you have a sore neck, avoid hands on treatment in the initial phases. Evidence supports active stretching and range of motion exercises (slowly turning your head to the right and left x 10 reps, slowly looking up and down x 10 reps, ear to shoulder movement x 10 reps).
  
  Overall treatment approaches your physiotherapist will be utilising:

• Acute: (0-4 weeks): Education, reassurance, sub symptom threshold training and non-pharmacological interventions.

• Post-Acute: (4-12 weeks): Focus should be placed on managing sleep impairment, headache, mood, fatigue, and memory/attention. The focus is on a graduated return to activity which may include work and school.

• Persistent: (3 months +): If symptoms persist for more than 3 months, patients require an interdisciplinary team for symptom management using an individualized management approach with focus on returning to pre-injury activities.
  
  Prolonged symptoms following concussion:

• Most patients recover in 2-4 weeks. Post Concussional Syndrome (PCS) is defined by the International Classification of Disease-10: Any 3 symptoms of: headache, dizziness, nausea, vomiting, fatigue, irritability, sleep problems, memory problems lingering for more than 4 weeks post injury [1].

• Recent literature is suggesting different subcategories of “PCS” or ‘symptom generators’ to better account for potential localisation of injury and lead to a more directive treatment plan [1].

• Symptom generators categories: Physiological: E.G. Possible altered cerebral cortex excitability. Reduced cerebral vascular reactivity and blood flow. Hormone influence. Ongoing inflammatory processes (gut brain link). Plus, vestibular-Ocular (inner ear and eye related), Vestibulo-spinal and cervical (balance and neck issues), mood and cognitive factors.
  
  Main categories of PCS and Research Supported Treatment utilised at VertiGO Physio and Rehab:

​      Physiological (post-concussion) disorders:

      *Graded return to exercise and daily activities. Buffalo treadmill test recommended.

      * Diet recommendations

      * Sleep hygiene

      *Referral to a neurologist if required.

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      Cervicogenic (post-concussion) disorders:

      *Somatosensory retraining of the cervical spine.

      *Strength retraining of the neck.

      *Pain relieving techniques.

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      Vestibular-ocular (post-concussion) disorders:

      *Vestibular rehabilitation and visual sensitivity retraining.

      *Ocular movement retraining- especially convergence.

      *Referral to a neuro-ophthalmologist and behavioural optometrist if required.

     

      Balance:

      *Graded balance retraining tasks.

      * Incorporating all components of balance integration- visual, vestibular, ‘joint sense’.

      *Dual tasking with cognitive and other motor tasks.

 

      Psychological:

      *Mindfulness techniques

      *Relaxation techniques

      *Yoga

      * Referral to psychologist for cognitive behavioural therapy if required.

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The role of your Physio in PCS:

• Identify the subcategory of post-concussion syndrome you fit in with.

• Assess using globally utilised PCS specific assessments.

• Treat as indicated for the type of PCS category you have.

• Continue to reassess the PCS specific assessments throughout treatment.

• Education around PCS and graded return to exercise and daily activities.

• Case co-ordinator where relevant.