Devon Konrad, MPT, is one of our physiotherapists at Ladner Village Physiotherapy. She has a special interest in vestibular rehabilitation and concussion management. She also has some opinions, if you couldn’t tell. Read about what’s annoying her in the field of concussion rehabilitation below!
The concussion world moves fast. It wasn’t long ago the first line treatment for someone with a concussion was to sit in a quiet, dark room until symptoms had completely abated. Only then was the sufferer allowed to crawl out of their hiding hole and into the world, often to be bombarded with a complete assault on their senses: everything was BRIGHT, everything was LOUD, and it was all TOO MUCH.
While many advancements have been made in the world of concussion rehab, there are so many myths and old school ways of thinking that still persist. In the past few months, I have heard people say you need to lose consciousness to have a concussion (you don’t), helmets prevent concussions (they don’t) and if the CT or MRI is normal, it’s not a concussion (imaging can’t see a concussion. Yet.).
While these myths annoy me, most health care practitioners now understand they are, in fact, myths. However, I still see too many people that have been given out-of-date and just plain wrong information from health care practitioners.
There Is No Mild Concussion Anymore
Just yesterday, I ran into a very common one: the concept of a graded concussion, either mild, moderate or severe. We used to grade concussions based on a few factors: if someone lost consciousness and for how long; if they had any amnesia; and the presence of certain symptoms that supposedly indicated if the concussion was more or less severe.
In the last few years, this concept has been thrown out the window.
We no longer discuss the grade of the concussion. Instead, we discuss the domains affected by the concussion. The research world still hasn’t figured out exactly how to break this down and different models exist. In general, researchers (see links below) consider these 8 areas to be ones of importance in concussion rehabilitation:
Ocular / visual - how your brain is taking in and processing visual information as well as how your eyes are moving. Problems with your visual system may result in blurry vision, difficulty reading or missing objects when you try to grab them.
Vestibular - how your brain senses your body’s movement and its relation to gravity. Problems with your vestibular system tend to be dizziness, vertigo or imbalance.
Cardiovascular / autonomic - your brain is implicitly involved in heart rate and blood pressure and how these respond to changes in posture and demand. Problems here may show as an elevated or blunted resting heart rate, inability to tolerate exercise or lightheadedness when standing up.
Anxiety / mood - emotional lability, irritability and anxiety are very frequently seen after a concussion. Often these symptoms dissipate as brains heal but it’s common for people to see a psychotherapist trained in brain injuries to help treat this domain.
Cognitive / fatigue - difficulty thinking, multi-tasking, remembering items and words, and navigating spaces are all common complaints after a concussion. This can be secondary to other domains (for instance, if you are having trouble with your vision, it’s going to be much more difficult to focus on reading a book and thinking about what you’re reading) but it may also be a problem all on its own.
Headache / migraine - one of the most common symptoms after a concussion, this is typically caused by any of the other domains or it could be a domain of it’s own.
Cervical - also known as the neck, people typically get some type of neck injury after a concussion. If necks aren’t treated properly, they can exacerbate the symptoms from all the other domains.
Sleep - this can often be thrown for a loop after a concussion, either with too much sleep, too little, or both at the same time. Sleep hygiene is imperative for a healing brain and, just like the neck, impaired sleep can exacerabte all the other domains.
At this point in concussion rehabilitation, health care practitioners who claim to treat concussions should be very well versed in this concept. They should be doing multi-domain assessments and referring to appropriate health care practitioners because one practitioner cannot possibly treat all these domains. Concussion rehab is a multi-discilpinary field and all practitioners involved in concussion care should understand this implicitly.
Get Out Of The Dark Room
I heard this one a few weeks ago - someone came in with a concussion and one of their health care providers told them to stay in a quiet, dark room until their symptoms went away.
The research on this one is super clear. No one should be living in a dark room for days or weeks on end.
Rest is great for the first 24-48 hours, but that’s it. In this time, people with concussions are allowed to sleep as much as they want and be relatively subdued. Even in these first two days, however, they need to be exposed to some level of stimulation. It is often as simple as a walk around the block with sunglasses and a hat, and that’s ok! But staying full time in a dark room for days and days is simply not allowed anymore.
After those first 2 days, exercise needs to start. However, when I say exercise, I don’t mean go for a 10km run. Here are the parameters I use in returning to exercise after a concussion:
Before exercising, take note of your symptom level out of 10.
Aim for 20 minutes of movement. Breaks are fine, especially initially!
During and after exercise, it is normal and safe for your symptoms to be slightly exacerbated. We want to keep those symptoms within 1-2 points of your baseline.
Once you have finished exercising, your symptoms should return to their pre-exercise level within one hour.
If you find that your symptoms went higher or lasted longer than they should have, that’s ok! Use this as a guide for next time and try your best to stay within this range.
Typically, people start exercising with walking around their neighborhood. It’s a great way to keep control of symptoms as well as get some visual and auditory stimluation. As brains heal, people find they can gradually increase their pace, intensity or how long they’re exercising. As long as symptoms aren’t peaking too high and coming down within an hour, then it’s all good!
The Resources Are Piling Up
There are lots of up-to-date concussion resources out there for practitioners, parents and people who have suffered concussions. Here’s my curated and definitely not complete list:
For People With Concussions & Their Loved Ones:
VCH My Guide: Concussion - a wonderful, up-to-date resource that everyone with a concussion should visit.
VCH My Guide: Teen Concussion - the same as above, but focused on adolescents with concussions.
Concussion Online Training Tool - a wonderful tool for athletes, coaches, parents, teachers, medical professionals and anyone who may come into contact with someone who has had a concussion. This one is much more focused on recognizing an acute concussion and what to do immediately after it happens. I recommend everyone take this training.
For Health Care Practitioners Wanting To Get Deeper Into Concussions:
There are so many weekend courses focussed on concussion management as well as units on concussion as part of another specialty (for instance, the CCVR course through 360NeuroHealth has a large unit on concussion from a vestibular perpsective). If concussion rehab is where you want to be, check out these:
Consensus Statement on Concussion in Sport - published in 2023, this is our guiding document in how we currently treat concussions.
University of Calgary Online Concussion Course - run by the world renowned Kathryn Schneider, a free online course that takes a deep dive into concussion pathophysiology and introduces rehabilitation strategies.
Concussion Nerds - a massive course designed to go as deep as possible into concussion rehabilitation as we know it. Facilitated by the amazing physiotherapist Natasha Wilch.
Canadian Concussion Network - for those wanting to stay up to date with concussion research, I implore you to join the CCN. The leading brains in Canada run this organization!
Looking for those research articles? Here they are!