Devon Konrad is a registered physiotherapist and vestibular therapist. She has taken several post-graduate courses in concussion and is a true believer in the multi-disciplinary approach to concussion - in other words, it takes a team and she is but a part of it.
In her first instalment of a three part series on concussion, Devon focuses on what a concussion is and how we approach it in the first 2 weeks. Part 2 looks at return to sport, school and work. Part 3 discusses persistent concussion symptoms.
I’d love to say that concussions are rare, but they’re not. A large study out of Ontario found 1.2% of Ontarians suffer a concussion every year, suggesting concussions are way more common than previously thought.
Before you learn anything else about concussions, learn this:
Most concussions heal fully and normally.
For adults, this means a full resolution of symptoms both at rest and at normal work/school/activity levels within 14 days. For kids, it’s a bit longer - 4 weeks. How we approach diagnosis and treatment of concussions has changed dramatically in the past decade, especially in the first few weeks after a concussion.
Not so long ago, “getting your bell rung” was a normal part of sports and life in general. Unless you were knocked out for a good period of time, it was brushed off and people were told to “get back out there”.
Thankfully, those days are gone.
A concussion is a form of a mild traumatic brain injury. It can result from a hit to the head OR forced transmitted through the head, neck or body causing acceleration of the brain within the skull. Translation:
You do not need to hit your head to have a concussion.
Concussions can occur as a result of car accidents, sports or an assault. They can happen at work and at home. Across all age groups, falls are the most common cause of concussions.
Signs and Symptoms of a Concussion
There’s a saying in the concussion world: when you’ve seen one concussion, you’ve seen one concussion. This is because of the sheer number of signs and symptoms seen with concussions (there’s a lot!) and the fact that each person will show different ones.
In general, we divide the signs and symptoms into three different categories:
Physical - headache, nausea, blurred vision, balance problems, dizziness, sensitivity to light or noise, ringing in the ears
Behavioural - frustration, anger, feeling down or depressed, anxious, sleeping difficulties (either too much or too little), tearful
Cognitive - feeling “slowed down”, difficulty concentrating, feeling dazed, memory problems, difficulty multitasking, feeling foggy, “not my self”
Remember: it’s totally normal to have some in one category and none in another. Every concussion is different!
We do have a few red flag signs and symptoms to keep in mind. If these are present, a medical assessment is required immediately to rule out more serious problems:
Double vision
Seizures or convulsions
Vomiting
Progressively worsening headache
Deteriorating consciousness
Weakness and/or tingling in the arms and/or legs
Increasingly restless, agitated or combative
Diagnosing a Concussion
A concussion by itself is not considered a structural injury of the brain but rather a functional one. What does this mean for diagnosis? It means that with our current level of technology a CT or MRI will not be able to show that your brain has a concussion.
A concussion diagnosis requires two things:
A clinical history - is there reason to believe there was some serious force through the head, like a car accident or a fall? Do the signs and symptoms line up with a concussion?
A physical exam - this includes testing different aspects of brain function (including balance, reflexes, muscle tone and coordination, eye movements) as well as a full neck assessment
This diagnosis should be made by a doctor or a nurse practitioner. Why? There are several reasons for this:
They are able to rule out more serious injuries forms of traumatic brain and spinal injuries as well as other medical conditions that can present similarly to concussions
They can order additional exams, if needed
They have the ability to refer to different health care practitioners and specialists, such as neurologists, otolaryngologists, ophthalmologists, physical and occupational therapists, etc.
They can (and should!) fill out a Medical Assessment letter for you - feel free to print it off and bring it with you
It is also for these reasons that your family doctor should always be involved in your concussion care, no matter who else is a part of your medical team.
While you’re there, book another appointment for 1-2 weeks later. When dealing with a concussion, it’s important to ensure you are healing as expected and if there are any concerns, they are addressed in a timely fashion.
The First 14 Days
We can break down this critical period into two big parts:
THE FIRST 24-48 HOURS
In the first day or two after a concussion, it is crucial the brain rests. There are a whole bunch of changes that happen in the brain after a concussion (termed the neurometabolic cascade), but they basically boil down to this one concept: energy needs skyrocket at the same time that blood flow decreases. For the first 1-2 days, the brain needs some time to adapt to these changes. Sleep is great in these first few days - don’t be afraid or worried about this!
So what does rest actually mean? Two things:
Physical rest - this means keeping your heart rate in check. No exercise, weight training, heavy lifting or physical exertion.
Cognitive rest - this means not doing anything that demands concentration and focus. School and work are out for this day or two, as are video games, computer use, texting and driving.
The goal of these first 24-48 hours is to allow your brain to get to a level of stability so you can figure out where to go from there. Symptoms of concussion can take hours to develop - it’s important you rest and allow your brain to do its thing so you and your medical team can figure out what you’re dealing with and up against.
Ideas for Rest
That is a whole long list of things you aren’t allowed to do! Here are some ideas for activities the first few days after a concussion:
Meditation - if you’ve never tried it before, why not now? A few great apps are Calm and Headspace - both offer introductory programs for meditation. There are also a tonne of Youtube videos if you’d rather go that route.
Podcasts - there are some great ones out there. My favourites focus on politics/current events (The NYT’s Daily Podcast, CBC’s Front Burner), comedy (NPR’s Wait, Wait, Don’t Tell Me, The Daily Show with Trevor Noah - Ears Edition) and stories (Serial, This American Life). There are some great and amazing options out there!
Colouring or doodling - for some, this is exactly what they need and crave. It’s gentle, slow and therapeutic in a lot of ways. There are lots of colouring sheets to download as well if that’s your thing.
Music - whatever feels good and easy to listen to. For some, the thumping of drums can be hard. Classical may be the way to go for now, but do what is right for you.
Audiobooks - most local libraries (including our Fraser Valley Regional Library) have a large bank of audiobooks that can be downloaded for free. I usually recommend listening to a favourite book so you already know the plot and don’t have to think too much.
Gentle yoga - as long as you don’t get your heart rate up and you can relax and breathe fully and deeply, yoga is a great option. New to yoga? You can try an app (Down Dog is my current favourite) or feel free to follow this basic program, specifically designed for beginners after a concussion. Tip: avoid inverted postures - no downward dog or handstands!
Simple board games - for me, this would be cribbage. I don’t have to think when playing crib - my hands can play without much thought at all.
THE NEXT TWO WEEKS
The goal of this time frame is to get slowly and progressively out of rest and back to normal activity levels. Remember - most adults get there in this time frame!
Since every brain is different, there is no perfect outline for what to do on every given day. Normal activity levels differ human to human, and one person’s concussion symptoms are usually totally different than the next person.
The Four P’s
When planning this phase, we look at the Four P’s:
Prioritize activities - pick what’s important for you to accomplish. That may be reading books to your toddler, getting back to work or walking your dog.
Plan activities - need to get to your doctor’s appointment? Schedule in 30 minutes after that for a brain break and a cup of tea. Take an honest look at your day, schedule your activities and plan in time throughout your day to allow your brain to rest.
Pace yourself - If you have a medical appointment in the morning, wait until the afternoon to get that grocery shop in. Spread out your activities to give yourself the best chance of getting them done with the least amount of symptom aggravation.
Position yourself in a calm environment - This is not the time to take your laptop into Starbucks for a “working hour”. Keep your environment calmer than normal. That does not mean sitting in a silent, dark room! If you normally listen to talk radio all day, throw on some soft classical music instead.
Do your best and be prepared to change your plan! You may find that you didn’t give yourself enough of a break after grocery shopping - that’s not something to beat yourself up for, it’s just something to be mindful of for later. As you progress through your recovery, you’ll find you are able to do more with less pacing and in busier environments.
Headache Management
Finally, headache management is a huge part of concussion recovery. Here’s how to manage them:
Identify and eliminate triggers - you may notice that loud noises seem to trigger headaches or watching hockey really does you in. Whatever it is, eliminate your trigger. That doesn’t mean you’ll never be able to do that thing again, it just means it’s not an option right now.
Eat and drink well - make sure your nutrition is where it should be and you’re drinking enough water. Maintaining a healthy diet is important all the time but especially so when you’re healing from an injury.
Sleep - this one is often a tricky but important one. Brains heal during sleep - it’s important you are allowing yourself enough time to sleep. (For more information on sleep hygiene, visit our blog on sleep.)
Speak to your doctor or nurse practitioner about medications - if the first three tricks aren’t keeping the headaches under control, it’s important to speak to your medical professional about options for medication. This may be over the counter options or prescription medications. Either way, have the conversation.
In Conclusion…
That’s a lot to remember! Here are your bullet points:
See your family doctor as soon as you suspect a concussion, even if you get a diagnosis in the ER
Have them complete the Medical Assessment Letter
Ensure physical and cognitive rest for the first 24-48 hours
Gradually up your activity after the rest period, keeping your symptoms in check
Book a follow up appointment with your family doctor for 1-2 weeks after your diagnosis
Coming Up Next!
In Part 2, I will outline how to safely get back to life - work, school, sports and everything in between (dying to learn more about this now? Visit Parachute Canada for some fabulous resources). Part 3 will focus on persistent concussion symptoms - what they are and what we can do about it.
If you would like more information than what this blog dives into, Vancouver Coastal Health has released two online tools for free:
My Guide: Concussion - an evidence-based guide for adults with a concussion or those who want to learn more about it
Concussion Awareness Training Tool (CATT) -an introduction course for medical professionals to ensure appropriate and evidence-based treatment of concussions
Both contain the latest evidence and best treatment advice and are well worth a look.
If you have had a concussion and could use the help of a vestibular physiotherapist, book online, email us or call at (778) 630-8800.