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 second instalment of a three part series on concussion, Devon focuses at return to sport, school and work. Part 1 looks at what a concussion is and how we approach it in the first 2 weeks - if you have recently suffered a concussion, start at Part 1 first! Part 3 discusses persistent concussion symptoms.

If you’ve had a concussion, you’ve likely heard that you need to return to activities slowly. But has anyone ever defined that for you? What does “slowly” mean? What “activities” are we talking about? Why is everything so vague?!?

It’s a fair point, dear reader - the concussion world is a vague one. Thankfully, there’s been a huge push in the past decade to answer these exact questions and give a solid framework for return to school, work and sports.

Remember: most adult brains heal wonderfully within 2 weeks and kid brains within 4 weeks. We expect most people to progress through their recovery even if things aren’t smooth the whole way.

Regardless of how progress is going, everyone should have a follow up appointment with their medical doctor or nurse practitioner within 2 weeks of their concussion. This allows any potential problems to be identified early and dealt with in a timely fashion.

First, A Word On Symptoms

We used to say you should not increase your activity level until you were symptom-free. Well, we were wrong. If you broke your leg, we would expect some pain and crankiness from your leg as it healed. The same goes for your brain - we do not expect you to progress through your recovery symptom free.

In these first few weeks, what we avoid are worsening symptoms. If you go into a day with your head feeling like a 3/10 (with 0 being completely symptom free and 10 being the worst symptoms imaginable), we want those symptoms to generally stay at a 3 or below. When symptoms start to increase, the activity needs to be changed and symptoms need to be actively managed.

Starting A Return To…

Here are the general points of any return to school/work/play plan:

Before starting a return to anything, a day or two physical and cognitive rest are needed.
Returning to work and school take priority over returning to sport (I know I’m breaking some hearts when I say that - I’m sorry!).
Each plan is broken down into specific stages that must be achieved before moving onto the next stage.
If a person feels ready to move onto the next stage and symptoms spike, they are brought back to the previous stage. This does not mean they fail, it just means they take a bit more time at the previous stage.
Every person will progress differently through the stages. Brains are complex and no two recoveries are the same!

Return To Work

It is important for all groups involved - the client, the employer and the medical team - to collaborate and work together in getting someone back to work safely. We follow the same guidelines for work as we do for other activities:

Take a day or two off work. Make sure your brain is able to rest, both physically and cognitively.
Work on you first. Keep your normal work day routine. Get dressed, make simple meals, go for walks. Make sleep at night a priority and keep a schedule during the day.
Start gradually adding work activities in (for instance, working on the computer or reading). Start in short bursts - no more than 15 minutes in one sitting - and pace yourself!
As you heal, gradually add more time, amount and intensity of the activities. Remember: the goal is to keep your symptoms from worsening.
If your symptoms worsen, back off. Go back a stage and stay there another day or two. An increase in symptoms is not a sign you are doomed, it just means you went a little faster than your brain was ready for. Listen to your body and try again later.

The decision of when to return to work is very job dependent. The administrative assistant may need to make sure their symptoms are controlled with a lot of computer work while the electrician may need to be comfortable working at the top of a ladder while looking overhead. Each job presents its own hurdles.

As physiotherapists, we are integral to the return to work plan, breaking down tasks into manageable components and gradually increasing these safely. The collaboration between the medical team, the employer and the client is crucial to ensuring a safe and successful return to work.

Return To School

We are very lucky to have the GF Strong Rehabilitation Centre, a leader in the field of traumatic brain injury research and treatment, in Vancouver. One area in which they have invested significant resources is the GF Strong School Program, a collaboration between teachers and medical professionals to get kids back to school after concussions (as well as other injuries and illnesses).

Their Return to Learn protocol outlines specific stages for return to school after a concussion. Every student needs to have a return to school plan with accommodations depending on symptoms. Teachers, principals and counselors need to be aware of the student’s concussion and the plan that has been set in place.

Here’s a snapshot of the Return To Learn protocol:

Physical and Cognitive rest - just like for everything else, this is max 48 hours or when symptoms start to improve
Light cognitive activity - working up to 30 minutes of reading, drawing or TV without an increase in symptoms
Stage (2) plus school work at home - working up to 60 minutes of school work in 30 minute chunks.
Back to school part time - with the return to school plan and maximum accommodations in place, working up to 120 minutes of cognitive activity in 30-45 minute intervals
Part time school - moderate accommodations, working up to 240 minutes of cognitive activity in 45-60 minute intervals plus up to 30 minutes of homework per day
Full time school - minimum accommodations with no limits on cognitive activity at school and up to 60 minutes of homework per day
Full time school - no accommodations or limits

If you are teaching kids with concussions, GF Strong created a Guide for Classroom Teachers with links to more resources.

The CDC also has a great document for returning to school - it outlines who at the school should be involved in the process and some great strategies when running into specific concussion-related roadblocks. They also have some great information about concussions aimed at school nurses, educators and parents.

Return To Sport

Good news for the athletes! Almost all of the research in concussions has been done in the sports world. As a result, several sports have tailor-made return to sport guidelines. A return to sport strategy can be started after the first 24-48 hours of physical and cognitive rest. Generally, it’s recommended that at least 24 hours pass between stages - no skipping ahead!

In general, the guidelines follow 6 stages:

Symptom-limiting activity - before the athlete can start back into their sport, they need to get back to school or work without worsening symptoms.
Light aerobic activity - here, the goal is just to get the heart rate going without worsening symptoms. Concussions can have a significant effect on heart rate and it’s important to get this under control before introducing anything else. Resistance training is not allowed in this stage.
Sport-specific exercise - now, movement is added in the form of running or skating drills. Resistance training is still a no go, as are any head impact activities (no tackle practice!).
Non-contact training drills - it’s time to add a bit of thinking to the physical exercise, making it significantly harder on a healing brain. Resistance training is generally allowed to start at this stage.
Full contact practice - after medical clearance from the athlete’s family doctor or nurse practitioner, contact is added into the mix.
Return to sport - goal achieved!

For sport-specific return to sport guidelines, scroll on down to Sport-Specific Return-To-Sport Strategies for everything from rugby and hockey to badminton, canoe and water polo.

Parachute Canada is a fabulous organization with a lot of sport concussion resources, including the Canadian Guideline on Concussion in Sport. It includes the Concussion Recognition Tool, a handy print out aimed at coaches and parents without a medical background to help figure out if an athlete has suffered a concussion.

Once again, I urge you to visit the Concussion Awareness Training Tool website - it has specific information for parents, coaches, athletes, educators and workers. It includes much more information than I am presenting here and is a fabulous road map to concussion recognition and recovery.

Next up is Part 3: persistent concussion symptoms - what they are and what we can do about them.

If you are looking for some help with your concussion (or anything else!), book online, email us or give us a call at (778) 630-8800.