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 final instalment of a three part series on concussion, Devon focuses on persistent symptoms after a concussion and what to do about them. 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 2 discusses how to approach returning to work, school and sport.

This is where we hope no one ends up - the world of persistent concussion symptoms. The latest research suggests 15-30% of people still have symptoms after their concussions after 2 weeks for adults and 4 weeks for kids.

People have prolonged recoveries for a lot of reasons. There are risk factors that cannot be changed; for instance, being born female or suffering a concussion as a teenager increases the chances of developing persistent concussion symptoms for reasons we still do not understand. Having ADHD, dyslexia or sleep disturbances prior to the concussion are also linked to persistent concussion symptoms.

In other words, while following the guidelines outlined in Part 1 and Part 2 help reduce the chance of developing persistent concussion symptoms, it is not a guarantee. There is no blame here - there is just a problem that requires a different approach.

Types of Persistent Concussion Symptoms

People suffering with persistent concussion symptoms need to discuss their symptoms with their family medical practitioner to ensure they are getting the right care. These symptoms often fall into one or more of the following categories:

Headaches - arguably the most prevalent symptom post-concussion, the best treatment approach for headaches first requires us to figure out what kind of headaches they are. Are they migraines? What about tension headaches? Do they actually come from your neck? The type of headache will determine the best treatment approach.
Dizziness and/or visual disturbance - another very common one, this is usually the result of an affected vestibular or visual system, or both! In order to treat dizziness and visual disturbances properly, the root of the problem needs to be sussed out first. Depending on the source of the problem, several different team members may be involved including vestibular physiotherapists, neuro-optometrists, neuro-ophthalmologists, neurologists, ENTs and more.
Sleep disturbances - to heal, one needs to sleep properly. Sleep hygiene needs to be addressed first. If that doesn’t work, your medical practitioner will often refer to sleep specialists, psychologists and/or try some medications to help normalize your sleep/wake cycle.
Cognitive Function - problems here can show themselves in a variety of ways: poor memory, inability to multi-task, difficulty with word finding or word swapping… I could go on! Luckily, neuropsychologists, psychologists and occupational therapists are equipped to help.
Mental Health - depression, anxiety and other mental health disorders are more prevalent after a concussion. Psychologists, psychiatrists and occupational therapists are your friends here.
Exercise Intolerance - for some, the inability to exercise without symptoms continues well past the initial healing period after a concussion. We tackle this a bit differently in the post-concussive phase but still gradually and carefully.

The Role Of The Physiotherapist

Given the multitude of ways a concussion can affect the brain, a physiotherapist has a huge role in concussion rehabilitation.

The Neck

Everyone has seen a concussion occur, usually watching professional athletes on TV: the head snaps back after hitting the boards, the ground or another person. That amount of force is huge! When you think about it, how can you suffer a concussion without also suffering whiplash? In my clinical practice, I see the two combined - I don’t think I have ever seen a concussion without a neck injury at the same time.

Just like most injuries, whiplash and other neck injuries often heal normally. However, they can also persist and cause symptoms that look a lot like concussion symptoms: headache, dizziness, head and neck pain, fatigue, blurred vision, sleep disturbances, irritability, difficulty concentrating, memory problems… are you seeing a link here? Most symptoms of concussions and whiplash are the same. This is not to downplay concussions (or whiplash, for that matter) - it simply highlights the need for an in-depth assessment of the neck and treat it appropriately.

Exercise

Beyond the well established health benefits of exercise in general, exercise is crucial for a healing brain. Aerobic exercise encourages the growth of new capillaries, bringing more oxygenated blood to the brain. Exercise improves sleep, enhances cognitive function and can help boost mental health.

For those suffering from exercise intolerance, physiotherapists with extra training in post-concussion care are key to getting the body moving again. In the first few weeks after a concussion, exercise is kept at a level in which symptoms do not worsen. Once someone has more persistent symptoms, we are a bit more flexible with this - we gradually and slowly push into the symptoms.

This does not mean that someone with persistent concussion symptoms has license to just suck it up and push through symptoms - on the contrary! The goal here is to safely increase exercise while being mindful of symptoms. A physiotherapist is your best guide.

Vestibular Rehabilitation

Dizziness, vertigo, blurred vision, imbalance, motion sensitivity… these are all indicators of a poorly functioning vestibular system.

Your brain receives information of where it is in the world from three main systems:

Vestibular - through two tiny organs in your inner ear, your brain detects gravity: where it is and how much it’s pulling you down. No wonder astronauts have so much difficulty when they come back from outer space!
Vision - uses cues from the environment to tell you where “level” is, often from the horizon. Your brain also loves trees and things that are vertical to help orient that part of your body in space. The visual information usually matches perfectly with the vestibular information.
Somatosensory - aka touch, this system is used in feeling things outside your body (ie. the floor! The wall!) as well as things inside your body (ie. whether your knee is straight or bent). This helps your brain place your body in the space it has verified with the visual and vestibular systems.

The main problem I see is when these systems no longer match - your ears say one thing but the eyes disagree, and now you have no idea where to put your body.

Vestibular rehab involves a lot of weird exercises - looking at targets while moving your head, balancing on one foot while tracing a box with a laser beam attached to your head, throwing balls side to side while squatting - all with the goal of making your vestibular system work with your visual and somatosensory systems to make sense of your world.

Physiotherapists with extra training in vestibular rehabilitation are few and far between - you can find one in your area from the Canadian Balance and Dizziness Society’s member list or the Vestibular Disorder Association’s member list.

For some simple strategies to help mitigate symptoms, check out our blog on Five Simple Strategies for Symptoms Post-Concussion.

Concussion rehabilitation does not come with an instruction manual - there is no one-size-fits-all approach. A person dealing with persistent concussion symptoms needs a team experienced, knowledgeable and up-to-date with the latest evidence. Surround yourself with a good team to help navigate your way out.

That’s it! If you have any questions about concussion rehabilitation, feel free to contact us through email or phone us at (778) 630-8800. If you would like to book an appointment, you can do so online.