Don't Call It A Mild Concussion

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 However, I still see too many people that have been given out-of-date and just plain wrong information from health care practitioners.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!

Kontos AP, Sufrinko A, Sandel N, Emami K, Collins MW. Sport-related Concussion Clinical Profiles: Clinical Characteristics, Targeted Treatments, and Preliminary Evidence. Curr Sports Med Rep. 2019 Mar;18(3):82-92. doi: 10.1249/JSR.0000000000000573. PMID: 30855306.

Lumba-Brown A, Teramoto M, Bloom OJ, Brody D, Chesnutt J, Clugston JR, Collins M, Gioia G, Kontos A, Lal A, Sills A, Ghajar J. Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery. 2020 Jan 1;86(1):2-13. doi: 10.1093/neuros/nyz332. PMID: 31432081; PMCID: PMC6911735.

Craton N, Ali H, Lenoski S. COACH CV: The Seven Clinical Phenotypes of Concussion. Brain Sci. 2017 Sep 16;7(9):119. doi: 10.3390/brainsci7090119. PMID: 28926944; PMCID: PMC5615260.

Five Simple Strategies for Symptom Management Post-Concussion

Stephanie Yip is one of our vestibular therapists here at Ladner Village Physiotherapy. Since her own concussion many years ago, she has been passionate about learning as much as she can about concussion rehabilitation. Here, Stephanie shares a few of her favourite strategies for symptom management post-concussion.

Have you (or a loved one) suffered a concussion? Are you finding yourself struggling with day-to-day tasks? Are you constantly overwhelmed by the onslaught of bright lights, noises, and people coming and going? Are you hiding in a dark room by late afternoon?

If you’ve answered yes to one or more of these questions, you are not alone. There are over 200,000 concussions diagnosed in Canada annually, and those are only the ones that are reported. When healing from a concussion, symptoms can be difficult to control.

Only about half of people know what to do when they or their loved ones suffer a concussion. For what to do in the first days and weeks after a concussion, check out Part 1 of our series So You’ve Had A Concussion and download Concussion Recovery 101.

Here are a few simple strategies that you can start implementing right away to start easing your symptoms when you’re having a bad day.

Full disclaimer: these are tools for symptom management, and can be used throughout the day to help you cope. These are not meant to replace concussion treatment/rehabilitation.

Five Strategies for Post-Concussion Symptom Management

1. Palming

This is my personal favourite strategy. Let’s say you’re at the grocery store because you desperately needed eggs but it’s a lot busier than you expected, and you are suddenly hit with a wave of dizziness as you scan the aisles. You want to run and hide in a dark room except there’s nowhere to go.

What do you do? Create your own “dark room”! Cover your eyes with your palm and bathe your eyes in darkness. Look forward into the black and count as you take 10 deep breaths. This works as a recovery tool and you can use it anytime you need a quick break from your surroundings.

2. Musician’s Earplugs

After a concussion, your brain becomes very inefficient at filtering out background noise. This is why you’ve probably noticed yourself yelling at the kids for playing their video games too loudly, or maybe you’ve suddenly developed a newfound loathing of the lawnmower. It can be tempting to start wearing earplugs or noise cancelling headphones to cope. The problem with this is if you start perpetually living in silence, you’ll never learn to tolerate noise again, which will stall your recovery.

Instead, give musician’s earplugs a try. These earplugs have varying levels of filter, so you can choose the least amount of reduction that you can tolerate. You’ll still be able to hear the lawnmower and hold a conversation with a friend, but you won’t want to rip your hair out.

3. F.lux

Do your eyes fatigue easily after using your computer or phone? I promise I’m not sponsored by F.lux but I do love their software.

F.lux is basically a fancier version of the “night mode” setting on your phone. F.lux makes your computer screen look like the “daylight” depending on the time of day, so it will be a warmer glow at night, and then brighter like sunlight during the day. You can adjust the settings to your bedtime so it gradually changes as your day progresses. You can also just keep it “warm” all the time if that’s what you’re able to tolerate that day. (But as your physio, you know I’ll be getting you to gradually increase the brightness over time...’cause that’s the only way we get better!)

4. Reading Tips

Reading is hard after a concussion! But that doesn’t mean you can’t still read and enjoy all the books you used to.

Try placing a piece of paper under each line as you’re reading. This reduces the amount of visual input that your eyes have to take in and filter and allows them to track the letters with less difficulty.

Large font books or enlarging the font on your kindle can be another lifesaver.

Audiobooks can also be a great option, and can even be used as a restful activity. I know they can seem daunting, but try starting out with some easy teen lit (think Harry Potter, Twilight or the Hunger Games) and make sure you like the voice of the reader! Before you know it, you’ll be listening to audiobooks every night.

5. Surface Orientation

Do you ever feel like you’re floating or walking on clouds? I’ve had clients also describe it as walking with pillows for feet. Or maybe you just get hit with waves of dizziness throughout the day. This one is for you.

You can do this sitting, standing, or lying down, depending on the situation you’re in. Whichever position you’re in, find something very firm and solid to stand, sit, or lie on. If you’re near a wall, press your full back against the wall. Focus on the feeling of your feet on the ground, your bum in the chair or the wall on your back. Really focus on each part of your skin that is touching the surface. Take a few deep breaths. Continue focusing on the firm surface you are supported against, and tell yourself that you are not moving. Imagine that gravity is gently pulling you straight down into the surface of the chair, wall, or floor. Check in with yourself. You should feel more grounded.

There you have it – five simple, easy strategies you can start implementing right away. And don’t forget the importance of sleep hygiene, exercise, and pacing!

Remember that 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.

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.

So You've Had A Concussion, Part 3 - Persistent Symptoms

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:

1. 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.

2. 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.

3. 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.

4. 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.

5. Mental Health - depression, anxiety and other mental health disorders are more prevalent after a concussion. Psychologists, psychiatrists and occupational therapists are your friends here.

6. 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:

1. 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!

2. 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.

3. 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.

So You've Had A Concussion, Part 2 - Returning to Life

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:

1. Before starting a return to anything, a day or two physical and cognitive rest are needed.

2. 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!).

3. Each plan is broken down into specific stages that must be achieved before moving onto the next stage.

4. 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.

5. 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:

1. Physical and Cognitive rest - just like for everything else, this is max 48 hours or when symptoms start to improve

2. Light cognitive activity - working up to 30 minutes of reading, drawing or TV without an increase in symptoms

3. Stage (2) plus school work at home - working up to 60 minutes of school work in 30 minute chunks.

4. 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

5. 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

6. Full time school - minimum accommodations with no limits on cognitive activity at school and up to 60 minutes of homework per day

7. 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:

1. Symptom-limiting activity - before the athlete can start back into their sport, they need to get back to school or work without worsening symptoms.

2. 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.

3. 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!).

4. 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.

5. Full contact practice - after medical clearance from the athlete’s family doctor or nurse practitioner, contact is added into the mix.

6. 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.

So You've Had A Concussion, Part 1 - The First Two Weeks

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:

1. Physical - headache, nausea, blurred vision, balance problems, dizziness, sensitivity to light or noise, ringing in the ears

2. Behavioural - frustration, anger, feeling down or depressed, anxious, sleeping difficulties (either too much or too little), tearful

3. 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:

1. 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?

2. 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:

1. 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

2. They can order additional exams, if needed

3. They have the ability to refer to different health care practitioners and specialists, such as neurologists, otolaryngologists, ophthalmologists, physical and occupational therapists, etc.

4. 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:

1. Physical rest - this means keeping your heart rate in check. No exercise, weight training, heavy lifting or physical exertion.

2. 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:

1. 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.

2. 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.

3. 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.)

4. 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.