Sidelined By Concussion: Rethinking The Restful Approach To Recovery
Among the many challenges to providing proper post-concussion assessment and treatment, such as a lack of biomarkers for concussion, no imaging techniques to fully diagnose the injury, and the numerous “neuro-mythologies” surrounding it, one of the hardest hurdles to overcome is debunking the myths surrounding concussion.
And what is the biggest myth surrounding concussion? That rest and inactivity are the only road to recovery. While initial removal from play and refraining from contact sports activities until clearance are part of the equation, we know that the best form of recovery is active, targeted treatment.
Not A One Size Fits All Injury
Concussions are heterogeneous and there are a variety of clinical profiles characterized by different symptom presentations1,2,3. Each clinical profile requires an individualized treatment approach. Within this clinic, we comprehensively assess each patient to provide a more accurate conceptualization of the injury and match targeted treatments to specific clinical profiles. This comprehensive assessment includes a clinical interview and examination, medical history (including risk factors) and injury information, concussion symptoms (somatic, cognitive, affective, sleep), and evaluations of impairment (balance, cognitive, ocular, vestibular). When evaluating and treating concussion, modifying factors such as sleep and cervical involvement are also considered. This individualized approach to concussion care- matching targeted treatments to specific clinical profiles -provides patients with a more efficient and safe return to sport, work, and daily functioning.
For example, patients who experience anxiety and worry post-concussion will likely benefit from non-contact physical activity, while those who are experiencing vestibular issues might need to follow a more modified approach to activity until dizziness or other symptoms improve through treatment. For a patient who is experiencing ocular issues, physical activity may be beneficial, but activities like focusing on schoolwork or a computer screen may be difficult and require additional time initially. Clear communication with workplaces, schools, and parents is key for engaging effectively in school and work activities.
Removal from Play in Sports
Immediate removal from play is recommended for athletes with suspected concussion to protect them from repeat injuries and potentially catastrophic consequences. Recent research supports that removal from play protects athletes from protracted recovery. Athletes who are not removed from play may take longer to recover and demonstrate worse symptoms after concussion6. Acute management of concussion by a medical professional is important to assist athletes in safely returning to sport after injury.
Sleep vs. Rest
After the initial injury resulting in concussion, it’s not uncommon for parents to be concerned about their child falling asleep. In actuality, a good night’s sleep is beneficial for recovery. However, excessive sleeping/napping and inactivity in the days and weeks following the initial injury are likely to result in deconditioning and dysregulation that may prolong recovery. Recent research supports that gradually resuming non-contact/non-risk physical activity after a concussion is not harmful and in fact, may be associated with improved rates of recovery from concussion4,5.
Conditioning Is Key
Much like a physical injury, sustaining a brain injury – even a mild one – requires that the patient be symptom-free at rest and with exertion to return to full-contact sports activity. To accomplish this goal an active treatment plan is required. We work with physical therapy and athletic trainers to ensure athletes are engaging in activities targeted to their clinical presentation. Adults returning to non-sport activities are also encouraged to use an expose-recover model to allow them to resume daily activities while appropriately managing symptoms Though it may be difficult at times, just as it is for an individual recovering from surgery or other injuries, post-concussion patients may also need to gradually “work through” discomfort to make progress.
Mood Management and Depression
One of the lesser-known symptoms of a concussion is a change in mood, including feelings of depression, anxiety, or even feeling hopeless post-injury. Though these anxiety/mood issues aren’t uncommon, it is important to ensure that patients don’t become isolated due to a lack of motivation or to avoid experiencing symptoms. In instances such as these, we work with patients to recommend active treatments, as opposed to encouraging rest and allowing them to remain isolated from the outside world.
Comprehensive evaluation and management, including matching targeted treatments to specific clinical presentations, by an experienced concussion clinician is important to safe, efficient recovery from concussion.
Relevant Concussion Videos
Anxiety/Mood Trajectory of Concussion
Ocular Trajectory of Concussion
Vestibular Trajectory of Concussion
1 Collins, M. W., Kontos, A. P., Reynolds, E., Murawski, C. D., & Fu, F. H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy, 22(2), 235-246.
2 Kontos, A. P., Sufrinko, A., Sandel, N., Emami, K., & Collins, M. W. (2019). Sport-related concussion clinical profiles: clinical characteristics, targeted treatments, and preliminary evidence. Current sports medicine reports, 18(3), 82-92.
3 Lumba-Brown, A., Teramoto, M., Bloom, O. J., Brody, D., Chesnutt, J., Clugston, J. R., … & Sills, A. (2019). Concussion guidelines step 2: evidence for subtype classification. Neurosurgery, 86(1), 2-13.
4Lal, A., Kolakowsky-Hayner, S. A., Ghajar, J., & Balamane, M. (2018). The effect of physical exercise after a concussion: a systematic review and meta-analysis. The American journal of sports medicine, 46(3), 743-752.
5Leddy, J. J., Haider, M. N., Ellis, M. J., Mannix, R., Darling, S. R., Freitas, M. S., … & Willer, B. (2019). Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA pediatrics, 173(4), 319-325.
6 Elbin, R. J., Sufrinko, A., Schatz, P., French, J., Henry, L., Burkhart, S., … & Kontos, A. P. (2016). Removal from play after concussion and recovery time. Pediatrics, 138(3), e20160910.