So we've now read about the RECOGNITION of concussion, and the REMOVAL FROM PLAY of athletes who are suspected to have sustained a concussion. But what do you do next?
The old advice was for anyone who sustained a concussion, or had concussion-like symptoms to rest, both cognitively and physically, until symptoms subsided. This included ZERO activity, mental or physical, and the advice was to stay in a dark room, with no visual, auditory or cognitive stimuli. It is very difficult for anyone to follow these guidelines, especially if they are a young child, or must return to work.
While this advice has not yet been debunked, and there is still great research being done to validate it, there are also other theories surfacing! Studies as recently as last year indicate that complete rest may actually prolong recovery and increase symptoms.
So what do we do during recovery?
During the first week following concussion, the rule is that rest is best, unless otherwise indicated by a health care professional. However, a qualified Health Care Professional will be able to assess an athlete as soon as 1 day post-injury to determine what kind of concussion symptoms are being experienced to target rehabilitation and treatment.
Type of concussion? This is all new!
There are four major systems that are affected by concussions. A concussion can have symptoms effecting just one system, but it is more common to affect two or three. Severe cases of Post Concussive Syndrome can cause symptoms affecting all four systems for many years.
Autonomic - Relating to the autonomic nervous system, which controls all the background processes of the body. Immediately following concussion, there is a rapid cascade of chemical changes in the brain which can alter the internal rhythms and the ability of the body to regulate things like sleep and wake schedules, hunger, concentration, and other metabolic processes.
Vestibular - Relating to the balance systems, and the vestibule system of the inner ear. The inner ear contains fluids and space that are used by tiny receptors to help the body to know where it is in space, and achieve compound movements without feeling vertigo or dizziness. Concussion can shift the delicate control of this system, and it needs to be retrained just like a strained muscle or sprained ankle to work properly again.
Visual - Studies have shown that between 50 and 90 percent of all mTBI or Concussion patients experience some sort of visual disturbance. These symptoms include loss of peripheral vision, poor convergence (seeing double), difficulty fixating on objects, or tracking with moving objects, or sensitivity to light and stimulus. If left untreated, these symptoms can persist, effecting every day life, and potentially reducing sport performance.
Cervicogenic - Relating to the cervical-spine (head and neck). The mechanism that causes a concussion almost always also produces a whiplash mechanism, which can cause dysfunction of the many joints and muscles in the neck. These dysfunctions can be the cause, or a major contributor to symptoms such as headache, dizziness, ear discomfort and face/eye pain. Treatment to the neck can help decrease symptoms, and help to make more clear what other systems require treatment.
So whats all this 'Treatment' you're talking about?
When a patient comes to me in the clinic following a concussion, I complete a thorough history and assessment. The history includes a discussion of the mechanism of injury, symptoms experienced, and a comparison to baseline testing (if available). From this history and assessment, I recommend one of three things: Immediate referral to a medical doctor, complete rest, or entry into a treatment program. This decision depends on the number and severity of symptoms, and if any red flags are encountered indicating that imaging and further medical testing is required.
Once a patient is ready to enter into a treatment program, a more thorough physical assessment is completed. This may include just one or all four of the systems that can be affected by concussion. For example, if the patient is experiencing headache, dizziness and difficulty sleeping, I would assess all four systems as they all could be contributors.
Treatment programs can commence prior to Return to Play and Return to Learn protocols, but require close monitoring and evaluation. There is a delicate balance between working hard enough to lessen the recovery time, without pushing too hard to lengthen it. The key is sub threshold activity to stay out of the "danger zone".
Dangerous Activity Pattern
Target Activity Pattern
So who can provide this treatment?
Depending on the severity of symptoms of a concussion, or of Post Concussive Syndrome, experienced by a patient, their team may consist of many professionals.
A sports medicine doctor may refer a patient to a neurologist for further examination, especially if physical damage to the brain or skull is suspected.
Consultation with an Ophthalmologist, or eye surgeon may be recommended if visual disturbances are extreme, especially if assisting devices or corrective glasses are required.
A hearing specialist may be consulted if there is suspicion of damage to the inner ear, or the nerves that lead between the ear and brain. Sometimes specialized ear plugs may be indicated that reduce ambient noise to allow a patient to function.
There are many other types of medical professionals that may be consulted during the journey of recovery from a complex or simple concussion. These can be very confusing or intimidating to athletes and families of athletes who are playing at the recreational or youth level of sport.
Athletic Therapists are trained in the recognition and treatment of many facets of concussion rehab. ATs are also very knowledgeable about the other professions and how they can help treat various conditions.
Take Home Message?
An Athletic Therapist should be your first line of defense against concussion, and once sustained your tour guide and treatment specialist to help over come symptoms. From baseline to return to play, AT's are specialists who care passionately about your health, and performance!
by: Alana Gulka CAT(C), BAHSc-AT, BSc
Certified Athletic Therapist