Rest is not best for concussion.

In fact it can actually make you worse.

All the recent evidence around concussion points towards a safe, but early return to exercise, and not a prolonged rest period, that was previously prescribed.

It is important that the exercise you prescribe does not heighten patient symptoms, especially in the early stages, but like any other injury we need to load the injured area to help it recover (in concussion this means the brain).

During the early stages of recovery following a concussive injury, moderate rest is still important, but what the evidence is showing is that this period of ‘rest’ is becoming shorter and that longer duration rest can actually cause more harm than good.

Concussion research is ever evolving so if you work with deal with concussions then keeping up to date with the current evidence is key.

To help you out, here are 5 top treatment options you can use with the patients or athletes you manage with concussion …

 

#1 Get Moving 

When a concussion happens there is reduction in blood flow to the brain. 

These changes were thought to be short lived but more recent research has shown that these changes may persist for some time following a head injury. 

It is thought these changes are due to alteration of the autonomic nervous system (ANS), which controls both the sympathetic and parasympathetic nervous systems.

The sympathetic nervous system is your “Fight, Flight, or Freeze” system – which is responsible for increasing your heart rate, dilating your blood vessels to pump blood to your muscles, releasing adrenaline, dilating your pupils and getting you ready for action.  

Your parasympathetic nervous system is your “Rest & Digest” system and is responsible for lowering your heart rate, increasing your digestion, activating your metabolism, and helping you to stay relaxed and calm.

When a concussion occurs this creates an imbalance in the ANS with the sympathetic nervous system becoming dominant.

Or put another way, your patient or athlete is stuck in that fight, flight or freeze state.  

This is why, particularly in the early stages of a concussive injury, the brain can not cope with exercise that requires a high heart rate because the heart rate is already elevated and because post injury blood flow to the brain is not as responsive. 

This is when you might see dizziness, headaches and similar such symptoms with an increase in physical activity and is why a graded return to exercise is needed post concussion.

And it is this exercise that helps return brain blood flow to normal…not rest!

More recent evidence even suggests that exercise might even help speed up this recovery in the early stages after concussion!

The key here is that your patient or athlete has no symptoms at rest before you start their graded return to exercise, but giving them a prolonged ‘rest’ period is likely to do them more harm than good.

 

#2 Strengthen the Neck

The majority of concussive incidents occurs as result of a direct blow to the head or rapid movement of the head on the trunk.

This is why you often see neck pain alongside a concussion.

It therefore makes sense that the stronger the muscles around the neck are, the more active stability will be provided to the head and neck.

If the muscles are able to better control the movement of the head on impact i.e. during a rugby tackle, this might limit the severity, even prevent, a concussion happening in the first place.

This is why neck strengthening is so often used within contact and collision sports to prevent both  neck joint, muscle and disc injury, but also to try reduce the incidence of concussive episodes.

So if you are working with athletes that play contact sports, including some neck strengthening exercises in their training would seem a no-brainer (no pun intended). 

 

#3 Avoid Red Meat & Sugary Foods

Just like a hamstring or ankle injury, with a concussion there is inflammation present as a result of injury.

We need inflammation to occur as it is the first stage of any tissues healing process, but what we do want to do is to prevent excessive inflammation occurring as this is only going to prolong recovery.

But unlike a hamstring or ankle injury you cannot ice or compress or elevate the brain!

But what you can do is avoid pro-inflammatory foods such as red meats, refined sugars, white breads and pastas and artificial sugars and sweeteners.

These types of foods can promote inflammation and as such are not great choices post injury.

Better alternatives would include fruits and vegetables, fish and foods containing good fats (coconut oil, flax seed, almonds). 

Such a small and simple change in diet may help to offset an ongoing inflammatory response and reduce patient symptoms.

 

#4 Concussion Specific Rehab 

You may have heard of vestibular and ocular (visual) rehab for concussion.

Primary symptoms of concussion can include dizziness, balance problems and visual problems, such as blurred or double vision, which can often extend well beyond the first few days following a concussion.

Often these symptoms can be linked to a disturbance of the vestibular-ocular-motor system. 

These types of symptoms need assessment but if present will generally respond well to rehab, usually with a fairly short course of treatment.  

Whilst this is a specialist area of therapy, there are some simple drills you can use in rehab like this…

Smooth pursuits https://www.youtube.com/watch?v=w9l-IZbX1NI

 

#5 Follow a Plan

If you have ever managed a patient or athlete post concussion you will have likely followed a graded return protocol that looks like this…

Stage 1 – 48 hrs cognitive and physical rest

Stage 2 – Low intensity exercise i.e. 20 min bike at less than 70% max heart-rate

Stage 3 – Running drills

Stage 4 – Non-contact training

Stage 5 – Contact training

Stage 6 – Return to match=play

In an elite athlete this process from injury to a return can be as little as 7 days.

It can be longer if an athlete is not elite, is less than 18 years of age or does not have access to enhanced medical care, in addition to not having a baseline cognitive assessment i.e. SCAT5 assessment and/or a computer based baseline test result.

Important here is to know the sport you are working in and what the requirements are.

Education is also key.

It is important you understand the protocol you will be using and can show and explain to your patient or athlete the stages they need to go through to get them back to full fitness. 

Like any injury, patients and athletes alike need to know how you are going to get them from A to B, from injury and back to full health, and a concussion is no different.

Educating your patient or athlete that they need to be honest and inform you if they get any symptoms at any stage of their recovery. 

This can be hard, especially in sport, as players feel pressured to get back on the pitch asap, but you need to ensure that players and patients have recovered significantly to allow them to return to their previous level of function. 

To summarise the key take-away messages…

 

#1 Get Moving – Rest is not best for concussion injury management,.

#2 Strengthen the Neck – Improving neck strength may reduce, or even prevent. Concussive incidents occurring so adding such training to at risk players appears beneficial.

#3 Avoid Red Meat & Sugary Foods – These foods are pro-inflammatory and as such may slow recovery from a concussive incident.

#4 Concussion Specific Rehab – Rehab including exercises to restore the vestibular-ocular motor system can be great to use for patients and athletes in their recovery from concussion.

#5 Follow a Plan – Ensure you understand the requirements of the sport and players you are working with and be confident with how to take a player through a full graded return to play.

I hope this blog has given you some new ideas about how to manage concussions.

There is a lot you can do as a therapist to help recovery post concussion and the days of just telling a player to rest are hopefully a thing of the past.

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As well as content on the assessment, treatment and rehab of ankle, shoulder, hip, lower back, neck and knee injuries I have bonus content on so much more including a sports injury management module…

So if you are working in sport, or want to get into sport, this type of content is gold-dust.

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