There’s a lot of myths around concussion symptoms and treatments and this often leads to confusion about what you should or shouldn’t do after a concussion. I’m going to discuss the most important questions like should you be resting or exercising? How should you handle school or work? What about screen time with laptops and smartphones? And when is it safe to return to activity after a concussion? I’m going to use the latest evidence based research to give you practical tips and treatment strategies to maximize your recovery.
A concussion falls under the category of mild traumatic brain injuries. It’s defined as a trauma induced temporary disruption of normal brain function. So when a sudden impact occurs, the brain undergoes a rapid acceleration motion and then a deceleration. And because the skull is a rigid structure, when the brain bounces around inside, it can get stretched or damaged. The end result is a complex cascade of metabolic pathways that disrupt normal brain function.
Researchers have compiled twenty of the most common symptoms related to concussions. These include headache, pressure in the head, neck pain, nausea or vomiting, dizziness, blurred vision, balance problems, sensitivity to light, sensitivity to noise, feeling slowed down, feeling like ‘in a fog’, feeling ‘just not right’, difficulty concentrating, difficulting remembering, fatigue or low energy, confusion, drowsiness, more emotional, irritability, feeling sad, feeling nervous or anxious, and having difficulty with falling asleep.
I want to stop here and point out that there are certain red flag symptoms that warrant immediate evaluation by a healthcare provider. Some of these include loss of consciousness, severe and worsening headache, persistent vomiting, and seizures. These are just some of the signs that can be indicative of much more dangerous conditions such as intracranial hemorrhage, skull fracture, and neurological complications. You’ll notice that there is considerable overlap between the red flag symptoms and common concussion symptoms. This is why concussion management should be supervised by a healthcare provider.
Ok so with the red flag symptoms out of the way, the twenty two concussion symptoms are part of the Sport Concussion Assessment Tool. This is a simple form that is used by sports medicine physicians around the world. We ask our concussed athletes to fill out how many symptoms they have and how severe they may be. We can then categorize their concussion into six clinical profiles. These include cognitive, fatigue, anxiety and mood, headache and migraine, ocular, and vestibular.
As you can see here, there is a lot of overlap between the clinical profiles. And the reality is that most people with concussions will have symptoms that fall under multiple categories. But the most severe symptoms typically concentrate in one or two of these categories.
For example, let’s say we have a concussed athlete that scored really high on headache symptoms and difficulty concentrating. The athlete may also have more mild symptoms in other categories like dizziness, trouble reading, fatigue, and feeling anxious. But because the most severe symptoms are headaches and concentration, the main clinical profiles would be headache-migraine as well as cognitive.
And the reason we want to try to identify these clinical profiles is because they then help us target and individualize treatment. So let’s take the headache migraine profile as an example. In many cases, the impact from an injury causes a lot of force to be absorbed by the body and most of that pressure concentrates in the neck muscles. This causes them to be extremely tight which then limits range of motion and induces headaches and migraines. So if someone has the headache migraine profile, we’ll want to focus treatment on the neck muscles to try to reduce tightness and improve range of motion. This can be done with stretches, self massage, and soft tissue modalities.
Those with cognitive involvement tend to have more difficulties with concentration. These people usually need a letter from a healthcare provider to give them accommodations for school or for work. They tend to also need more frequent breaks and longer periods of time to help them process information.
People with vestibular or ocular involvement have a lot of difficulties with balance as well as reading. These patients can improve dramatically when given balance exercises and eye training exercises.
Those with anxiety and mood symptoms benefit from maintaining social engagement and having extra support from friends and family. This is especially important for those who already suffer from anxiety or depression as these symptoms tend to be magnified after a concussion. Having a strong social support system can really help mitigate a lot of these symptoms.
Those with the fatigue profile really benefit from activity modification, stress reduction, and a slow graded exercise program. Prioritizing sleep and maintaining proper sleep hygiene is also really important for those with severe fatigue symptoms.
So as you can see, grouping symptoms into clinical profiles makes it easier for us to provide targeted treatments. But there are some things that everyone should and should NOT be doing, regardless of the clinical profiles that they have. And I want to touch on some of these.
The first thing is activity. We used to tell people to hole up inside their room, turn off the lights, and don’t do anything for one week. This is called cocooning, where you literally act like you are in a cocoon and don’t do anything while your brain slowly recovers.
The best available evidence shows that this method is NOT beneficial and can actually slow recovery. In clinical trials, concussed athletes randomized to strict rest had MORE daily concussive symptoms and slower symptom resolution.
Relative rest, but not STRICT rest, is recommended for up to the first two days after an injury. This means you can perform most activities of daily living including showering, managing household tasks, and preparing meals. But what we don’t want you to do is to stay in your room and not do anything.
And what about physical activity? When can you start exercising again? This topic has always been controversial but now the latest research suggests that light intensity physical activity such as walking or stationary bike can be BENEFICIAL during the first 24 to 48 hours after a concussion. Said in another way, light intensity physical activity has been shown to ENHANCE concussion recovery.
After the first 48 hours, a slow and graded aerobic exercise regimen can further help recovery and REDUCE the risk of symptoms that persist after one month from injury. But here’s where you need to pay attention. You can’t do too much too fast. Moderate to high intensity physical activity in the first three days after a concussion has been shown to EXACERBATE symptoms and delay return to normal activity. You really need to start low and go slow.
So how is this done? Light physical activity such as walking can be done as soon as day 1 or day 2 after a concussion. I typically recommend starting with an easy walk for about 15 to 20 minutes. You may notice that some of your symptoms will get a little worse. But as long as it’s tolerable and nothing more than a mild increase, it’s okay to continue.
If at any point, symptoms get severely worse, that’s ok. Stop and rest. Try again or if symptoms are too much, finish for the day. Mark down how long you were able to exercise. And the next day, try to get that same number or, if you can, a little bit longer. Aim to increase to 30 minutes of light physical activity.
What’s very clear in the literature is that incorporating more light aerobic exercise, of course within the limits of what your symptoms allow, results in a faster time to recovery and a reduction in overall symptom severity. After day 2, you can slowly advance your physical activity back to your previous baseline. Again, go slow and advance only as your symptoms allow.
Now let’s talk about cognitive load which includes school and work. Similar to the approach with exercise, it's essential to avoid pushing yourself too hard too soon. Gradual progression is key. This might mean in the first 48 hours, attending classes or going to work for a half day instead of a full day. And as your symptoms allow, you can then slowly increase the cognitive load. Some individuals may be able to return to their regular cognitive activities within a few days, while others may require more than 1 to 2 weeks to advance to their usual workload.
Open communication with your school or employer about necessary accommodations is crucial during this recovery period. Fortunately, most people understand the impact of concussions and the need for additional time to recover. If you encounter difficulties, don't hesitate to seek help from your healthcare provider. Often, a letter of support from your doctor is all that's needed to advocate for your recovery and ensure your needs are met during this crucial time.
Now I also want to talk about screen time because that also falls under cognitive load. A lot of research has gone into this area and it does seem that too much screen time in the first 48 hours can slow down concussion recovery. Therefore, I recommended reducing usual screen time within the first 48 hours after an injury. Once this initial 48-hour period has passed, the evidence becomes much less definitive. I would only recommend further restriction if it provokes severe symptoms.
The last thing I want to talk about is sleep. In the past, there was a misconception that staying awake for 24 hours after head trauma or having someone wake you up every hour following a concussion was beneficial. However, recent evidence suggests that sleep disturbance soon after the injury can potentially impair concussion recovery. Studies indicate that poor quality sleep and reduced total sleep time are associated with increased concussion symptoms the following day. That’s why it’s so important to maintain proper sleep hygiene and to try to maximize rest while you recover from a concussion.
Here is a sample chart that summarizes everything we just discussed. The key thing to understand is that returning to sports prior to concussion resolution is really dangerous. Athletes who do so have a higher risk of repeat concussions. They also have higher rates of musculoskeletal injuries ranging from ankle sprains to meniscus tears and ACL tears.
Additionally, it's vital to recognize that every concussion is different. A personalized treatment plan based on your concussion profile can help reduce symptom severity and expedite recovery. Talk to your healthcare provider about what treatment plan may be best for you.