Treatment and management of concussion

Treatment immediately after a concussion

A period of real rest for 24 to 48 hours immediately after the injury is recommended. Real rest means napping in a quiet, low-stimulus environment.

Normal activities should be put on hold. Real rest does not include going to work, school, using technology or doing chores.

As long as your level of consciousness is not deteriorating, being awakened every few hours after a concussion is unnecessary – sleep after a concussion is good for the brain.

It is also important to seek medical attention by visiting a primary care physician to make sure you are medically stable.

If the concussion took place at work or in a motor vehicle accident it is especially important to have your symptoms documented by a physician; this documentation is critical for any insurance claim and monitoring your history.

Dangerous signs related to concussion during the first 24-48 hours

If you have any of the symptoms listed below during the first 24-48 hours after sustaining your injury, seek medical attention right away – call 911 or go to the nearest hospital emergency department:

• one pupil larger than the other
• extreme drowsiness or inability to wake up
• headache that gets drastically worse quickly
• slurred speech, weakness, numbness, or decreased coordination
• repeated vomiting or nausea, convulsions or seizures (shaking or twitching)
• unusual behaviour, increased confusion, restlessness or agitation
• loss of consciousness (passed out/knocked out) – even a brief loss of consciousness should be taken seriously

Treatment 48 hours after a concussion

After the period of real rest, reintroduce cognitive and physical activity slowly while staying below symptom-exacerbation thresholds (challenge the symptoms but don’t pass the threshold).

Challenging the threshold means allowing symptoms to increase overall slightly but making sure the symptoms return back to baseline level within 30 minutes to an hour of rest. If symptoms remain high after this period of rest, it is likely you have pushed it too far.

Slow resumption of physical activity means gradually reintroducing activities of daily living such as light housework and simple grocery shopping. It does NOT include more vigorous activities such as hiking or running. In one to two weeks, visit your primary care physician for reassessment. Brain rest is a crucial part of concussion recovery. Resting your brain can be a tough concept to adhere to in our fast and connected world.

Brain rest in the initial stages of recovery

This includes activities such as: meditating, mindfulness or breathing exercises; listening to quiet music; lying down, napping or sleeping; having a bath; and taking a slow walk.

Brain rest does NOT include activities such as: using a computer for two hours straight; multi-person conversations; using a cell phone; going to the mall, busy grocery stores or movie theatres; watching TV; driving; or exercising.

Not all concussions present in the same way

Concussions often follow a number of main presentations. The form of primary presentation affects treatment. Main presentations include:

• Physiologic – returning to activity or exercise causes significant problems. Anything that changes the heart rate or blood pressure, from walking or running to bending over and getting up off the ground, may cause concussion symptoms to increase.
  Exertion therapy done with a kinesiologist, exercise rehabilitation specialist or physiotherapist may be helpful. Physiatrists, physicians who specialize in physical medicine and rehabilitation may also be of help.
• Cervicogenic (neck-related) – changes to the neck muscles as a result of injury can cause many of the concussion symptoms. Stiffness in the neck, difficulty moving or rotating the neck and/or ongoing neck pain may occur.
  Hands-on work on the neck including massage therapy, chiropractic treatments and/or physiotherapy may be beneficial. Retraining the perception system in the neck, for example through laser-beam training, may help reteach the neck where it is in space.
• Migraine – migraine symptoms and triggers need to be under control and well managed.
• Affective – psychological and emotional components, such as depression, need to be considered.
• Vestibular (balance mechanism in inner ear) – a concussion can cause direct injury to the vestibular apparatus in the inner ear. Or it can disrupt the brain’s ability to integrate signals from three main sensor systems: vestibular (inner ear balance mechanism), visual, and proprioceptive (limb position) sensations. Working with a certified vestibular therapist may be beneficial.
• Ocular (visual) – visual issues, such as posttraumatic vision syndrome, taking in information, light sensitivity, or sensitivity to motion near the face, cause problems. A vestibular therapist, neuro-ophthalmologist or a developmental optometrist may be able to help.

It takes a team to treat a concussion

Concussions may result in a large number of symptoms, some primary and some secondary. A team approach to treatment often works best.

It may take some time and persistence to find out what approach is the best fit for you, your main problems and recovery goals. The Ontario Neurotrauma Foundation outlines guidelines to choosing the right practitioner, as well as identifies post-concussion symptoms.

Those with cognitive problems may find it helpful to work with:

• Physicians – search the College of Physicians and Surgeons of BC to find physicians who specialize in brain injury.
• Occupational therapists (OT) specializing in concussions – their skill set includes dealing with issues such as word finding, memory, sleep, planning and return to activities of daily living or work.
• Neuropsychologists – help with the problem-solving component, either through cognitive behavioural therapy (CBT) or other exercise tools.
• Speech and language pathologists – help with difficulty recalling words, memory, hearing in noisy environments and processing issues. They often work within the team of the OT and neuropsychologist.
• Audiologists – help with the diagnosis and management of hearing and vestibular problems, such as hearing loss, tinnitus, sensitivity to sounds, balance and dizziness disorders.
• Clinical counsellors – help with anxiety and the emotional aspects of healing.
• Social workers – help with a variety of home situations. For example, parents often take longer to recover because they have no down time.

Due to the varied nature of concussions, not all patients require all types of interventions from all providers; there is not one single course of treatment or recovery. All assessment and treatment need to be individualized.