ACTIVE REHAB FOR CONCUSSION AND POST-CONCUSSIVE SYNDROME
It is the standard of care for those who have concussions to be put on bed rest until they feel better. Lets go over why that isn't the best idea and what we can do instead.
THE LITERATURE LOW-DOWN
This segment is meant to give you the skinny; the short and simple; the low-down on a noteworthy scholarly article from a number of different scientific journals to give you the knowledge and power to take your health into your own hands (within reason).
THE LITERATURE
Today we are going to go over “Active Rehabilitation of Concussion and Post-Concussion Syndrome” written by John Leddy, MD at the University of Buffalo along with their colleagues.
It was published in the journal Physical Medical and Rehabilitation Clinics of North America on 05/27/2016. The journal Physical Medical and Rehabilitation Clinics of North America has an average impact factor of around 2.25. The impact factor basically gives you an estimation of how popularly cited the articles in the journal are and by proxy its reputation in the academic community. The most popular journal in the world, The New England Journal of Medicine, has an impact factor of around 70.
It is important to note, the impact factor does not tell you anything about the content or validity of each of the articles written in the journal, just its popularity. Just like social media, the more popular journals have more reach and publicity than less popular journals.
This means that this information in this article might not be known by your healthcare provider due to the lack of reach of this journal. With those caveats out of the way, let’s dive into it.
THE LOW-DOWN
Our primary recommendation for concussion patients has been for the longest time to rest until you no longer have any symptoms which don’t come for around 10-15% of those who suffer a concussion or mild traumatic brain injury (mTBI). Unfortunately, new research finds that this strategy past 24-48 hours isn’t only ineffective but can be detrimental.
Just to make sure we are on the same page we should define a few things. A concussion or mTBI is an injury coming from biomechanical forces that creates a number of complex injury processes. These can span from macro problems, like damage to the neuronal structures controlling cerebral blood flow (CBF) and your heart rate, to micro problems, like altered cell energy metabolism and a pro-inflammatory state in the tissue.
Post Concussive Syndrome (PCS) is defined as symptoms persisting for longer than 3 months after the initial injury, but clinically patients with concussion symptoms after 10 days have been categorized as PCS patients. Both Concussions and PCS consist of nonspecific symptoms (ie. headache, fatigue, anxiety, depression, sleep issues, etc) and make it hard to evaluate and manage.
Throughout this article, the authors review the new treatment areas that have been shown to provided positive results for concussion/mTBI recovery. They include Psychological Interventions, Physical & Cognitive Rehab, Vestibular Therapy, Ocularmotor Training, and Aerobic Exercise.
A WORD ON REST
Rest does have its place in concussion recovery but not at the levels that it is currently recommended. There currently is no evidence that states rest past 3 days does nothing to improve recovery, if anything, it hinders it. Abnormal CBF is a hallmark of concussion and PCS and is associated with prolonged inactivity, while regular physical activity increases your ability to control CBF. In Athletes, it has been shown that physical deconditioning, metabolic disturbances and psychological symptoms like anxiety and depression are associated with extended rest.
Due to the changes in cell physiology within the first 48 hours, limiting your cognitive and physical activity is beneficial. The fragility of the brain during this time frame is greater than any other time. This is where most people are warry of the fatal Second impact syndrome but you can also experience a phenomenon called excitotoxicity during this time.
Excitotoxicity is basically stimulating your cell to death. They cannot take the metabolic load of all the activation it is being asked to do so it goes through programmed cell death (which is bad) and, if not properly cleaned up by the immune system, poor out all of its excitatory neurotransmitters which can cause the death of the cells around it (which is double bad…)
This is why it is recommended 24-48 hours after your concussion you should take everything off your plate and recover. Once that time frame is passed it is time to incorporate the strategies we will talk about next.
PSYCHOLOGY & EDUCATION
The saying is true that knowledge is power as well as the saying “The problem is not the problem, your attitude about the problem is the problem” (shouts out to Jack Sparrow…).
The evidence behind providing patients educational information and psychological support has had mixed results. Some studies show improved PCS symptoms as well as better functioning in daily social circumstances. Others show increased symptom reporting and disability.
The psychological intervention with the best track record for PCS has to be Cognitive Behavioral Therapy (CBT). CBT focuses on patients focusing on figuring out the patterns of thinking and behavior that increase or cause their psychological pain and change them. In one study, those at risk for developing PCS who had CBT were almost 60% less likely to develop PCS compared to those who did not receive CBT.
COGNITIVE REHAB
Difficulties with attention, memory and other cognitive functions are common among concussed individuals. This comes from a number of different factors including general brain inflammation, sensory processing errors, and altered CBF. Although other therapy strategies can address these underlying issues, neurocognitive rehab has had some experimental success especially in the realm of memory.
One very simplistic form of neurocognitive rehab for memory can be performed with just a deck of cards. Its official name is Concentration (how fitting) but has also been called match-match, match-up, memory, or pairs.
You play Concentration by simply placing any number of pairs of cards face down randomly in a grid, Flip one card over and try to flip over the matching card. If you successfully flip over both, take the cards away. If you choose two different cards, flip them both back over and try again. Continue until you have found all the pairs. This game is easy to set up and a great memory task that we use with our patients all the time.
PHYSICAL REHAB
When talking about concussion, it is easy to become tunnel-visioned into only looking at the head and what it contains but we need to also take into account what the head is attached to. The neck is commonly injured during concussive events and is vitally important for things like vision and balance.
Cervical (neck) injuries alone have been associated with headaches, dizziness, vertigo, visual problems and cognitive issues pertaining to attention and memory. These are all the same non-specific symptoms that appear with concussions leading to the thought that concussion symptoms can result from either the neck, brain, or both.
Although the exact interconnection between the neck, the vestibular system, and oculomotor systems are beyond the scope of this blog, treating the neck can improve its integration with all of these systems and reduce concussion symptoms. All participants, in a case series of elite athletes, had improved functional and symptomatic outcomes from a course of combined cervical spine manual therapy (chiropractic adjustments), neuromotor and sensorimotor training, and vestibular therapy.
VESTIBULAR THERAPY
Unbeknownst to most people, you actually have 6 senses. The one that gets swept under the rug and is arguably one of the more important senses (way better than smell..) comes from your vestibular system. Your vestibular system (aka inner ear) is responsible for sensing translation, the most famous of translation being gravity (you are translating towards the ground at 9.81m/s2…), and rotation.
Think back to the last time you were in an elevator starting to move or quickly accelerated or decelerated in a car. That change in translational is picked up by one part of your vestibular system called the otolith. The other part consists of your semi-circular canals and you may have felt these while in Disney Land on the spinning teacups or worse when it is “unleashed” after a night of too much drinking (aka. the spins…).
The Vestibular system interacts with your visual system, to help you maintain visual stability while moving, and your spinal system for postural control. This can lead to Dizziness which has been reported in nearly 50% of concussed athletes. Other studies have found that over 60% of those with PCS have vestibulo-ocular dysfunction, which is known to cause dizziness, as well as almost 30% of those with recent Sport-Related Concussion (SRC).
OCULAR THERAPY
Though we take it for granted, the control and accuracy of our eye movements are extremely complex. Think of the following questions; how do you keep your eyes on a target while moving your head? How do your eyes know exactly where to land when shifting your gaze into something you only see peripherally? How can you follow a bird’s flight pattern when you have no idea which way that bird is going to go?
Although those questions can be answered it again is beyond the scope of this article. Take my word, eye movements are pretty complex but, as complex as they are, eye movements are twice as cool. When you receive a brain injury many of the neural structures that play a part have the chance to get damaged due to their anatomy. Almost 30% of athletes report some sort of visual problem during their first-week post-concussion and almost 70% of teens with PCS show oculomotor (eye movement) dysfunction.
AEROBIC EXERCISE
Finally getting back to one of the issues brought up in the Rest section that has not been addressed by the other therapies the altered CBF. Regardless if you are receiving (or providing if you are a medical practitioner) great therapies, if you still have altered CBF while performing these, it’s like trying to bail water out of a canoe with a bucket full of holes.
The most recent international conference on concussion in sports advise that once someone is asymptomatic at rest, they should be progressed, under medical supervision, into light aerobic activity working their way up to sport or job simulating tasks. Individualized sub-threshold aerobic exercise treatments have been shown to improve PCS symptoms, recovery time, and restore their ability to work or play their sport for those who suffer from persistent concussion symptoms
It should be emphasized again, this is sub-threshold aerobic exercise as in not eliciting any symptoms. When athletes participate in high levels of activity before they have recovered they display worse cognitive performances as compared to those who participated in activity that was appropriate to their recovery level.
The mindset behind the exercise is also important. In animal models, FORCED exercise elicits an increased stress response without stimulating Brain-Derived Neurotrophic Factor (BDNF) which is involved in the neuronal repair process. VOLITIONAL exercise, on the other hand, had the opposite effect; increasing BDNF levels without spiking stress chemistry.
TAKE-AWAYS
Humans operate their best when around their preferred social and physical environment. Those who were/are lucky enough to live through the COVID-19 Shelter in Place orders know what I mean. Prolonged rest from daily and sports activities is an antiquated and unsupported treatment strategy for the care of concussions.
There are many ways we can start to enhance our ability to recover from a concussion. You should build a team of healthcare practitioners that you can leverage to provide these therapies to get you back to what you love. If you are having trouble finding those who can best support you, please reach out to us at Action Potential and we can connect you to the right people.
Again, having a plan on how to best support these factors should be something you discuss with your healthcare provider. If you or someone you know is dealing with a concussion, share this blog and spread the knowledge. For access to the article Click Here. If you have any other questions or comments, please leave a comment so a discussion can take place and those answers can help other people.
Dr. Chase Davidson, DC is a Board Eligible Chiropractic Neurologist and specializes in concussion and sports rehab, as well as functional medicine and immunology. He is the Director of Neuroscience and Metabolics at Action Potential – Sports and Neurological Rehab. He also is a member of the International Association of Functional Neurology and Rehabilitation (IAFNR). Stay connected with Dr. Davidson on Linkedin: @dr-davidson / Instagram: @thatneurologyguy / Email: dr.chase@actionpotentialcenter.com
visit us at Action Potential - Sport & Neuro Performance across our multiple offices across the Austin, Texas area. Call today at (512) 686-6611 to get scheduled for an appointment at our offices located in Lumos Fitness Collective, Defiant CrossFit, & Black Metal CrossFit
BIBLIOGRAPHY
THIS ARTICLE
Leddy, J. J., Baker, J. G., & Willer, B. (2016). Active Rehabilitation of Concussion and Post-concussion Syndrome. Physical Medicine and Rehabilitation Clinics of North America, 27(2), 437–454. doi:10.1016/j.pmr.2015.12.003
OTHER SUPPORTING ARTICLES
https://en.wikipedia.org/wiki/Concentration_(card_game)
