Post-concussion symptoms occur in approximately 15-30% of people who have sustained a concussion. Whilst most people are symptom-free within 7-10 days, some experience ongoing symptoms which can be debilitating. These symptoms commonly include headaches, constant dizziness, constant fatigue, light sensitivity, fogginess, memory/concentration changes, emotional changes and anxiety.
Post-concussive symptoms (PCS) can be extremely disruptive. Symptoms can be quickly exacerbated with normal physical or cognitive activity. People often feel the need to ‘completely remodel’ the way they live to avoid situations which will cause symptoms to worsen. This can seriously get in the way of enjoying life, both personally and professionally!
Post-concussion syndrome can be an intense and frustrating experience. Many GPs and healthcare professionals receive little or no training in concussion management and often wrongly advise patients that they have to “live with the condition”. Being an invisible and prolonged disorder, friends and family may start to doubt the severity of the symptoms, leading to more anxiety.
PCS symptoms are real – you are not alone! You may feel like you have tried everything – consulting doctors, referrals to specialists, receiving negative brain scan results, more specialists, more tests….and still you have no real answers!
Don’t lose hope! There are some very definite ways forward to beat this!
There are 5 different pillars which can contribute to post-concussion symptoms which inhibit your recovery. The trick is to find which ones you need to beat!
1. The Physiological Pillar – a dysfunction of the ‘autonomic’ nervous system
2. The Metabolic, Inflammatory or Hormonal Pillar – everything to do with chemical factors preventing full recovery in the brain
3. The Visual and Vestibular Pillar – the visual and balance system of the brain
4. The Neck Pillar – an often ‘overlooked’ component
5. The Psychological Pillar – emotional and psychological effects, including those of anxiousness, depression and loneliness.
Sydney Concussion Centre aims to give you a clear plan, moving forward, which is crucial to recovery. Strategically assessing and treating your symptoms, one by one, will give you the best chance to take back control of your life by knocking down these pillars. Concussion is treatable with the right management, even long-lasting symptoms that have been present for years!
To find out more about each pillar, keep reading…
The Physiological Pillar
In many people who suffer concussion, exercise can be a real symptom trigger. This is largely thought to be due to a dysfunction of the autonomic nervous system. Like the name suggests – the ‘automatic’ system works ‘without thinking’! Think of the system that controls heart rate, blood pressure, digestion, breathing etc. The ‘headquarters’ for this system is located within the brainstem, and as concussion is a brain injury, the brainstem can be strongly affected after a concussion.
Why is this system important when it comes to exercise?
We know that with increased exercise the autonomic nervous system is crucial in gradually increasing heart rate, blood pressure and breathing. If the system is compromised, it will struggle to deal with the exercise you are trying to do. Therefore, symptoms will worsen.
To dig a little bit deeper, the autonomic nervous system is made up of two sub-systems; the sympathetic and the parasympathetic nervous system. The sympathetic system is also known as the ‘fight or flight’ system, whereas the parasympathetic is more known as the ‘rest and digest’ system. Those with concussion are found to have a higher sympathetic nervous system compared to those who are not concussed. In other words, for concussed people, heart rate and blood pressure is higher than what would be in a non-concussed state, at both rest and during exercise. These changes can induce blood flow changes to the brain and can typically contribute symptoms during both rest and exercise.
How do we treat this pillar?
Exercise!!!
There is a ton of evidence supporting the use of exercise to normalize the physiological deficits following concussion – even those who have had symptoms for years! “The key is to find out how much exercise is just right for you!”
Too little in exercise intensity can mean that heart rate would not increase enough to have a good training effect on the autonomic nervous system. Too much exercise intensity would mean that the autonomic nervous system just couldn’t cope with it at all, resulting in a flare up of symptoms. Training at a level that challenges this system, whilst provoking symptoms very mildly, results in a stronger body. This is one of the best ways to beat concussion symptoms.
Practitioners at Sydney Concussion Centre will perform a walking treadmill test to determine the best exercise intensity for your best recovery. We will gage your symptoms, heart rate and exertion. Based on these results, we will prescribe you a heart rate range to safely exercise within. As you get stronger, you will be able to slowly exercise at a higher intensity.
Deep breathing exercises.
Especially in the early stage of concussion, the sympathetic nervous system can be in overdrive, resulting in a feeling of being ‘highly strung’. The parasympathetic nervous system has connections from the brain to the lungs.
By simply doing slow breaths in and out, we can start to get the parasympathetic system going again. Sometimes the easiest things can be extremely effective!
The Metabolic, Inflammatory or Hormonal Pillar
These three words clumped together might be a little confusing at first but let’s break it down. This pillar has everything to do with chemical factors preventing full recovery in the brain. The three contributors to this pillar can be approached in different ways to allow brain recovery.
METABOLIC
In the early stages of a concussion, the brain uses up a massive amount of energy due to the nerves in the brain, all firing at once during the event of the concussion. As a result, the brain gets fatigued and takes time to build the energy back up (usually 3-4 weeks). It is most likely that, by the end of week 4, the brain has restored its energy levels fully BUT there are a couple of reasons why there may still be a lingering energy deficit.
“You didn’t initially rest.”
If you were concussed but still went full throttle into work/school life and sports, it is possible that the brain just didn’t have a chance to return its energy levels back to normal. It’s like spraining your ankle; the brain needs to have a small amount of rest then gradually build itself up. The brain shouldn’t continue to go 100% full throttle through the injury. If this is the case, 1-2 weeks of relative rest would be recommended.
“You sustained a second concussion whilst already concussed.”
This can be a little more common. If you hit your head and were concussed a second time whilst recovering from your first recovery, it is likely there may still be energy deficits in the brain. Recovery from these symptoms can take much longer compared to just a single concussion. The best way forward through this will be to focus on other aspects of rehabilitation (such as prescribed exercises) while the energy levels in the brain normalize.
INFLAMMATORY
In a healthy brain we have something called the Blood-Brain Barrier – a function to let certain nutrients in, whilst keeping pathogens out. In concussion, this barrier can become compromised. Furthermore, there is a direct connection from the brain to the gut (called the vagus nerve) which usually works to keep undesired molecules from food entering the bloodstream. During a concussion, this system may become compromised which means that certain foods may have a negative effect on the brain.
For example, let’s say a molecule of gluten made it to the blood supply; inflammatory molecules will then be released in the blood to control the gluten, but the inflammatory molecules also have the potential to cross into the brain via the blood-brain barrier. When these undesired inflammatory molecules enter the brain, it can create prolonged symptoms.
The best way to move forward in this situation is a temporary dietary change. Avoiding things such as gluten and refined carbs and promoting vegetables and legumes for a two-week period will significantly help symptoms if the inflammation component is a big driver.
HORMONAL
The pituitary gland within the brain can sit in a vulnerable position if a concussion were to occur. If your symptoms have been going on for a year or longer it will be worth going to the GP to organise a blood test to check your hormones. If there is any deficit, then the doctor may recommend hormone replacement therapy. Your concussion symptoms should significantly decrease if the change in hormones was a big symptom contributor.
The Visual and Vestibular Pillar
The visual and vestibular systems are together in this pillar as they can both strongly contribute to post-concussion symptoms and can often be hard to differentiate. The visual system has everything to do with an image hitting the eye and then led to the brain via a nerve to be interpreted. The vestibular system has everything to do with our main balance centre which is mostly controlled by structures within the inner ear. Sometimes what looks like a visual issue can, in fact, be vestibular and what looks like a vestibular issue can be a visual one
Symptoms you may feel with a vision/vestibular issue are dizziness, being off balance, motion sensitivity, or moving your eyes from one point to another. Things which may really provoke symptoms could include reading a book, driving in a car, fixing a gaze on an object while your neck is moving and bumping into things at the supermarket. These systems can be assessed by the practitioners at Sydney Concussion Centre and treated through a variety of methods depending on what is contributing the most.
Lets break it down further…
Our central visual system involves fixating your gaze on an object which is then projected on your eyes and travels to the brain via a nerve called the optic nerve. From there the brain can interpret what the object you are looking at actually is!
Our peripheral visual system involves being able to interpret information about our surroundings – otherwise known as things you can see in the corner of your eye. This peripheral system allows us to see where objects are in relation to us – this is our sense of spatial awareness. After a concussion there can be a notable disconnect between our central and peripheral symptoms, meaning your brain can struggle to deal with both of these inputs at once. The brain will try but get overwhelmed quickly which can lead to symptoms being provoked.
The visual system can be treated in a few ways depending on the root reason for your symptoms. Treatment may be co-managed with a neuro-optometrist and can include:
- Vision Exercise Rehabilitation: The aim is to not just strengthen your eyes but also to retrain your brain to command your eyes in an effortless manner. This could include exercises such as following a pen with your eyes as it moves in front of your visual field or catching a ball without directly looking at it.
- Prism Lenses: These have been shown in many cases to help with the visual stress following a concussion and positively influence your spatial awareness. These can just relax the visual system significantly even if the lenses are just a temporary measure! Referral to a neuro-optometrist will be required for lens prescription
This is a system which we find can be extremely irritated after a concussion leading to frustrating symptoms, but also a system which can improve dramatically. Symptoms associated with this system are vertigo, lightheadedness, imbalance and even ringing in the ears. At times, it might feel like the room spins around when you turn your head, or the room is moving (similar to being on a boat).
There are three parts of your body which tells your brain where you are in relation to space. These systems are:
the inner ear (vestibular system),
the eyes (visual system), and
the neck (proprioceptive system).
Each of these systems work together to give your brain a blueprint of where you are. If one of these systems is off, the brain gets confused and you can get dizzy! Think about getting seasick on a boat – what happens is that your eyes sense movement, but there is no movement being registered in your neck and your inner ear, so you get dizzy or nauseous!
In some cases, dizziness can be fixed immediately, but if not, your dizziness can be managed through a dizziness-specific rehabilitation program based around specific exercises. There are many different exercises you could be prescribed from your practitioner, based on the underlying reason of your dizziness. These exercises may include
- Following a moving pen with just your eyes in your visual field
- Quickly alternating your gaze between two distinct targets on the wall
- Fixating your gaze on an object while rotating your head
- Spending more time in real life-situations which bring on your dizziness symptoms.
These exercises should only be attempted if prescribed to you by your healthcare practitioner. They are designed to moderately increase symptoms in the short term, which helps your brain get trained and can eventually adapt. As your brain adapts, the dizziness symptoms that you once had should start to diminish.
The Neck Pillar
The neck is one of the most underappreciated reasons for persistant concussion symptoms. We often see patients who have “been everywhere” with no improvement. In most of these cases the neck hasn’t been assessed.
There are a few reasons why the neck is important in concussion.
Firstly a concussion can occur around 70 G’s (“G”= Force of gravity) whereas a mild whiplash injury can occur with as little as 4.5 G’s. Therefore, it is safe to say that a neck or whiplash injury will happen simultaneously with a concussion.
Secondly, the symptoms of concussion and whiplash are actually identical. Both can lead to dizziness, headache, trouble focusing and more. So, what was originally a concussion injury as the main driver for symptoms, can develop into a lingering whiplash injury as the driver for your symptoms.
As the neck and head are closely related, it is quite common for an injured neck to feel headache without any neck pain! Practitioner at Sydney Concussion Centre take pride in being experts in manual therapy and rehabilitation of the neck to control the symptoms of a whiplash injury.
Manual Therapy
This refers to the gradual mobilization of joints and soft tissue in the neck which may have become sensitized after a whiplash injury. This technique can be helpful to decrease pain in the head and increase range of motion in the neck. In the context of post-concussion symptoms, the aim is to provide pressure on specific joints or muscles in the neck which will refer similar symptoms of headache, dizziness or fogginess to the head. With a sustained hold, these symptoms should start to subside. With repeated bouts of manual therapy we expect a significant reduction in your post-concussion symptoms.
Neck exercises
Much of the self-management of a whiplash injury will involve a home exercise program to keep the neck muscles supple and loose. Your practitioner will decide which neck exercises will be relevant to you to keep your symptoms at bay!
The Psychological Pillar
In the early 2000’s, new light was shed onto the mental health aspect of NFL athletes following individual careers with multiple concussions. Less commonly acknowledged for those with Post-concussion symptoms are the emotional and psychological effects, including those of anxiousness, depression and loneliness.
Mental health issues can, at times, become exacerbated following traditional healthcare practitioner advice.
In years past, after concussion, we were told to self-isolate, avoid phone usage, completely rest for a week, have time off school and no physical exercise allowed. No social outlets and no exercise is a recipe for anxiety and depression – it’s no wonder why people can struggle with mental health after a concussion if managed this way! We also know that those with underlying anxiety and depression are more likely to have a poorer recovery for this very reason. Being in complete social isolation with underlying anxiety and depression is like adding fuel to the fire.
Fortunately, experienced concussion practitioners now realise the best form of treatment isn’t social isolation or complete physical rest!
Those with post-concussion symptoms and anxiety are more likely to avoid behaviors which bring on symptoms. Even though this idea sounds fairly logical, by removing yourself from certain situations (eg. reading) you can become more sensitized. So, the next time you try it, your symptoms may come on stronger. This can create almost a negative loop.
A strategy to move forward or improve is to engage in those type of activities which may bring symptoms on, BUT allow symptoms to come on only mildly; even if that means you are only doing it for a minute or so. Wait until your symptoms settle down and try again. Your brain will get used to this and you will gradually get stronger whilst your symptoms get weaker.
Recent studies also suggest that mental health therapy session can be extremely beneficial in reducing cognitive symptoms of concussion (such as memory and concentration issues). This can be even more effective than cognitive retraining (eg memory and brain tasks). Therefore, the value of a neuropsychologist can be huge!
The important thing to remember is that there is always a path forward and post-concussion symptoms are reversible.
Sydney Concussion Centre aims to give you a clear plan, moving forward which is crucial to recovery. Strategically assessing and treating your symptoms, one by one, will give you the best chance to take back control of your life by knocking down these pillars. Concussion is treatable with the right management, even long-lasting symptoms that have been present for years.
This blog was written by Matthew Gregory, Concussion Physiotherapist and CCMI Registered Practitioner at Sydney Concussion Centre
Recent Comments