Two Italian research papers written in 2012 give us the best evidence for the timing of a safe return to Sport. (1,2).  

It is well known that after a concussion, the brain has reduced energy levels, often by up to 20%. The brain weighs about 2% of our body weight but uses 15-20% of our blood flow. This is because it needs a lot of energy to perform the complex processing of all the information it receives as well as driving all the functions it performs, even when we are sleeping! 

Measuring these energy stores is very difficult but this group of Italian researchers were able to assess energy levels using a complex and costly measure called Proton Magnetic Resonance Spectroscopy (PMRS). 

A concussion disrupts the important energy stores in our brain. Here are the important points they learned from their research.  

• Eleven athletes, (3 females and 8 males) who had a Sports Related Concussion were tested using the PMRS on Day 3, 15, 30 and 45 after the concussion. They compared the results with 11 healthy matched controls, who did the same testing. The athletes with concussion had reduced energy levels, compared to the non-injured controls at Day 3  and Day 15. At Day 30 they were still less but very minimally, (and not significant), with energy levels back to normal at Day 45. 

• Those results were for the athletes who did the proper rehabilitation. However, 6 of the athletes decided to go back to sport before their energy levels were back to normal. “Why did they do that?” you ask…. It was because they felt OK.  

Even though energy levels take 30+ days to recover, the athlete’s symptoms settled much quicker,  on average by Day 15,  post injury. As they ‘felt’ ok,  they thought they were ready to go back to sport. (Interestingly all 6 were males – 2 soccer players,3 boxers and a rugby player) 

• All 6 of these athletes sustained another concussion, whilst their brain was still low on energy from the first concussion. The results showed that the second time around, they had more symptoms (4-6) compared to the initial injury (2-3) and they took, on average, 41 days for the symptoms to settle. That’s almost three times longer than the single concussion athletes.  

• The most telling result was the time for the energy levels to get back to normal for the double concussion athletes. This was 81 days(av) – THREE TIMES LONGER than the athletes who didn’t return to sport 

WHATS THE LESSON TO BE LEARNT? 

1. Feeling good (that is, no symptoms) is not a great measure for return to sport. 
2.  Having a second concussion before your brain has recovered from the first, creates longer term issues and may be the end of your season! 

References 

1. Decrease in N-Acetylaspartate Following Concussion May Be Coupled to Decrease in Creatine Roberto Vagnozzi et al, J Head Trauma Rehabil (2012). 

1. The Importance of Restriction from Physical Activity in the Metabolic Recovery of Concussed Brain, Giuseppe Lazzarino et al, Chap 25, Brain Injury – Pathogenesis, Monitoring, Recovery and Management, (2012). 

Did you know that nearly 50% of the brain is dedicated to processing visual information? We normally have two eyes which can work together as a team. Following a concussion, there is often an interruption in communication between the eyes and the brain.  

Your eyes work together with your vestibular (inner ear) and proprioceptive (touch) systems to maintain balance and help you accurately navigate the world. If your visual system is feeding inaccurate information to these systems, they may cause ongoing symptoms.  

If this happens, you may find you get sore eyes, headaches, or dizziness after using your vision. You may even get light sensitivity and/or misjudge where objects are.   

Here are some common vision problems that may occur following a concussion:  

1. Eye focusing (accommodation) 

 Efficient eye focusing is the ability to maintain clear vision when looking at up close and accurately switch focus between close and far. Difficulty with eye focusing skills can cause blurry & fluctuating vision at near (e.g., for reading and computer work) and difficulty switching focus between objects (e.g. from reading to the whiteboard).  

If you have an eye focusing problem, you may find your eyes fatigue quickly. Vision at near can flicker between clear and blurry, causing watery eyes, eyestrain, and headaches.  

2. Eye teaming (vergence skills) 

This means when we look at an object, both our eyes are pointing at that object in a precise and coordinated way, giving us single comfortable vision which we can sustain for long periods. This is good eye teaming. 

Problems with eye teaming can cause double vision, headaches, visual fatigue, tension around the eyes and words can appear to float or move on the page.  

3. Eye tracking (oculomotor skills) 

Eye tracking skills include the eyes’ ability to accurately jump between targets (saccades) and smooth eye movements to follow a moving target (pursuits). If you have difficulty with your eye tracking skills, you may find yourself losing your place when reading, skipping words and lines. You may notice that your eye-hand-body coordination may be affected e.g. catching a ball.  

While some patients have visual symptoms that settle over time, others may need some support to get back on track. 

 Patients who have visual symptoms from concussion can benefit from seeing an Optometrist who has a special interest in the visual aspects and rehabilitation of concussion (neuro-optometric vision care). There, a thorough evaluation of your visual skills and eye health will be performed.  

Optometrists can work together with you & your other healthcare professionals to tailor a program to reduce your visual symptoms and help with the impact of concussion on your visual system. The treatment offered can include glasses, sometimes with specific tints, prisms or occlusion, and neuro-optometric vision therapy. We will also give you strategies to help reduce your symptoms from day to day. If needed, we may also refer you to other specialists for their expertise.  

Celine Zhang graduated from the UNSW Bachelor Optometry/Science course with First Class Honours. She has also completed the Specialist Certificate in Management of Paediatric Patients (Optometry) from the University of Melbourne. 

She has completed additional training with the Neuro-Optometric Rehabilitation Association & Optometric Extension Program Foundation and is currently pursuing her Fellowship with the Australasian College of Behavioural Optometrists.

Celine Zhang practises at Eyecare Plus Kareela and Eyecare Plus Bankstown in Sydney. https://www.eyecareplus.com.au/kareela/ 

To recover effectively from concussion a structured approach, both physically and cognitively, is important. The following outlines our recommended process.  
These stages run concurrently with each stage being assessed by our practitioners to ensure your effective recovery and safe return to activity. 

It is important to remember that this is a guideline only – every concussion is unique so the rehabilitation process has its own ‘nuances’ and curve balls which is why we strongly recommend that you have our practitioners support you through the process to make it as efficient as possible. 

Sydney Concussion Centre practitioners look forward to helping you navigate your concussion rehabilitation process! 

The answer to this question is “Yes” and “No”. 

Concussion is caused by an acceleration and deceleration of the brain inside the skull. Due to this, the nerve cells in the brain to become stretched and stimulated, resulting in a surge of electrical activity. This causes the initial symptoms of a person falling to the ground, finding it difficult to stand up and generally being disorientated. This may only last a minute or two but the surge utilises a huge amount of energy which the brain finds difficult to restore to normal levels; hence, the ongoing symptoms of concussion.  

What if you could limit the effect of the acceleration/deceleration injury to the brain. Neck strength has been suggested as one way of limiting the effect of the concussion on the brain, however it’s not really as simple as that. 

Research has shown that decreasing the forces applied to the head can possibly reduce the likelihood of suffering a concussion. Reducing these forces to the head is more related to neck stiffness, not necessarily neck strength. Increasing neck stiffness could reduce the forces applied to the head therefore reducing the chance of suffering a concussion.  

There is a big difference when an athlete is prepared for impact and when they are not.  

When an athlete knows an impact is coming, they are more likely to tense up and contract their neck muscles and therefore increase their neck stiffness. When an athlete is unaware of a potential impact, they are more likely to be relaxed and therefore reduce their neck stiffness.  

It is important to note that an athlete with a stronger neck will have greater neck stiffness and therefore a decreased chance of sustaining a concussion.  Generally, it comes down to whether the athlete is ready for impact or not. The athlete who is unaware of potential impact will be more likely to suffer a concussion injury.  

Ultimately improving your neck strength will reduce the likelihood of concussion as long as the athlete is prepared for the impact. Improving an athlete’s ‘game awareness’ could lead to a decreased chance of concussion because they will be more likely to know when a potential ‘concussion hit’ may be about to happen, hence they will be prepared for the hit. This comes with experience but can also be accomplished with coaching proper technique and game preparation. 

It can be very hard to predict how long a concussion will last, especially if you take into the account other systems that may be injured when the concussion takes place.  

We know that concussion is a functional injury, resulting in abnormal brain function. When it comes to the brain itself during the concussive episode the neurons in your brain shear and stretch resulting in what is called a neurometabolic cascade. In simple terms, when the concussion happens your brain releases a massive amount of cell energy which takes time and more energy to replenish. This causes an energy deficit and requires time to restore.  

Research shows that it takes about 22-45 days for the brain to recover metabolically from a concussion. However, physiologically recovering from a concussion is a lot different. Typically, symptoms following a concussion with take 7-10 days to subside. Most of the time symptoms persist because of other systems that were affected by the injury itself.  

When a concussion occurs, other systems can be affected and, if not treated, can lead to symptoms persisting long after the brain has metabolically recovered. 

Studies have shown that the sooner you get treatment following a concussion the less likely you are to experience persistent concussion symptoms.  

Treatment comprising of functional testing, not just symptom management, is more likely to produce a quicker recovery and a sooner return to sport.  

Practitioners at Sydney Concussion Centre take a holistic approach to concussion recovery. Things we consider include: 

• Neck injury 
• Headache management 
• Vestibular impairment 
• Reduced Exercise Capacity 
• Advice regarding return to work, school and sport 
• Diet 
• Visual impairment

When treating concussion and post-concussion symptoms it is important to look at the big picture to find out why these symptoms are occurring and what can be done to manage them better. Being proactive in your rehabilitation and seeking help from an experienced Concussion Practitioner is the best approach. 

What’s all the fuss about sleep hygiene? 

Well to put it simply, sleep is an essential part of healing and restoring our body to optimal functioning. We all feel miserable after a poor night’s sleep! 

When it comes to headaches, migraine and concussion sleep is a crucial piece of the puzzle to help improve brain function and allow healing to occur.  

Most adults require about 7-9 hours of nightly sleep. Teenagers between the ages of 14 and 17 years need 8 to 10 hours sleep. Children and teenagers between 6 and 13 years need more sleep, about 9-11 hours.   

Our internal body clock is known as the circadian rhythm. It is a 24-hour cycle which, after waking in the morning, makes a feel increasingly more tired as the day progresses. This peaks in the evening when leading up to bed time. Light influences the circadian rhythm as it signals to the brain whether it is day or night. As the light starts to disappear in the evening our body releases melatonin, a hormone that induces drowsiness.  Therefore, we do not want too much artificial light at night time as we don’t want to disrupt our circadian rhythm. 

As we wake in the morning the light from the sun helps our body release cortisol that promotes energy and alertness. A walk outdoors does wonders to absorb natural light whether it is off to the train for work, to school or walking the dog. Who knew that releasing melatonin could be your new motivation to put on those walking shoes! 

TOP 10 TIPS FOR BETTER SLEEP 

1. Avoid napping during the day 
2. Avoid stimulants such as caffeine, nicotine, high sugar or heavy spicy food, vigorous exercise leading up to bed time. A light snack rich in magnesium and that promotes melatonin production may be helpful – fruit such as strawberries, bananas, cherries, nuts like almonds, oatmeal are some ideas. Herbal teas with no caffeine can be a nice way to calm the mind and relax the body ready for sleep.  
3. Keep the same bedtime and wake up time. Stick to it, even on the weekends. 
4. Wake up and enjoying sunlight in the morning can help set the melatonin released for that night’s sleep.
5. Cooler, rather than warm temperature, is more conducive to sleep. As the weather (hopefully!) warms up think about cooler sheets.
6. Consider a screen ban in the bedroom: TV’s, computers, tablets, mobile phones another electronic devices. The blue light emitted from screens trick the brain into thinking it is still daytime. Your brain then works hard to stay awake. 
7. Exercise during the day can help your body wind down and prepare for sleep by the evening. 
8. Create a bedtime routine. Our brain recognises the sequence of activities as a precursor to sleep. We probably teach our children this but forget to do it as an adult! It all helps…Keep your mind focused on relaxation, calming the sympathetic nervous system down ready for sleep. 
9. Some nice routine ideas include: cup of herbal tea, relaxing bath with essential oils like lavender, vetiver, roman chamomile, listen to calming music or ambient noise. The years of COVID has meant the calming apps out there are plentiful. How does listening to rain falling sound??  
10. Choose your favourite stretches, Yoga, deep breathing, especially nose breathing. Progressive Muscle Relaxation technique (PMR) is a wonderful way to relieve tension and be mindful of your body. We can teach you here at Sydney Headache and Migraine Centre. Meditation and Mindfulness all go along way in reducing stress, managing emotions. 

Many people have heard of migraine but are not sure of what vestibular migraine is all about. It is a migraine event where vertigo is the main symptom. It is one of the common causes of episodic vertigo in children and adults. Episodes can last for minutes or up to a few days. 

Vertigo – a sense of spinning either the room or yourself, can be sitting still (no trigger, spontaneous) or when changing positions (triggered by positional change, head movement)

Nausea and Vomiting

Headache – during or after the episode 

Disequilibrium – rocking, tilting, swaying, unstable on feet, floor under feet feels like it is moving

Visual Motion Sensitivity – feel nauseous or unwell with vision not matching up with surrounds

Anxiety – fear avoidance of certain movements of head, body. Panicked feeling, shortness of breath.

Dissociation symptoms – disconnection from your body or from the environment around you

Dissociation symptoms – disconnection from your body or from the environment around you

Light / Sound/ Smell Sensitivity – sensitive to light such as light coming through trees, car lights, fluorescent lights in office; sensitivity to sounds such as loud noises, busy restaurants, concerts or muffled hearing or ear pressure; sensitivity to certain smells like strong perfumes, cooking smells.

The assessment

Practitioners at Sydney Headache and Migraine Centre take a thorough medical history of our patients and then perform a physical examination of the Vestibular System, Balance and Cervical Spine. 

We use specialised goggles that detect any abnormal eye movements known as nystagmus (jerky eye movements). These eye movements can mimic conditions like BPPV, Meniere’s disease or Vestibular Neuritis. These conditions can also coexist with Vestibular Migraine making it complicated.

The treatment

Treatment involves Vestibular Rehabilitation exercises to improve dizziness and imbalance. These exercises may not prevent an episode of vestibular migraine occurring, but they help reduce the symptoms and improve daily functioning.

Migraine-specific neck treatments, using the highly renowned Watson Headache® Approach, is an exceptional treatment option for headache and migraine conditions. This involves physically assessing the Upper Cervical Spine (UCS) for stiffness and pain, with particular interest in referral of pain from the neck into the head. It is particularly effective in treating those with dizziness as the main migraine symptom.

Treatment for coexisting BPPV or other vestibular dysfunction will be done based on assessment findings as well as balance training to reduce falls risk.

Management of lifestyle factors such as diet, hydration, alcohol, sleep, exercise tolerance, managing stress and anxiety can also be very useful. We have a strong referral network should patients require specialised care in more specific areas.

Concussion injury can cause numerous issues to a variety of different body systems.  These include headache, dizziness, fatigue, light sensitivity, tinnitus, neck pain, poor concentration and confusion.

Diagnosis of Domains of Dysfunction is crucial to address all the areas effectively, thus enabling the most successful and speedy recovery.

Post-concussion syndrome occurs when a number of the common concussion symptoms continue for longer than six weeks, the usual maximum period of time for recovery. This is the generally accepted time period for the ‘energy’ dysfunction in the brain to recover.

Ongoing symptoms can be caused by any of the 8 Domains of Concussion Treatment outlined below:

Cervical spine (neck) 

 The actual concussion injury does not require a ‘knock’ to the head. Any whiplash type injury can also cause a concussion. If someone has sustained a concussion, we know there must have a whiplash injury to the neck as well. The neck can be a source of headaches, dizziness, eye or balance problems. Treatment focuses on restoring normal function of range and strength. Sydney Concussion Centre uses the Watson Headache® Approach to treat dysfunction in the upper neck to address these issues.

Vestibular, vertigo, dizziness 

The vestibular system in the ear can be affected by the acceleration/deceleration injury which causes concussion. This involves the release of ‘crystals’ called otoconia from the utricle into the semi-circular canals of the vestibular system affecting its function. Known as Benign Paroxysmal Positional Vertigo (BPPV), the result is vertigo where people feel like the room is spinning with a change of position, eg rolling over in bed or rising from lying. Nausea and vomiting can be associated with vertigo. Specialised assessment and treatment are required to restore the system to normal.

Oculo-motor. eye movement control 

The burst of activity in the brain that results in an ongoing fatigue state, affects its ability to control normal body functions; the eye muscles are one of those areas. When eyes aren’t tracking properly, it affects our ability to read and concentrate on tasks.

Balance, equilibrium

Our balance is controlled by a very refined system in our brain. Information from the three previous areas, the neck (muscle/proprioception), vestibular system (ears) and eyes (vision) is processed in the brain to help us maintain our balance. The disruption to the brain of a concussion can affect this processing system, leading to a feeling of disequilibrium or ‘floating’. This is often described as walking on a trampoline or boat. Specific exercises can target this problem however treatment may be required to attend to any dysfunction in the individual areas first. These are often a combination of eye movement exercises, neck treatment and balance retraining.

Physiological fitness and fatigue

A concussive episode can impact on a person’s physiological fitness in a number of ways. The initial period of inactivity is enough to start the process of losing physical fitness. Complicating this, concussion can often cause a disruption to the Autonomic Nervous System which controls how we respond to exercise. The Autonomic Nervous System looks after the increased blood flow to the areas that need more oxygen and removing waste products out of the system – we don’t have to think about it! When the body doesn’t respond appropriately to the required demands, our ability to exercise is significantly affected. This is the case in concussion – a person’s ability to exercise can be diminished very quickly.

Cognitive, Concentration, thought processes

Disruption to the brain function also affects our ability to think clearly. Often described as ‘brain fog’  it is characterised by its impact on executive function, ability to learn, memory & recall, ability to focus and slowed processing of information. Some recent research suggests post concussive amnesia may lead to more cognitive issues during recovery.

Anxiety, mood, psychological disorders

It is believed that symptoms of psychological (mood and anxiety) disorders have a contribution from the Limbic system, which includes the emotional centres of the brain. A concussion can potentially cause further disruption to this part of the brain, leading to an aggravation of symptoms that may already be present. Anyone with pre-existing symptoms of a psychological nature should be aware of this possibility and seek follow-up with their GP or trusted psychological health professional. Even without a pre-existing condition, some people who are rehabilitating from a concussion will benefit from psychological intervention, especially if symptoms persist for an extended period of time.

Post traumatic migraine 

Migraine is a severe headache involving significant neurological dysfunction and hypersensitivity, similar in many ways to concussion. This type of headache often has a strong genetic predisposition. There are 40 genetic factors associated with migraine, a majority only being isolated in recent years. Consequently, it is not surprising that a concussive episode can either trigger or exaggerate a person’s migraine frequency or intensity. There has been much debate in the medical literature as to the association between concussion and migraine are becoming more obvious.

The program carried out at Sydney Concussion Centre uses best practice techniques, established by the latest research to assess the Domains of Concussion This involves a wide range of assessments to determine where your concussion symptoms are originating. Once the areas of dysfunction are determined, a specific treatment and exercise program is developed to address the issues and expedite recovery.

Thanks for reading our blog on The 8 Domains of a Concussion Injury.

Read more of our blogs here