Until very recently, the widespread recommendation by the medical community
to patients who had
suffered a concussion was simple and straightforward: rest, rest and more rest. The trauma that
the brain sustains during a concussion can be from linear forces (like
when the brain is forcefully pushed up against the hard ridges and walls
of the skull), or from rotational forces (like when a boxer’s neck
twists violently after an opponent lands a hook to the jaw). Yet another
example involves the wave of energy from an IED blast experienced by a
soldier in combat. Any of these mechanisms can leave the sufferer with
a wide range of side effects such as
headaches, dizziness, confusion and fatigue. Typically, with appropriate treatment
and rest, these symptoms subside over a period of a few days to a few
weeks, and most young athletes will
recover from a concussion with no residual problems.
The previous guidelines for concussion rehabilitation stated that
young athletes should refrain from all physical activity until all the lingering symptoms
were resolved. This type of treatment is referred to as “cocooning”
– when all forms of exercise and brain stimulation are halted, including
reading, watching television or using smartphones, engaging in lengthy
conversations and even exposure to the visual stimulation of light. This
type of all-encompassing brain rest historically made sense. Concussion
was known to involve a “metabolic mismatch,” which involved
a reduction in blood flow to the brain at exactly the time more energy
was needed for healing. As more was learned about physiologic mechanisms,
it was realized that there were other contributors to the “energy
deficit.” And people generally felt lousy in the early stages after
a concussion. The logical conclusion was that the brain needed rest to
heal. And if
some rest was good, more should be better. But new guidelines are flipping
the well-known script and encouraging most young athletes to start being
physically active as early as a few days after the concussion occurred.
So what gives on the guideline retool? Well, new research has shown that
the brain actually likes activation and stimulation. Early evidence indicates
that the brain benefits from and recovers faster with physical activity
and movement post-concussion, and that prolonged rest time may even delay
healing and recovery. Of course, as with any brain injury recovery plan,
management must be individualized and return-to-play guidelines strictly
followed. There is still no return to full play or competition until all
symptoms have resolved, a step-wise and monitored return to play has been
successfully achieved, and official clearance has been provided. And even
the early cognitive and physical activity must be carefully monitored
to ensure that it is, in fact, helping and not hurting the patient. But
the current trend of early activation is based on evidence that a) activation
seems to be beneficial and b) cocooning may actually be harmful.
After a concussion, the acute post-injury period (the initial 24 to 72
hours) should consist of rest and symptom monitoring in most situations.
Even this recommended period of rest should not involve complete cessation
of all activity. The more appropriate goal is to reduce exposure to physical
or cognitive exertion and refrain from or discontinue activities that
worsen symptoms. When those kinds of restrictions are relaxed, and gentle,
cautious return to physical activity is allowed, it does not mean jumping
right back into a
football or baseball practice or engaging in any contact sports, for obvious reasons.
Rather, we want to see young athletes begin with a very low-range physical
activity such as taking a slow walk around the neighborhood or pedaling
on a stationary bike, or any low-impact, low-risk physical movement that
will encourage healthy blood flow and circulation to the brain and body.
The key with early activity is to take note when feeling any significant
worsening or return of symptoms, such as visual changes, nausea, dizziness
or headache. The goal is to limit activity to that which doesn’t
cause symptoms and to be aware of symptom threshold. Daily exercise that
provides enough movement to promote healing, but not enough stress to
exacerbate symptoms, is the “sweet spot” athletes are urged
to maintain for the remainder of the healing process until the concussion
symptoms disappear completely. Since every patient has a unique physical
anatomy and chemistry as well as unique recovery needs, the amount of
time each patient should engage in daily exercise after a concussion will
vary, and finding that personal threshold is imperative to healing without
re-injury.
In addition to the physical benefit,
returning to activity sooner was also studied to produce noticeable positive effects on emotion, mood
and general well-being for the person who suffered the concussion. In
retrospect, it makes perfect sense. Imagine a young athlete who is used
to being out with friends, active playing sports, with the associated
adrenaline and endorphin release. Then require that athlete to stay in
bed with the lights out and no real activity for days on end, restricted
from cell phone interaction with friends and forbidden from any form of
digital entertainment requiring the use of a screen. What do you get?
Much higher rates of depressed mood, fixation on symptoms, worry and anxiety.
Letting the athlete return to a more “normal life” faster
contributes to less emotional side effects post-concussion, which can
also assist in a faster recovery from symptoms.
One aspect of healing that should not be rushed is accommodations associated
with school, work, and cognitive activity. It’s important to be
aware of the anxieties and difficulties often encountered when heading
back to class or participating in any intense learning activities. The
cognitive side effects from a concussion – such as memory loss or
problems with concentration – can linger longer than the physical
symptoms in some cases. Partnership with a neurologist is highly recommended
to continue monitoring that avenue of healing. On the plus side, physical
activity may also help to lessen the severity of those cognitive issues, too.
Rest after a
traumatic brain injury such as a concussion is necessary, and “shutting down” for
the first few days can be vital to recovery. But prolonged bedrest is
a thing of the past. The brain likes activation. For the best recovery,
rest time must be balanced with stimulation and activation. Consult with
a neurologist after any head injury (no matter how mild) and together
he/she can help develop the most efficient treatment plan for you or a
loved one’s specific needs to get your player back to health and
back into the game.