Updated May 16, 2021
Historically, patients with concussion were told to rest, rest, rest. And when that didn’t work, they were told to rest some more.
The research on concussions is evolving at an exponential rate and we are realizing that not only does prolonged rest not work; it can actually make you worse.
Sadly, many healthcare practitioners are not keeping up with the explosion in concussion research and are still telling patients the only treatment for concussion is rest. If you have fallen victim to this, you don’t need more rest; you need a second opinion.
While it is true that during the early stages following injury, moderate rest is still important, that timeline seems to be getting shorter, with longer duration rest creating worse outcomes for patients.3,4,5
It needs to be made clear that the approach for treating prolonged or persistent concussion symptoms (PCS) is the exact same for preventing them in the first place.
So, if you have been resting for more than a week, and are still having significant symptoms, it’s time to switch it up. More rest is likely contributing to your ongoing symptoms.
What Causes Prolonged Concussion Symptoms in the First Place?
Concussion results in a metabolic dysfunction (read: energy deficit) in the initial stages, which is why strict rest used to be prescribed early on; the thought was – anything that burns energy, such as thinking or physical activity, could increase symptoms. As mentioned above however, rest is no longer considered an effective treatment for concussion.
It is important to note that the majority of studies examining this metabolic disruption show a recovery between 22 and 45 days after injury.15-17 In other words, beyond a 3-6 week period, there is little metabolic explanation for your symptoms; unless of course you did not rest in the initial stages and/or received a second concussion soon after the first.
Any symptoms lasting longer than 30 days are considered PCS. And, at this point, whatever is happening in your brain and body is no longer attributed to the initial energy deficit.
There are typically five causes of prolonged concussion symptoms:
1. Autonomic Dysregulation
Your autonomic nervous system – AKA your “fight or flight” and “rest and digest” modes – becomes dysregulated. This can create blood flow abnormalities, issues with gut permeability and much more.
2. Inflammation
Any time you have an injury, whether it’s an injury to the brain or another part of the body, there will be inflammation. When it is a brain injury, you will have inflammation within the nervous system, and this is very hard to turn off. Nervous system inflammation creates mental fogginess, cognitive problems, anxiety and depression.
We should also add hormone dysregulation here. Since your pituitary gland, which is your hormone centre, sits in a precarious spot within the brain, it can often get damaged during the initial injury, causing hormonal disruptions that then cause persistent symptoms.
3. Visual and Vestibular Dysfunction
Over 50% of your brain is dedicated to vision and visual processing, and nearly 80% of all sensory processing in the body is directly impacted by the information coming from your eyes. Most concussion patients experience at least some sort of visual dysfunction. This may include problems with tracking, scanning, teaming, focusing or eye movements. Unfortunately, these visual impacts can also cause other problems like issues concentrating or remembering.
Dysfunction of the vestibular system – or balance issues – is another area that can be the cause of persistent symptoms. And it must be noted that these two systems are heavily intertwined.
4. Cervical Spine Injury
Every concussion will be accompanied by an element of neck dysfunction, due to the nature of the injury mechanism. And, the symptoms of whiplash are typically the same as concussion symptoms, including headaches, dizziness, nauseousness, mental health problems, and balance impairments.
Oftentimes underlying neck issues are not addressed, and so the person thinks their concussion symptoms are not resolving when really the symptoms are stemming from their neck.
5. Psychological Health
And finally, many persistent concussion symptoms stem from an underlying mental health issue such as anxiety and depression.
Traditional Treatments – Where Clinicians Go Wrong
We’ll dive into the 5 most effective evidence-based treatment options for concussion in just a moment, but first let’s talk about what typically happens when someone sustains a concussion.
After sustaining a concussion from a fall, car accident or sporting injury, a person will typically head to their local emergency room where the clinicians may order a CT scan to rule out more serious injury. If they find no brain bleeds, the patient will be told that everything looks good, no brain damage, and are sent home with minimal instructions.
The problem with this is that concussion injuries do not show up on MRIs or CT scans. Concussions are functional injuries; meaning they cannot be seen through structural diagnostic imaging.
After a few days the patient may follow up with their family doctor, who will most likely advise them to take a couple of weeks and do absolutely nothing but rest. Even though the science is now telling us this is the wrong way to treat a concussion.
So what happens then?
The patient finds that while they feel a bit better after two weeks of rest, they still have symptoms. They go back to normal life and are shocked and frustrated when a month later, they still have persistent symptoms.
They return to their family doctor who refers them to a neurologist who, after performing numerous (and expensive) tests, finds absolutely nothing wrong.
And once again, the patient is sent off, told that they are fine, and left to wonder what is happening. They have now entered what we at CCMI term “The Concussion Care Maze.”
Picture someone with persistent concussion symptoms that are negatively impacting their life. They are sitting in the middle of a large, round room and around them are dozens of doors. Each door has a sign on it like “vision therapy” “neuro optometry” “vestibular rehab” “occupational therapy” and so on.
Frustrated, the patient chooses a door and walks through to see if that is the answer to their persistent symptoms. But it doesn’t work. They return to the centre of the room, look around at the doors and choose another.
That doesn’t work!
Back to the middle of the room, back to choosing some other treatment, hoping that THIS time it will work.
Meanwhile, they are spending thousands of dollars trying random treatments, hoping they will work, with no real guidance or positive outcomes.
Unfortunately, this is what happens to so many concussion patients. They become lost and stuck in the giant Concussion Care Maze.
Yes, there are usually a series of treatments that will need to happen, but they need to happen in the right order and at the right time. Concussion patients need to have a combination of tools at their disposal. And it is for this reason that the Concussion Fix Program developed the Concussion Recovery Pyramid, helping patients to tackle concussion recovery in the right sequence. You must first build the foundation of the pyramid. If you skip this part, treatment will fail.
This concept is crucial to recovery because you must get treatment protocols in the right order. For instance, if you don’t tackle inflammation and gut permeability and skip right ahead to vision therapy, you won’t get the outcomes you hope for as inflammation can cause visual issues too. So you will think rehab didn’t work and you’ll be left scratching your head and wondering what door to try next.
With this in mind, let’s now take a look at the 5 most effective evidence-based treatments for concussion, and the order we tackle things at CCMI trained clinics.
The top 5 most effective evidence-based treatment options for concussion:
Before getting into specifics, it’s also important to mention that at CCMI clinics, we start these treatments within 5 to 10 days after the initial injury. We’ve seen that the sooner you start treatment, the better your chances of reducing PCS. The scientific literature has indicated without early treatment, 30% to 40% of patients will go on to have symptoms that last longer than a month.
Since we implement these treatments early, we see less than 5% of patients having symptoms after a month. So if you or a loved one has recently sustained a concussion, we recommend finding a CCMI clinic near you so you can get the right treatment plan in place.
1. Education and Reassurance (due to Psychological Comorbidities)
It has been well established that patients with a pre-existing history of depression and/or anxiety tend to have prolonged symptoms. Not only that, the symptoms of these and other mental health conditions can result in, or mimic, the same symptoms as concussion (ie. dizziness, mental confusion, concentration problems, sadness, emotional outbursts).
Many of these issues can begin before or after the concussion, which may be due to the concussion itself, or a direct result of being mismanaged due to improper advice. In other words, being told to sit in a dark room, avoid all social contact, not go to work or school, and not do any physical activity for months on end – may be the very thing causing the anxiety, depression, and other symptoms that you are attempting to stop.
At CCMI clinics, we tackle the bottom of the Concussion Recovery Pyramid first, meaning we focus on providing education and reassurance to all of our patients because we have found that it is one of the best ways to reduce concussion symptoms. In fact, after the first two weeks, the average reduction in symptoms is 50%. In other words, the average person’s symptoms will have reduced by half, just because we have educated and reassured them. Once they understand what’s going on, that initial fear goes away and we can continue.
Staying in the bottom section of the pyramid, we next tackle any negative mindset. Through the Concussion Fix program we have found that Cognitive Behavioral Therapy (CBT), a type of psychotherapeutic intervention which focuses on challenging and changing cognitive distortions and behaviors, can greatly improve a person’s emotional regulation and coping strategies. This is really a foundational key, as we know those with good coping skills recover faster than those with poor coping skills.
And the use of CBT is not just for adult patients. A recent study showed CBT reduces persistent concussion symptoms in children and adolescents.48
And finally, many people who have sustained a concussion will have trouble focusing their attention. To mitigate this, patients can follow a mindfulness Based Stress Reduction practice, which helps them improve their attention deficits.
Before moving on, it’s important to talk briefly about cognitive rehab. One of the main symptoms of concussion is memory problems. This is a tricky area because memory is subjective. For instance, many people who have not sustained a concussion, and who have not been diagnosed with Alzheimer’s or dementia, have memory lapses from time to time. They may forget someone’s name, their pin number, or why they entered a room. It is very common for people of all ages to have these lapses in memory.
The problem is, when a concussion patient has a memory lapse, they may very well blame their concussion. In other words, it is easy to attribute everyday occurrences to a concussion injury. A recent study, looking at self-reported cognitive changes following concussion found the majority of people who reported they had cognitive impairments tested normal for cognitive performance.49 The only thing that had changed was their emotional status or they had more symptoms.
So if you have more symptoms, or you have more emotional symptoms, you may start to have more cognitive problems. This is, again, why we always start our treatment with education and CBT. Because when a patient is feeling better, their cognitive abilities also improve.
Hopefully, what you have read so far has even made you feel better about your condition. In more serious cases you may need to see a psychologist, psychiatrist, or other mental health professional such as a social worker. If you feel that you are depressed or hopeless, please talk to your doctor or seek the help of a mental health professional.
Let’s continue to make our way up the pyramid…
2. Diet/Nutritional Changes
With injury to any tissue, there is inflammation; concussions are no exception with several studies demonstrating increased inflammatory markers following injury.12-14
It’s important to talk about where this inflammation comes from. We do not see only localized inflammation in the neck or brain, as happens when you cut your finger or break your arm. We instead see systemic (read: whole body) inflammatory markers.
Few clinicians understand that brain injuries cause an increase in gut permeability, in as little as three hours post injury. This increase in food matter and bacteria into the bloodstream causes inflammation throughout the body, including the inflammatory markers that end up in a patient’s brain. So it’s important to fix any gut issues early in treatment, as healing cannot happen when inflammation is allowed to run rampant.
Another reason why it is crucial to work with a concussion management team is because gut issues can also be related to mental health issues such as depression and anxiety. Patient’s need guidance to understand how all these symptoms tie together.
A recent research paper, found that the typical Western diet aggravates neuronal insult in post-traumatic brain injury.
At our clinics, we promote the Concussion Fix Diet, which focuses on reducing inflammation, repairing the gut, regulating hormones, and improving sleep. Usually this means having patients make simple dietary changes such as avoiding pro-inflammatory foods (refined sugars, white breads and pastas, artificial sweeteners) and replacing them with healthier options such as fruits and vegetables, fresh caught fish (salmon, mackerel, herring), and good fats (coconut oil, flax seed, almonds). These changes may help to offset an ongoing inflammatory response and reduce symptoms.
There is also increasing support for supplementation throughout recovery from concussion such as Omega-3 fatty acids, creatine, curcumin, magnesium glycinate, vitamin D and melatonin.18-24 Please speak with your healthcare professional prior to starting on any supplements as there can occasionally be adverse effects and/or interactions with other medications that you may be taking.
Another option would be to speak to your doctor about a short course of anti-inflammatory medications. Note that we say “short course” as, over a prolonged period, these medications can begin to harm your stomach and gut leading to ulcers.
3. Exercise Therapy
Following concussion, animal (and many human) studies have demonstrated a reduction in blood flow to the brain in the early stages. Recent research has found that these blood flow changes may persist for some time following injury due to ongoing dysfunction in the Autonomic Nervous System (ANS).1,6-8 The ANS consists of two sides that tend to work in opposition to one another. The Sympathetic Nervous System is also known as the “Fight, Flight, or Freeze” system – this side of the ANS is responsible for increasing our heart rate, dilating blood vessels to pump blood to our muscles, releasing adrenaline, dilating our pupils, and getting us ready for action. Our Parasympathetic Nervous System on the other hand is our “Rest & Digest” system – this side of the ANS is responsible for lowering heart rate, increasing digestion, activating metabolism, and helping us to be relaxed and calm.
These two systems can be thought of like a teeter-totter. When one is up, the other is down. They fluctuate their dominance throughout our days but overall the system should maintain a harmony and balance.
Concussion creates an imbalance in the ANS with most suffering from high “Sympathetic Tone” – this means that we are stuck in a fight or flight state. Our heart rate tends to be elevated and doesn’t respond well to increased demands, blood flow to our brain is not as responsive, our digestion shuts down sometimes leading to stomach pains, food sensitivities, and increased inflammation, our anxiety levels increase, we may get lightheaded more easily, and we suffer symptoms with increased cognitive and physical activity.
The good news is this problem can be tested for and rehabilitated very easily. And, there are two main ways to approach ANS dysregulation.
The first way is to raise the parasympathetic nervous system (PNS) by stimulating the vagus nerve. The vagus nerve, also sometimes referred to as the Wanderer, goes everywhere in our body, affecting many things, one being digestion. Deep breathing techniques stimulate the vagus nerve, raising our PNS dominance so our heart rate slows and our digestion improves.
Deliberate breathing exercises, along with meditation, are some of the things we may start patients with when they first come in and we are focused on the foundation of the pyramid. But as we move up, we want to begin adding some physical exercise; the very thing that most clinicians tell patients not to do!
Researchers at the University of Buffalo have published numerous studies demonstrating complete symptom resolution and improved brain blood flow (as measured on fMRI) through a specific graded exercise program alone.9-11
More recent evidence suggests that exercise might even help speed recovery in the early stages after concussion!
It is important to see someone who knows exactly what they are doing with this protocol. Testing with a trained professional must be done first to establish set points as well as your specific and individualized program. There is also more to balancing the Autonomic Nervous System that must be taken into consideration.
There is a growing body of research in this area, with many studies showing significant changes in brain blood flow and return to full function in subjects treated with graded exercise assessment and progressive exercise treatment in comparison to usual care.9 While a recent RCT, focusing on early intervention (within 10 days of injury), showed that the exercise group was 50% less likely to have persistent symptoms than those in the placebo (stretching) group, 4 weeks after injury.47
Overall, the balance of research shows that there is great evidence to support early controlled aerobic exercise after concussion with little to no harm. In other words, exercise is good!
4. Manual Therapy & Neck Rehab
With every concussion, there is also a whiplash.
Studies have demonstrated that the acceleration required to cause a concussion is somewhere between 70 and 120 G’s (where G = force of gravity = 9.8m/s2).30 Whiplash, on the other hand has been shown to occur at only 4.5 G’s.31
It is therefore conceivably impossible for a concussion to occur without also causing a sprain or strain injury to your neck! In fact, a Canadian study found that 100% of the time, these injuries are happening together.32
What becomes even more confusing is that the signs and symptoms of whiplash and neck dysfunction are the exact same as concussion!33 Headaches,34,35 cognitive and emotional problems,36 balance problems and dizziness,37-42 eye movement control problems,37 and brain blood flow abnormalities43 have all been shown to occur in whiplash and neck pain patients.
There is actually no way to tell if the symptoms are coming from your neck or from your concussion except with testing (some specific tests that we won’t go into here). In fact, most of the patients healthcare practitioners see in this category don’t report any neck pain; which makes this confusing for practitioners. In a recent unpublished study with the University of Buffalo, the researchers found that there was absolutely no difference in the symptoms that whiplash patients report and the symptoms that concussion patients report.
Concussion is an injury that typically resolves quite quickly in most people (symptoms generally disappear for 80-90% of patients within 7 to 10 days); however, whiplash symptoms can linger for up to a year or more.
A headache originating from your neck is called a cervicogenic headache. Your nervous system sometimes plays tricks, making you think a pain’s location is the origin point, when really, the pain may be originating from a completely different location!
An example of this are the occipital muscles in the upper part of your neck. These muscles are connected to eye movement, which is a protective mechanism. Dysfunction in these muscles due to injury may refer pain to your forehead or directly behind your eyes. But the pain is really originating from the neck.
Treatment for this is manual neck therapy. We often find in our clinics that by treating the necks of patients that come in with persistent concussion symptoms, they get better almost immediately.
A randomized controlled study looked at the relationship between neck injuries and PCS.44 Subjects experiencing PCS and daily headaches for an average of 359 days post-injury, were given either manual therapy, or ice packs to the neck. After two sessions, the manual therapy group saw a 60% reduction in their headache pain scores, whereas the ice pack group remained unchanged. Similarly, a 2015 case series demonstrated that 4 out of 5 patients had complete or near-complete recovery after 6-8 sessions of manual therapy and rehabilitation directed to their cervical spine.46
The bottom line is, if you are still having concussion symptoms, even if you don’t have neck pain, you may actually be suffering from symptoms that are coming from your neck; which are easily treated with manual therapy and rehabilitative exercises.25,35,44-46
5. Vestibular and Visual Rehab
Dizziness is one of the most common ongoing complaints of patients with persistent symptoms. This may be due to several overlapping issues such as problems with the balance centres of your brain (vestibular system), your visual system, and/or problems with the muscle and joint sensors of your neck, which we just touched on.
The problem is, it’s often hard to tell whether symptoms are stemming from the visual system or the vestibular system. And this is because the eyes are very much attuned with the vestibular system. When the vestibular system becomes dysfunctional, eye movement and vision will most likely become distorted. Similarly, as we just explored, when the neck is dysfunctional, eye movement may also become disordered.
What we have found is that it is most beneficial for patients to complete neck treatments, vision therapy, and vestibular therapy simultaneously. Because these three systems work together, it is less effective to tackle one therapy at a time. Following a thorough assessment of these areas a proper rehabilitation program can be set up. The research on rehabilitation for these areas is extensive with numerous studies showing resolution of dizziness,25-27 and visual abnormalities28,29 with a fairly short course of treatment.
A 2014 randomized control trial, looked at the efficacy of combining cervical with vestibular rehabilitation in patients that were still symptomatic 10 days after injury.25 After 8 weeks, 73% of the people from the group receiving cervical and vestibular rehab, had been fully cleared and were able to return to play, versus only 7% of those from the group receiving standard care (which at the time was rest).
Dizziness is a common symptom after concussion. But in our experience and based on the numerous research papers, vestibular therapy is only helpful 50% of the time in resolving dizziness. This is because of the closely linked visual problems and neck issues that may not have been addressed.
In conclusion, it’s not that vision therapy, vestibular therapy and neck therapy aren’t effective. It’s usually that they have not been addressed simultaneously. Yet another reason to work with concussion specialists who recognize that these three areas need to be treated at the same time.
Final Thoughts
Hopefully, this article has helped you understand the top reasons concussion patients may experience persistent symptoms, where traditional medicine goes wrong in treating these symptoms, and the top 5 evidence-based treatments for concussion.
There is help out there! The trick is finding the right clinic, practitioner, or team that can help you.
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Ask Concussion Doc – The Concussion Treatment Episodes
Part I – PCS: Why some people get better quicker than others
Part II – Top 5 most effective evidence based treatment options
In these episodes, we discussed the top 5 causes of PCS and the top 5 treatments for managing concussion.
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Disclaimer
This article is not intended as a substitute for the medical advice of doctors and/or healthcare professionals. The reader should consult their physician and/or healthcare providers in matters relating to their health, and in particular, with respect to any concussion and/or symptoms that may require diagnosis or medical attention.
