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Is Rest The Best Thing For Concussion?

Is Rest The Best Thing For Concussion? - Dominick Hussey

Rest has been the mainstay of concussion management for years. Doctors base this approach to the treatment of concussion on three central ideas. Firstly, that the energy crisis caused by a concussion renders the brain vulnerable to physical and physiological stress, secondly, rest keeps the patient more comfortable and less at risk of exacerbating symptoms. Thirdly, studies have shown that patients engaged in higher levels of cognitive and physical activity post-concussion have taken longer to recover. However, is rest the right approach for managing a concussion.

What is the evidence?

Research does not support the strategy of complete rest following a concussion.

In 2002, researchers found that there was no difference in outcomes with bed rest versus no bed rest in the week after a concussion.

In 2013 a study concluded that the recommendation for cognitive rest had no significant association with recovery time.

In 2016, researchers found that two days of complete cognitive and physical rest did not improve recovery times.

Does Rest Lengthen Recovery Times?

In 2015, researchers carried out a randomised control trial to look at the effect on recovery times of 5 days of strict rest compared to 5 days of usual care. Usual care consisted of 1-2 days of rest followed by a gradual return to activities. Results showed that the participants in the strict rest group had increased symptom reporting and slower resolution of symptoms.

What are the risks of rest?

Health professionals traditionally interpret rest as lying in a dark room, limiting noise, no school, no work, no use of electronics, no reading or cognitive exertion of any kind.

However, what happens when symptoms persist despite rest. There is no evidence that continued rest improves outcomes persistent cases.

Furthermore, continued rest is not without risks including reinforcement of symptoms such as depression, withdrawal, social isolation, generalised anxiety, physical deconditioning, insomnia, and missed academic/work time.

What about Physical Activity?

In a 2016 study, researchers investigated the association between physical activity within seven days post-concussion and the incidence of symptoms. The researchers found that 69.5% of participants who participated in light aerobic exercise within seven days of injury had a lower risk of persistent symptoms.

Another recent 2018 study looked at the time of initiation of aerobic exercise and whether it influenced recovery time. The researchers found that early participation in the aerobic exercise was associated with faster recovery and the longer that exercise was delayed, the longer the recovery time.

The study supports the early (within one week) start of sub-symptom threshold aerobic exercise.

In 2017, researchers published a consensus guideline on concussion regarding the rest as a means to alleviate symptoms and promote recovery.

“There is currently insufficient evidence that prescribing complete rest achieves these objectives. After a brief period of rest during the acute stage (24-48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds.”

What Can We Take Away?

Research shows that intense cognitive/physical activity in the acute stage of concussion may be harmful. Furthermore, strict rest has also been shown to ineffective and potentially dangerous!

Current consensus guidelines recommend 1-2 days of complete rest followed by a gradual return to activity. However, these guidelines still leave us what rest involves and which activity should be introduced and when.

Such a cookie cutter approach is unlikely to work.

Post Concussion Syndrome – Symptoms, Diagnosis and Treatment

Post Concussion Syndrome Symptoms, Diagnosis and Treatment - Dominick Hussey

A Concussion is a common occurrence in daily life in Canada. There is a strong association between concussions and Canadians favourite sports especially ice hockey, Canadian football, rugby and soccer. The majority of people who suffer a concussion do not experience any lasting health consequences. However, for some people, the effects can be debilitating and longlasting known as post concussion syndrome. In this article, we will discuss the pathophysiology, symptoms and signs, and treatment options for a concussion and post concussion syndrome.

What is a Concussion?

A concussion is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. In laymen’s terms, this means that an impact to the skull causes chemical changes that affect how the mind works.

Head injuries cause a disruption in the movement of ions in and out of nerve endings. This disruption is known as an Ionic Shift. When an ionic shift occurs, the brain uses a large amount of energy in the form of glucose to correct this shift. If change continues over a long period the demand for energy outweighs the supply leading to an Energy Crisis.

At the same time as the ionic shift, a reduction in the blood flow to the brain occurs further reducing the supply of energy/glucose.

A brain injury affects the visual and vestibular systems and cognitive or thinking processes.

How Do Concussions Affect the Visual System?

The brain dedicates about 70% of its energy to processing signals from the eyes. This strong connection between the brain and eyes mean that a concussion will significantly affect the visual system.

Common ways in which a concussion affects the visual system include difficulties tracking and focusing on objects. According to research, up to 90% of concussions can cause at least one visual disturbance.

How Does a Concussion Affect the Vestibular system?

Along with cognitive and other sensory processes the vestibular system uses the remaining 30% of the brains sensory processing. The vestibular system is also densely connected with the visual system. As such the vestibular system is highly susceptible to injury following a traumatic brain injury. For example, for people with concussion dizziness is the second most common symptom.

How Does a Concussion Affect Cognition?

According to research an energy crisis during the acute stages of concussion can lead to cognitive difficulties such as:

  • Attention
  • Reaction time
  • Information processing
  • Working memory

What are the symptoms of Concussion?

The common symptoms of concussion include:

  • Headaches
  • Dizziness
  • Light and sound sensitivity
  • Nausea and vomiting
  • Balance problems
  • Fatigue /Sleepiness
  • Sleep issues
  • Difficulty concentrating
  • Fogginess
  • Memory issues
  • Anxiety and Depression

It is important to realise that symptoms may be immediate, but are often delayed. Loss of consciousness occurs in less than 10% of cases and is not a marker of severity. Similarly, the degree of force of impact is always consistent with symptom severity.

How to Treat Concussion

When treating a concussion, it is essential to recognise and address the injury as early as possible. If a person experiences a head injury, even if they do not appear to have symptoms, it is essential to seek out an objective clinical evaluation. Diagnosis of concussion should not be made on symptoms alone.

How Most Medical Doctors Treat Concussion

Most medical doctors traditionally prescribe rest for a concussion. This rest includes avoidance of time watching TV, playing video games, reading, and texting. All these restrictions are related to the eyes or visual system and do not address the vestibular and cognitive processes.

Complete rest of the visual system is critical within the first 24 to 48 hours following the injury because the eyes are a significant drain on energy. After that time it is vital to address the other systems.

Clinical recovery vs physiological recovery

The majority of well-managed concussion cases will exhibit clinical recovery in a relatively quick timeframe. Clinical improvement is defined as a remission of symptoms. For adults, clinical recovery is usually within two weeks while children and adolescents are generally within 30 days.

There is some evidence however that complete physiological from concussion recovery may take longer than clinical improvement. Physiological recovery is defined as the normalisation of objective medical testing.

Physiological Susceptibility

A concussion renders the brain more susceptible to cellular injury. If additional trauma is sustained before physiological recovery more severe brain damage may result in an increase in symptoms, a more prolonged recovery timeframe, and Second Impact Syndrome.

Second Impact Syndrome

Second Impact Syndrome (SIS) happens when a second trauma occurs when the brain is still in a state of energy crisis.

SIS results in severe neurological impairment and brain swelling which may lead to coma and death.

SIS is a rare but devastating consequence of a premature return to sport.

Post Concussion Syndrome

Post concussion syndrome occurs when symptoms exceed expected the anticipated timeframe for recovery. According to research, 15 to 20 % of individuals with a concussion continue to experience persistent and potentially debilitating problems months after injury.

Unfortunately, the current Canadian healthcare system is not currently for this patient population.

What Causes Post Concussion Syndrome?

The causes of Post Concussion Syndrome are not well understood, and they are thought to be a combination of neuropathological and psychological factors. Researchers have identified some risk factors for persistent symptoms from concussion including:

  • A high initial symptom load
  • History of a migraine
  • History of vestibular or visual symptoms
  • History of anxiety or depression
  • History of insomnia
  • Teenage females tend to at a higher risk for a protracted recovery

Symptoms of PCS

Symptoms of PCS may include:

  • Visual and balance problems
  • Dizziness
  • Neck pain
  • Anxiety and depression
  • Headaches and migraines
  • Insomnia

The symptoms of PCS are not specific to a concussion and share clinical features of other conditions such as PTSD, depression, chronic pain and insomnia. As such, PCS requires an interdisciplinary approach to treatment.

Conclusion

Concussion results in an energy crisis that is typically resolvable, but should be appropriately managed.

During the acute stage of concussion, the brain is highly susceptible to further injury so underscoring the importance of a delayed return to sport.

It is critical to managing the injury early and effectively, particularly in those at higher risk of symptoms.

The treatment of Post Concussion Syndrome relies upon the identification of triggers and managing them accordingly.