Part II

Last week an anecdote was presented with Nate, a high school athlete, sustaining a significant hit to his head during a game. The first question most parents and players have is how to recognize a concussion. That was covered in last week’s article. This week the next question is being addressed: Once a concussion is diagnosed, what should be done?? What if Nate has exams in school over the next few days… should he take them??

Rest. Let your child rest for a few days. Limited screen time is commonly advised, together with limiting physical activity. However, “rest” is for some a vague recommendation that is problematic since it is the most critical step toward recovery from a concussion. Most of us think of rest as what we do when we are sick with the flu—staying in bed, sleeping a lot and generally laying low. Brain rest is different in that the brain is involved in all activities so that rest has to be approached more carefully.

Current treatment recommendations consist of limiting cognitive activities, limiting physical exertion (but not completely avoiding activity) and being very diligent about eating healthful meals, drinking a lot of water and getting regular and appropriate sleep. Use of over-the-counter pain relievers is often discouraged because the best advice experts can give to a patient suffering from a concussion is to let their symptoms guide them.

The most critical part of resting is recognizing that when symptoms hit, the brain is suffering. Symptoms are the body’s way of reporting that the current activity must be stopped. For example, if a headache occurs with reading, the person needs to stop reading and maybe go for a walk or close their eyes and listen to music for a while. By changing activities, we allow different areas of the brain to work and the area that is exhausted gets a chance to rest.

When should a person “push through the pain” after a concussion? Never. Again, proper rest after a concussion is one of the most critical steps toward recovery. Ignoring symptoms will prolong recovery. One of the worst things a person can do after suffering a concussion is to push through the pain. That will only cause symptoms to intensify and will extend the time it takes for the person to heal.

The good news for many teenagers (and many adults too) is that they do not, in fact, have to give up use of their cell phones. Use of cell phones can be very irritating and can increase symptoms due to the nature of the demands it puts on the visual system. Often after a concussion, there are complaints of photosensitivity (sensitivity to light). However, since screens can be dimmed, cell phone usage can sometimes be tolerated well. As with all activities after a concussion, use of a cell phone should be done with careful attention to the body’s response. If it causes an increase in symptoms, it must be limited.

Pacing and planning are key elements in managing concussion recovery. Activities and tasks that must be done can be put into a schedule with breaks built in to decrease the chance of bringing on symptoms. Alternating types of activities, as stated above, between more cognitive tasks such as reading and physical tasks like taking a walk can give different parts of the brain time to rest. This will make symptoms less likely to intensify. Use of timers, e.g., when playing video games or snapchatting, can allow a person to pre-emptively take the necessary break from a visually taxing activity, preventing a headache response. The limitation on activity of any sort should be based on the individual’s response to the activity and modifying accordingly.

Involving the patient in the process promotes cooperation and education to help protect the patient in his or her future as well. Working with a good concussion management team is the best way to make sure that a person who has suffered a concussion is brought into the process and is being treated in the optimal way. The patient should be given ongoing education and support in managing their daily activities within their tolerance. Most concussions resolve without treatment in 7-21 days (it takes younger kids longer to heal due to ongoing brain development). Consultation with a knowledgeable provider can make a difference in managing recovery in the best way from the beginning.

Accommodations at school should be addressed to support “Return to Learn” in the most efficient time periods, and, for student athletes, a “Return to Play” protocol should be followed for safe return to sport. For adults, “Return to Work” protocols are also available and can be crucial for successful management of returns to daily activities.

Academic accommodations can be provided, once a student has been evaluated by a medical professional with experience working with concussions, through collaboration with a school’s guidance department and nurse to help a student return to full school participation as quickly and effectively as possible. Some accommodations include permission to take breaks from class, taking tests in separate, quiet rooms with extended time, limiting participation in gym class and being allowed to wear sunglasses or earplugs if light or noise are issues. Current concussion management recommendations include a return to normal activity with appropriate accommodations as quickly as possible within the individual’s tolerance. This has been shown to be more effective than removing the student from regular activities. The treatment of concussion, once more of a “cocoon” approach (dark room with no noise until symptom free), has progressed to immersion with modifications. Healing takes place in shorter amounts of time without the side effects of depression and social isolation that were once prevalent after concussion.

What if the concussion symptoms are prolonged? Unfortunately, there are times that a concussion does not heal in the expected 1-3 or even 4-5 weeks. This happens in approximately 20 percent of concussion incidents. For many in this group with prolonged symptoms, concussion may not resolve without intervention. Typically persistent symptoms include headaches and dizziness. These symptoms can be related to oculomotor (eye movement), vestibular (balance) or other dysregulation in the body. Similar to treatment of other injuries, specialized physical therapy is needed to target these systems and to facilitate the healing process. Other times, there can also be psychological components such as anxiety or depression that require therapy with a psychologist. Any time symptoms are prolonged, intervention must be handled through a team approach with involvement of specialists to fully assess the areas that are affected and to decide on the best way to treat them.

Conclusion: A concussion is a serious injury even though it is referred to as a mild traumatic brain injury. It is a brain injury. It must be taken seriously and handled properly from the time the injury occurs. While a concussion may mean that an athlete misses a game, or some time in their sport, job or school, it does not mean that they are sidelined for good. Just as in an ankle sprain or knee injury, activity must be monitored and accommodations must be made while healing takes place. Medical supervision by a knowledgeable provider with input from an expert rehabilitation team is critical to optimizing recovery from concussion. So get help and get well!

By Danit Macklin PT, DPT, ITPT

 Danit Macklin PT, DPT has a doctorate degree in physical therapy as well as advanced certification in vestibular and concussion testing and treatment. She has been affiliated with Hackensack University Medical Center for over 10 years in the pediatric physical therapy department where she provides inpatient care in the Neonatal and Pediatric Intensive care units as well as outpatient services. As there were no post-concussion treatment centers providing care to patients with prolonged symptoms and diagnoses of post-concussion syndrome, Dr. Macklin is pleased to now be offering these specialized services. She can be reached at the Balance & Concussion Therapy Center, 551-888-2282 or at her website mybalancecenter.com.