Now that we know what a concussion is, and that there is an energy deficit in the brain causing issues, we can now look at how to recover from a concussion. Note - this is NOT a guide on how to rehab a concussion on your own. Any concussion should be monitored and progressed by a qualified healthcare provider! The following article is for educational purposes only and to lay out what a concussion recovery plan generally looks like.

Management & Recovery

With proper recognition, evaluation, and management, concussions can resolve without long term complications. As we previously discussed, there are neurometabolic changes that occur in the brain during a concussion, therefore, anything that requires significant cognitive demands should be minimized. The brain needs energy to function, so any task that requires significant brainpower can take away from the energy needed to heal (remember we are already in a deficit) which can cause a flare-up in symptoms or a lengthened recovery period. A quiet, dimly lit room can help moderate head pain, light, and noise sensitivity. Reducing how hard the brain has to work will allow all available energy to be used by the ion pumps to help bring the brain’s chemistry back to homeostasis. Rest and relaxation are key in the beginning to manage symptoms prior to adding school and physical activity back into an athlete's schedule. Any medications should be administered by your healthcare provider.

Return to School 

There are no standardized guidelines for returning to school, however, there are general Return-to-School progressions that can be implemented (see Table 1). It is generally recommended that for the first 3-5 days following injury, patients should be advised to scale down their cognitive activity, then increase as tolerated (Mullally, 2017). However, the American Medical Society for Sports Medicine recommends that if an athlete develops increased symptoms with increasing academic load, then academic accommodations may be required such as reduced workload, extended test-taking time, days off, or a shortening school day (Harmon, 2013). They also recommend withholding athletes from contact sports if they have not returned to their ‘academic baseline’ following a concussion. So if an athlete can’t return to a full school load, then they should not return to sport, though this doesn’t mean they need to abstain from physical activity completely.

Return to Play (RTP) Process

RTP after a concussion should be an individual, gradual and progressive process. Old school thinking used to dictate that all activity should be avoided, due to it being harmful to the brain and delaying recovery. In actuality, recent research has found that early physical activity is beneficial, with higher levels of activity being associated with lower rates of persistent post-concussive symptoms (Grool, 2016). After 1-2 days of rest patients should be encouraged to exercise as tolerated (Mullally, 2017), as complete rest beyond the first few days following a concussion can actually be detrimental to recovery (Leddy, 2016)!

Part of the reason exercise is thought to be beneficial for concussion rehabilitation is due to an increase in cerebral blood flow, which if we remember is decreased following head trauma and can prolong symptoms (Howell, 2016). Not surprisingly, removing an athlete from sport and activity can increase the risk of depression and anxiety, so introducing an athlete back to some sort of activity can improve psychosocial factors (Broglio, 2016). Finally, prolonged inactivity (read: complete bed rest) can result in physical deconditioning and can increase the risk of sports injuries once activity levels pick back up (Gabbett, 2016). Therefore, ensuring an athlete is training in some fashion (symptom dependent) will likely help to improve short-term and long-term outcomes. 

Currently, the most commonly cited RTP program is the Graduated 6-step Protocol (Table 2). According to this protocol, an athlete begins this process and moves through each stage at 24-hour intervals as long as no symptoms occur. If an athlete develops symptoms during a stage, progression should be stopped and the athlete must return to the previous stage and try again 24-hours later to allow symptoms to dissipate. To move from stage 4 to stage 5, a documented medical clearance note from a licensed healthcare provider must be obtained. Progression is dependent on being asymptomatic at each level. If symptoms return and are persistent after 24-hours, the athlete may need to drop down to stage 1 again. 

This logical progression from rest to full activity forces an athlete to not rush back too soon, as each stage takes a minimum of 24-hours. The soonest an athlete can complete all 6 stages is around a week, which coincides with the usual time needed to normalize the brain's energy deficit (~7-10 days). By following this protocol, we can ensure proper brain recovery while making sure symptoms do not return with increasing physical exertion. This protocol can also be adapted for various sports, for example, a soccer player may need to reintroduce heading the ball prior to full game play. Ideally, a qualified strength and conditioning coach should oversee and progress stages 2-4 to ensure proper mechanics and loading, in conjunction with the medical team and sports coaches. An example of how this protocol may be used has been included. 

Explanation of each Stage:

Stage 1: More or less complete physical and cognitive rest to decrease symptoms.

Stage 2: Introduce a slight increase in heart rate and blood pressure to see if symptoms become exacerbated. Nothing too strenuous, this would be more boring than anything.

Stage 3: Increase the intensity and duration of the physical challenge. Again, nothing too intense but the athlete should get a little more sweaty. Very light resistance training may be included, moreso to get moving rather than loading like a normal workout.

Stage 4: This stage incorporates components of normal strength and conditioning, without the heavy impact. So moderate resistance training (still not heavy loading), sprinting, jumping and change of direction components can be incorporated, though not all at once. Sport specific drills can be included as long as the risk of contact is avoided. This will begin to increase the physical demands on the body to see if symptoms come back with higher levels of activity and bring the athlete back into full training.

Stage 5: After clearance from a medical professional, the athlete can reintroduce full lifting, practice drills and contact. The sports coaches and performance staff should use this time to evaluate the athletes functional abilities to ensure there are no persistent issues like altered movement patterns, poor reaction time or balance problems. Ensuring the athlete re-establishes their confidence is important in this stage.

Stage 6: If symptoms haven’t returned, and the athlete is performing well and feeling confident, they may be cleared to return back to sport by their healthcare provider (note - not the parent!).

Hopefully, this gives clarity on what a concussion rehab plan should look like. This should also allow parents and athletes to advocate for their own health if proper progressions are not being carried out and to seek further information or a second opinion if contrary advice is given (i.e., a youth sports coach wanting an athlete to come back to early).

Part 4 will look at how can we decrease the risk of concussions.

~Coach Gies