The prevalence of traumatic brain injury is greatly underrepresented within currently available statistics. In the period of July 2016 – June 2017 ACC statistics indicate in New Zealand there were 14,682 new claims for Concussion/Brain injury. Of this number, 6,734 new claims were for under the age of 19 years, and 6,090 new claims were sports related (for all ages). These statistics only indicate the traumatic brain injury that are reported to health professionals then become an ACC claim, and not the actual number occurring. As outlined in the Sport Concussion in New Zealand: ACC National Guidelines, an estimated 35,000 head injuries occur per year and approximately 11% of sports related concussions claimants have had multiple concussions within a 2-year period. Education and understanding of concussion is therefore a crucial part of ensuring early identification, and adequate and effective intervention, to prevent longer term effects.
Concussion, as a mild form of traumatic brain injury, is usually caused by a jolt or blow to the head or face. Research now shows that high velocity impact to the body can also result in impact forces sufficient to cause a concussive effect. Signs and symptoms experienced by the patient are due to complex, transitory pathophysiological process causing neuronal dysfunction from the impact of ionic shifts, altered metabolism, impaired connectivity, or changes in neurotransmission . Additionally, neck strength appears to be a factor as one of the potential mechanisms of injury for concussion . Increasingly, research is showing that cervical spine injuries can be a common cause of at least some of the symptoms experienced, such as headaches, dizziness and cognitive issues. Studies also show that there may be a gender difference in risk of injury, for example Tierney and colleagues (2005) found males have a better head-neck segment dynamic stabilisation than females when angular acceleration is sustained by the head , suggesting female athletes may be at greater risk of concussion than males, in part because of less developed neck muscles to reduce the ability to cushion impacts.
Enhancing Recovery from Concussion
Activity versus rest
Rest in the immediate post-injury 24 – 48 hour period is important. This allows for the neurometabolic cascade effects to reduce and recover. Rest needs to include limitations in cognitive and physical activities. Education to patients requires informing them to cease activities such as reading, video games, or screen time and avoid all mental activity that makes them feel worse. This may include absence from school or work, however prolonged absence significantly increases the likelihood of prolonged symptoms and disability.
a). Physical activity
Gradual/gentle resumption of aerobic physical activities has been found to result in superior recovery from concussion compared with complete rest. Specifically, recent research indicates early return to light activity is key in reducing the risk of Post-Concussion Syndrome (PCS). For example, the study by Grool and others (2016) identified that in the subject group studied (3063 subjects aged 5 to 18 years) with acute concussion, physical activity within 7 days of acute injury (when compared with no physical activity) was associated with reduced risk of PCS at 28 days. It is theorised that controlled aerobic exercise may improve recovery through restoring normal cerebral blood flow regulation. In contrast, physical inactivity may result in psychological consequences of removal from life-validating activities, combined with physical deconditioning, which contribute to the development of PCS .
Within the Proactive Concussion Service, endurance to physical activity can be objectively measured by using the treadmill test, with a graduated programme developed specific to the patient’s needs. Other physiotherapy treatments can also be provided, such as identification and treatment of cervical spine dysfunction with musculoskeletal treatment; vestibular and visual rehabilitation; and cardiovascular training. Medical Specialist input can provide medical treatment of headaches and other physical symptoms, as well as assisting in determining when return to play may be appropriate.
b). Cognitive activity
As with return to physical activity, increasing cognitive activity duration needs to be balanced carefully with cognitive rest. The degree of rest versus activity varies from patient to patient. Short bursts of cognitive effort, as opposed to prolonged sustained effort, are recommended with rest periods that involve low sensory stimulation. A progressive, but incremental, increase in time spent on cognitively demanding tasks will aid in building of mental endurance. Photophobia, visual difficulties, phonophobia, headaches, and/or dizziness all can contribute to cognitive fatigue and therefore management of these can aid improvement in cognitive abilities.
Within the Proactive Concussion Service, Clinical Neuropsychologists and Neuro-Occupational Therapists work together to provide the patient with education and strategies to manage and improve cognitive issues and performance, through a carefully formulated programme individualised to their specific needs. Psychological intervention can assist in reducing the emotional reactivity to the difficulties experienced, thus helping the patient to cope as well as reducing magnification of symptoms that potentially could result in PCS.
Return to activity during recovery should not include activities that pose a risk to re-injury. Return to play (based on ACC SportSmart Guidelines) is considered most appropriate after a graded programme of exertion (physical and mental) is completed and the patient has fully returned to school or work, and social activities. If there is a history of repeated concussions, then a longer period of time before return to play may need to be considered. Research on gender differences suggest females should have a longer delay to return to sports than males. Adolescents may have increased risk of concussion due to reduced ability to dissipate forces applied to the head as a result of weaker neck muscles, decreased nerve myelination, greater head-to-body ratio and growth spurts resulting in increases in the body’s weight and mass . Consequently, return to play needs to take into account all these individual factors.
d). The Influence of Lifestyle on Recovery
As with any injury or illness, recovery from is greatly influenced by a range of lifestyle factors. Education regarding recovery-oriented lifestyle choices can help to empower the individual to take control of certain elements of their recovery. In addition to guidelines around physical activity and exercise, research demonstrates that aspects of specific nutritional and sleep hygiene intervention can lead to enhanced recovery from concussion and its associated symptoms. A 2008 editorial in Surgical Neurology states that “When diet and exercise are combined, the success of regeneration and healing seems more pronounced than when either option is implemented by itself“. Lifestyle based strategies to optimise recovery from brain injury that show promise:
- Avoidance of alcohol consumption
- Omega 3, Vitamin E, and Curcumin Supplementation
- Intermittent fasting and Health Fat / Low Carbohydrate diets
- Recognition and treatment of pre-existing or resulting sleep disorders
- Education regarding Sleep Hygiene to optimise quality and quantity of sleep
Proactive’s “Four Corners of Health” approach integrates the best of treatment and rehabilitation, with lifestyle advice and coaching to ensure that clients are empowered to make positive choices in line with aspects of their recovery that they can control, whether this be in the form of physical activity, diet, sleep or adopting a mindset that will foster recovery.
Ten-day post-injury period – prior to referral to Concussion Service
For the majority of people, concussions take less than 10 days to recover from, however there is a minority which take longer . Initial acute symptoms are typically dealt with within the GP practice or Emergency Department, with a referral to Concussion Service able to be made from 10 days post-injury.
Additional suggestions for GP’s dealing with concussion
- If headaches are reported, consideration of neck strain/injury as cause or contributing (as outlined below). Vision issues can also be a cause of post-injury headaches. A pre-existing history of headaches/migraines, even if not frequent, as well as family history of migraines, indicates a potential vulnerability to development of post-traumatic headaches. Occipital neuralgia, with positive Tinel’s sign over the occipital nerve, can also be a cause.
- Anxiety, distress, and low mood may be part of the concussion symptomatology. It can be very frightening for patients when they are advised they have a concussion (or mild traumatic brain injury), as they can perceive or imagine this as serious and permanent. This may result in high levels of stress/distress which then contributes to a very strong symptom focus, magnification and maintenance of symptoms and disability beyond the physiological effects of the initial injury. Early education on how stress can exacerbate symptoms and encouraging a pragmatic reaction can be very helpful in effective symptom self-management by the patient.
- In the first 24 – 48 hours (extending to 5 days if significant symptoms)- as much rest as possible, including low sensory stimulation environments.
- Thereafter, encouraging patient to gently increase activities as symptoms permit, and to ensure a ‘boom and bust’ approach does not occur. It is important the patient does not expect symptoms to be entirely gone before return to activity (including work or study), as this creates secondary effects which will prolong recovery.
Cervicogenic Headache criteria (CGH) Diagnostic Criteria
- Unilaterality of pain, although it is recognised that bilateral cervicogenic headache may occur. Restriction in range of motion in the neck.
- Provocation of usual head pain by neck movement or sustained awkward neck positions.
- Provocation of usual head pain with external pressure over the upper cervical or occipital region on the symptomatic side.
- Ipsilateral neck, shoulder, or arm pain, usually of a vague non-radicular nature, occasionally radicular.
Proactive take a very contemporary approach to Concussion whereby key research is translated into clinical practice to ensure the best outcomes for patients. A very client centric approach is vital, with the individual’s background, age, social milieu, co-morbid factors, and prior functioning (such as type of work or study demands, psychological status, and life role responsibilities) taken in to account in order to provide the most appropriate individualised programme. We believe regular communication and updates between clinicians, patient and GP are a key component to the programme, and therefore critical to successful outcomes. A truly inter-disciplinary team-based approach allows the patient to have ready access to very experienced clinicians, in an integrated way, with the team ensuring there is consistency in the education the patient receives and the care/support they receive. The core team comprises of two Medical Specialists (Neurosurgeon and Occupational Physician), Clinical Neuropsychologists/Psychologists, Neuro-Occupational Therapists, Neuro-Physiotherapists, as well as a wider team which includes Speech-Language Therapists, Dieticians, and Social Worker.
The Proactive Wellington Concussion Service can be accessed directly by Medical Practitioners on behalf of the patient. For more information and access to the ACC883 Referral form, please visit the following links:
- Concussion Service Referral Form can be found on the ACC Website by searching for “Concussion Referral”; or at this URL: www.acc.co.nz/assets/provider/acc883-concussion-service-referral.doc
- For more information regarding our Concussion Service: www.proactive4health.co.nz/wellington-concussion-service
- Contact us for more information or advice email@example.com
Giza, C.C. & Hovda, D.A. (2001). The Neurometabolic Cascade of Concussion. Journal of Athletic Training, Vol: 36(3), p. 228-235.
Morin, M., Langevin, P. & Fait, P. (2016). Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. Journal of Sports Medicine, Published online 2016 Jul 26. doi: 10.1155/2016/1590161
R. T. Tierney, M. R. Sitler, C. B. Swanik, K. A. Swanik, M. Higgins, and J. Torg, (2005).”Gender differences in head-neck segment dynamic stabilization during head acceleration,” Medicine and Science in Sports and Exercise, Vol. 37(2), p. 272-279.
Grool, A.M., Aglipay, M. & Momoli, F. (2016). Association between early participation in physical activity following acute concussion and persistent Post-Concussive symptoms in children and adolescents. JAMA, Vol: 316(23), p. 2504 – 2514.
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Gomez-Pinilla, F. & Kostenkova, K. (2008) “The Influence of diet and physical activity on brain repair and neurosurgical outcome”. Surgical Neurology, 70 p. 333-336