In “Athletic Concussions (Part 1),” I discussed how recent research has guided the immediate assessment and management of concussions in sports. With this article, I will continue this topic by discussing how research has affected the subsequent evaluation and treatment of concussions.
One evolving change to the evaluation of concussion is realizing that not all concussions are the same. At least six different subtypes of concussion syndromes have been identified, and many patients will display more than one of these subtypes simultaneously. This is important to understand because these different subtypes may require different treatments. For instance, some patients will have a disruption of communication between the eyes and the brain. These individuals will have increased symptoms when their eyes are moving, such as when reading, driving or watching television. Individuals with this type of disruption benefit greatly from eye exercises. Other patients may have issues with fatigue during cognitive or concentration activities, and these individuals might benefit from time away from school and homework. Still others may experience mood disturbances due to the concussion, and their symptoms actually worsen if they are removed from school and their friends. Recognizing these different subtypes can be helpful in choosing the correct treatment and advancing athlete recovery.
Probably the most drastic change in management of concussions in the last few years is the use of rest. In the past, both physical and mental rest were recommended until symptoms resolved. However, the latest research suggests we have been resting patients with concussions too much and slowing their recovery. The practice of “cocooning” in which the athlete with a concussion is placed in a dark, quiet room and told to sleep is no longer recommended. Now, athletes are encouraged to start returning to their normal activities as soon as they can tolerate it.
The key is to allow activities that do not reproduce symptoms. If an activity causes an increase in symptoms, then the athlete should stop that activity for the day. The next day, he or she can try the same activity again, attempting to partake in the activity a little longer than the previous day. In this way, the patient can gradually increase his or her activity over time, therefore returning to his or her usual routine more quickly. For instance, the athlete may try to walk a little each day and lengthen the walk 10 to 15 minutes every day if symptoms do not significantly increase. This is true of both physical and mental activities. In the past, providers recommended patients with concussions refrain from using “screens” such as computers, smart phones and video games. Now, as long as they do not increase symptoms, it is okay to use electronics. Additionally, if using electronics does cause symptoms, patients are permitted to attempt to gradually increase their use over time.
The one exception to returning to activities is anything that would have a risk of another head injury. Athletes should not return to any contact or collision activity until all of their concussion symptoms and findings have resolved, and only with the consent of his or her physician.
While these new recommendations allow athletes to return to daily activities more quickly, it is still important for all athletes who may have a concussion to be evaluated by a physician. Providers can help determine which activities are safe for athletes to resume and give guidance on how to gradually increase others. They can also determine if more specific treatment is needed, such as eye exercises, physical or cognitive therapy, or medications, as well as what modifications to school and work may be necessary.