Physical and cognitive rest is the cornerstone of acute treatment. Physical rest should entail no sports or training, but this should be backed up by taking time off work or school. It is also important to minimise mentally stimulating activities such as reading, computer work or television. This should remain the case until symptoms settle, following which a gradual re-introduction of cognitive exertion can begin. Any relapse of symptoms should result in a further period of rest.
A return to normal levels of mental exertion should precede any attempt to return to exercise. Once physical activity does resume, this should initially be non-contact exercise. This is dealt with further below.
Recovery from concussion
Symptoms of concussion will resolve in the majority of cases within 7-10 days. The same is true of balance problems, although cognitive dysfunction can persist for longer. A small but significant proportion of patients can experience symptoms beyond this time-scale, and when they do, it is very difficult to predict when they might resolve.
Failure of recovery within a usual time scale (10 days) represents post-concussion syndrome (PCS). The reported incidence varies widely, but is most commonly described in 10-15% of concussions. It usually lasts a few months, but occasionally symptoms can last for many years. PCS can be distressing and debilitating with considerable impact on the individual, their family and their work and pastimes.
Factors predisposing to PCS are not well understood, but may include previous concussions, younger age (particularly adolescents) and female sex. The main principles of management are time, neuropsychological support, cognitive therapy and supervised return to exercise.
Repetitive concussions can potentially lead to other long-term consequences such as chronic traumatic encephalopathy. This is receiving increased attention in the media and medical literature, although it is still not clear why some people develop late neurological degenerative conditions. Specifically it is not yet known whether PCS is a predictor of such long-term health issues, although there is much ongoing research in this area.
Acute concussion without impaired Glasgow Coma Scale or concern of a cervical spine injury can be managed outside of a hospital setting with rest and symptom control. Symptoms often settle promptly, and further management entails advice about a gradual return to mental and then physical activity.
Onward referral should be considered for the following groups of patients:
- Persistent symptoms (post-concussion syndrome) whether these be physical or cognitive.
- Complex cases with previous concussions or pre-existing neurological or psychiatric conditions
- Sportsmen and women requiring a carefully managed rehabilitation and return to play.
A variety of medical disciplines may need to be involved in such management. These include neurosurgeons, neuropsychologists, neuropsychiatrists and rehabilitation medicine specialists. Physiotherapists, cognitive therapists and counsellors may also have a role to play.
The surgeons in the Brain and Spine Clinic have great experience in dealing with traumatic brain injuries of all severities. They will be able to offer you advice and insight about concussion and the recovery from it.
Return to sport following concussion
Any sports person suspected of having a concussion should be removed from play and assessed by a competent individual. If concussion is confirmed, they should not return to play the same day.
The subsequent return to play decision-making is one of the most fraught areas of concussion medicine. It needs to be an individualised decision, but based on a sequence of steps. Following resolution of symptoms, low level physical exertion is initially introduced. If tolerated, the intensity and duration are increased, as well as a gradual re-introduction of sport-specific but non-contact activities. Throughout this process the sports person should be monitored for recurrent symptoms, and if so, the process should be temporarily reversed. Ultimately contact training followed by competitive play can resume.
There is little evidence for what the timeline for this incremental progression should be. If any doubt exists regarding such decisions, the patient is best referred on to a specialist with concussion expertise.
Factors that may modify this process and delay a return to play include younger people, a significant number and duration of symptoms and multiple concussions. Retirement from sport may need to be considered with multiple lifetime concussions, structural brain abnormalities, persistent impaired brain function, prolonged recovery times or a reduction in injury threshold.
Second impact syndrome
Premature return to competitive sport undoubtedly predisposes to further concussion due to poor balance and/or poor cognition and decision-making. This then risks subsequent brain injuries being far more significant. Repetitive injuries may lead to post-concussion syndrome, or cumulative neurodegenerative effects.
However, the most dramatic consequence of a repeated traumatic brain injury is second impact syndrome. This is a very rare condition, but can occur when a second concussion occurs before a full recovery has been made from the first concussion. The second impact may only be mild, but can lead to loss of brain autoregulation, alteration in cerebral blood flow and cerebral oedema. The effects can be devastating, and even fatal.