Return to activities
One should keep in mind that a concussion is a brain injury and we should get away from thinking of them in terms of mild, moderate or severe. Concussions are a subset of brain injuries known as mild traumatic brain injuries and each one requires respect and diligence. The eventual effect that any concussion may have on any given patient can be hard to predict as it depends on many factors: the area of the brain affected by the trauma, the types and severity of symptoms one may experience after a concussion – not necessarily correlated with how mild or severe the injury that resulted in the concussion appeared – and the patient’s unique neurological abilities and psychosocial context. That is, a seemingly “mild concussion” as assessed by a layperson may fester and have a more deleterious effect on one’s life than a seemingly more “severe concussion” in another patient. Most patients will get back to their previous level of functioning. However, some may still experience symptoms even longer than a year after their concussion.
2. First stages
As previously mentioned, initially after an injury, rest is important – both physical and cognitive. The perfect rest strategy is still not known so it is still a bit of an art. There is some evidence that inactivity may negatively impact recovery so generally:
• Limit bed rest to less than 3 days.
• In the first few days the goal should be to minimize physical and mental activity (rather than eliminating it).
• People should gradually return to their normal activity as tolerated (without provoking symptoms) and as advised by the healthcare team.
The cognitive load of activities is not intuitive and ignorance of the same can negatively impact symptom resolution. This topic has largely been dealt with in the section “Executive Functioning and Rest Strategies”. Specific recommendations that could be helpful include:
• Avoiding and/or modifying school hours.
• Avoiding and/or modifying school duties (homework, notes, assignments, exams).
• Limiting activities that demand attention, concentration and visual effort (TV, mobile devices, computers, video games, etc.).
• Limiting activities that can decrease restfulness (Stimulating conversations, loud music, stressful situations, busy environments, etc.).
• Trying to get more rest and sleep.
3. Getting ready for work
Workers can find the invisibility of their injury stressful as it can mislead co-workers/family/friends to minimize workers’ experiences or to apply unwanted pressure on them. This may also be aggravated by ongoing symptoms affecting their ability to do their jobs and a lack of guidance on effectively returning to work. Return to work prematurely can shift the focus away from the crucial first three to six months of rehabilitation and recovery effort, potentially resulting in long-term consequences on the patient’s overall functioning and employability. There are many factors involved in helping patients gradually get back to work: the nature of their jobs, their psychosocial situations, their general medical health, their baseline level of functioning, their concussions’ symptoms, etc. This complicated process is best quarterbacked by an occupational therapist in a multidisciplinary setting.
4. Getting ready for learn
Helping patients in getting back to class is similar to helping them in getting back to work. We are all aware of a student’s duties. Students are heavily reliant on their cognitive abilities in performing curricular and extra-curricular activities and so to pace their cognitive load to avoid worsening symptoms is imperative. Fortunately, school administrators are aware of concussion and its effects and are generally very cooperative with students by allowing special accommodations and curricular concessions. Reintegration strategies are individualized to the student and require consideration of the same factors one has to take into consideration for reintegrating workers back to work. Similarly, they are best managed by an occupational therapist in a multidisciplinary setting.
The general framework for return-to-learn (RTL) widely used is:
a. Limit activities to the usual daily activities the child does at home (e.g. making a lunch, chores, painting, etc.) provided that they do not give the child symptoms (e.g. texting, reading, screen time). Start with 5-15 minutes at a time and gradually build up. The objective is to have the child resume a more normal lifestyle.
b. At home, resume homework, reading or other cognitive activities. The objective is to increase the child’s tolerance to cognitive work.
c. Return to school part-time with the objective of increasing academic activities.
d. Return to school full-time with the objective of returning to full academic activities and catching up on missed work.
5. Getting ready for sport
To get an athlete back in the game requires a stepwise approach and should be done with the guidance of a multidisciplinary healthcare team. There are a few facts to keep in mind:
i. Youth recover slower from concussions than do adults
ii. Return to sport prematurely can lead to:
• A lower threshold for subsequent concussions
• More severe or prolonged concussions if another is received
• Serious neurological injury
The general framework for return-to-sport (RTS) widely used is:
a. No physical activity until one’s symptoms have dissipated.
b. Light aerobic exercise with the objective ensuring the patient can tolerate an elevated heart rate.
c. Sport-specific exercise with the objective of adding more movement to the patient’s experience and ensuring the patient can tolerate it.
d. Non-contact training drills with the goal of testing the patient’s ability to handle more physical and cognitive tasks; to further challenge their cardiovascular resilience; to further challenge their coordination; and to add resistance.
e. Full-contact practice to assess their suitability for regular game play and restore confidence.
f. Return to normal play.
When deciding on whether you should progress to the next level it can be difficulty to know if you challenged yourself sufficiently to test your capabilities. Similarly, for those who seem to be stuck at a level, it can be difficult to figure out why. For these reasons, patients should consult their healthcare teams for guidance on how best to progress through these levels. The specific cardiovascular, movement and cognitive tasks required to confidently reintegrate an athlete back to sport requires the knowledge gained from thorough assessment and observation of RTS efforts.