What is the right amount of rest after a concussion?
Up until recent years, “rest” post-concussion has been interpreted as isolating yourself in a dark room, avoiding electronics, and limiting all sources of light, noise, school and work. However, there is no definitive research to support complete, prolonged bed rest after sustaining a concussion. More studies are showing that full physical and cognitive rest over a prolonged amount of time does not improve recovery time, and that there can be more significant risks associated with prolonged rest after sustaining a concussion (de Kruijk et al., 2002). One study showed that an introduction to light aerobic exercise, like walking, within seven days post injury was associated with lower risk of persistent post concussive symptoms (Grool et al., 2016). Another study saw that those prescribed one to two days of full physical and cognitive rest did not improve recovery time compared to those offered light accommodations without aggravating symptoms (Buckely et al., 2016). Most guidelines recommend one to two days of rest followed by a gradual return to activity, but this leads to a lack of understanding on what that rest involves and what activities to introduce when. In order to gain a better understanding of this, let’s talk about what is happening in the brain after you have sustained a concussion.
A concussion causes an increased demand for energy in the brain in order to continue performing all its processing needs, however the brain’s supply of energy cannot keep up with that demand. During a concussion, the neurons in the brain get stretched, causing an ionic shift to occur. You get an efflux of Potassium exiting the neurons, and an influx of Calcium rushing into them. This causes blood vessels to constrict, resulting in decreased blood supply to the brain (Giza & Hovda, 2001). This decreased flow of blood increases the need for glucose, or energy, causing an energy crisis to take place.
Some of the main players involved in energy conservation of the brain are the visual system, vestibular system, and cognitive processing. Approximately 70% of sensory processing in the brain is dedicated to visual information, so a concussion can severely affect the efficiency of the visual system (Haller., 2021). Common visual impairments post-concussion include difficulty eye tracking with decreased accuracy, eye strain, difficulty focusing on an object, and trouble with peripheral or spatial visual awareness.
The vestibular system is heavily integrated with the visual system and is responsible for your sense of balance and spatial orientation. If this system is not working efficiently, it can lead to symptoms including dizziness, nausea, and imbalance when you move your head. Lastly, the cognitive processes of the brain are responsible for attention, reaction time, information processing speed and working memory. It is common to see an impairment in all these areas post-concussion due to this energy crisis in the brain.
So, imagine that post-concussion you are operating at 100% available energy, and we add an increased demand of 30% from the visual, vestibular and cognitive systems. You are now operating at 130% of the energy needed by the brain to function, which is not sustainable. Functioning like this for one day might be similar to getting a poor night's sleep. You may feel fatigued the next day, or possibly be a bit more irritable than normal, but you can get through the day okay, doing everything you need to do. However, after a concussion, this imbalance can become an ongoing problem. You now have not slept for a week and can no longer function day to day until you are able to build that energy reserve back up. This energy crisis post-concussion can lead to a lot of the common symptoms you hear about, including headaches, nausea, dizziness, light/sound sensitivity, fatigue, balance issues and the list goes on. The key to managing a concussion, is to manage this energy crisis with the appropriate amount of rest and exposure to the systems causing the crisis.
So how much rest do we really need?
An initial two day period of rest can help the brain solve this energy crisis on its own if you avoid aggravating concussion symptoms in the majority of cases. However, full bed rest for a prolonged period of time can lead to further issues that could negatively affect recovery and further contribute to the energy crisis happening in the brain. This can include depression, anxiety, withdrawal, social isolation, physical deconditioning, sleep irregularity/insomnia, as well as missed academic and workplace opportunities. Activities with high visual, vestibular and cognitive loads will likely increase your symptoms at this time, but there are many activities you can still do. While a full return to work, school and sport will take some time and guidance from a healthcare professional, listening to audio is a good idea in the initial stages of a concussion to conserve energy because it does not take a huge toll on the visual system. Activities such as listening to an audiobook, soft music, or a short phone call to a friend are okay as tolerated. Light activities such as walking for ten minutes outside or easy household chores are encouraged as long as they do not aggravate your symptom load. It is always encouraged to speak with a medical practitioner before engaging in any activity post-concussion, as no two people will have the same symptom experience and there is no right answer for everyone when it comes to recovery. As a general guideline, if you try an activity or task and find that you experience an increase in your symptoms, then more rest is required and you may not be ready to start that activity again.
Whenever you have sustained a concussion, it is important to follow up with your family doctor and a healthcare professional trained in concussion management. Your healthcare practitioner(s) will consider your functional complaints and clinical findings from the assessment to figure out which systems may be further driving the energy crisis. From there, they will give you valuable advice on what type and amount of activities are appropriate as well as guide you through your recovery and return to regular activities. Much like a muscle needs to be physically stressed to get stronger, your visual/vestibular systems need some erroneous signals to adapt. A trained concussion specialist can give you an individualized home program, to “retrain” your brain, and help to gradually reduce your symptoms while achieving the appropriate amount of rest needed to recover. Returning to school, work and sport must always be cleared by a professional to avoid further risk and complications. Energy management is key when it comes to determining the amount of rest needed to fully recover from a concussion.
At Momentum Health, you have access to Physiotherapists, Chiropractors and Kinesiologists who will collaborate with your family physician to help you resolve a concussion. Please reach out to us at any of our locations!
Nicole Smith is a Kinesiologist with additional interest in concussion management under the supervision of a physiotherapist.
de Kruijk, J. R., Leffers, P., Meerhoff, S., Rutten, J., & Twijnstra, A. (2002). Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. Journal of neurology, neurosurgery, and psychiatry, 73(2), 167–172. https://doi.org/10.1136/jnnp.73.2.167
Grool, A. M., Aglipay, M., Momoli, F., Meehan, W. P., 3rd, Freedman, S. B., Yeates, K. O., Gravel, J., Gagnon, I., Boutis, K., Meeuwisse, W., Barrowman, N., Ledoux, A. A., Osmond, M. H., Zemek, R., & Pediatric Emergency Research Canada (PERC) Concussion Team (2016). Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA, 316(23), 2504–2514. https://doi.org/10.1001/jama.2016.17396
Buckley, T. A., Munkasy, B. A., & Clouse, B. P. (2016). Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. The Journal of head trauma rehabilitation, 31(4), 233–241. https://doi.org/10.1097/HTR.0000000000000165
Giza, C. C., & Hovda, D. A. (2001). The Neurometabolic Cascade of Concussion. Journal of athletic training, 36(3), 228–235.
Haller, S. (2021). Concussion Pathophysiology [Shift Concussion Course Level 1 Course Notes]. Retrieved from https://www.shiftconcussion.ca/