Q&A: Concussion Rehabilitation for the Tactical Athlete
By O2X Injury Prevention Specialist Colin Tomes
What is a concussion?
Mild brain injury (MBI) is the overarching term given to any of the complex but not immediately life-threatening mechanical injuries affecting the brain1. Concussion is a specific type of MBI that typically occurs when the brain makes contact with the inside of the skull as a result of a fall, strike to the head, or other sudden acceleration or deceleration force1 2. Concussions can be “simple” or “complex.” Simple concussions are those that resolve without any intervention in 7-10 days while complex concussions are those lasting longer than 10 days1. Unlike in sports, where MBI and concussion may seem less distinct, in tactical populations MBI may occur from a variety of sources, including blast shockwaves3. It is important to note that while concussion is a type of MBI, not all MBIs are concussions1. For this resource, concussion will be the specific focus, with other MBIs covered later.
Normally suspended safely in layers of connective tissue called meninges and fluid known as cerebrospinal fluid, the brain lacks many of the features of other tissues and body regions that enable a rapid healing process after injury4. As such, the road to recovery following concussion can vary substantially from recovery following other injuries3 5. Because this process is often not straightforward or clear, the following guide serves to offer information in a question-and-answer format to address common concerns known to surface during concussion recovery.
A Quick Anatomy Lesson
First off, a quick anatomy lesson. The nervous system is divided into the peripheral nervous system and the central nervous system. The central nervous system includes the brain and spinal cord6. It is separated from the rest of the body by the blood-brain-barrier. This is important because it keeps the brain and spinal cord safe from many illnesses caused by bacteria, viruses, and parasites, and can also help protect against toxins that make their way into the bloodstream, such as inhaled smoke or other fumes. However, this strict gate keeping has a downside; the immune system can’t act as effectively within the central nervous system because many of the cells that play key roles in our usual recovery processes are unable to access damaged nervous system tissues4. Even more, nervous tissues are typically delicate, slow growing, and don’t replicate quickly or at all, meaning that the healing process within the brain can be slow and less complete than other regions of the body. With this important information in mind, we can begin to consider more thoughtfully answers to the questions below.
Q: I wear a helmet on the job, I should be safe from a concussion, right?
A: Although the focus of this article is primarily on the recovery and rehabilitation process after a concussion, rather than on prevention or diagnosis, this is an important topic to clear up right away. Just because you might wear a helmet on duty doesn’t mean you are necessarily any safer from concussion; ballistic or fire helmets are designed to protect the skull, not the brain1. Materials like aramid fiber and polycarbonate will protect the head from sharp projectiles and crushing forces, distributing energy from impacts over enough surface area to prevent a skull fracture, but that energy will still be transmitted into the brain and can potentially cause a concussion3. For example, when a tactical athlete wearing a helmet bounces their head off a hard object in a collision, the brain will keep moving even after the skull stops. This internal ricochet is known as a coup-countercoup injury and is one of the most common mechanisms of concussion. Put another way, remember the “egg drop” experiment from grade school science. The exterior of a contraption designed to protect the egg might be totally unharmed, but often the egg within would still break because it could move freely within the system, continuing to accelerate even after the outer device stopped moving.
Q: Should I try to stay awake after a concussion?
A: Staying awake for as long as possible and avoiding deep sleep was once considered the safest thing to do after a head injury. This practice might originate from observations of individuals who suffered from massive brain injuries, beyond the subcritical sports or duty-related MBIs focused on in this report. In cases where the brain has suffered catastrophic damage, the gradual swelling of the brain eventually leads to brain death if not treated right away, and so once a person lost consciousness, they would not regain it. Today’s understanding of concussion has improved much over the past 20 years with substantial research conducted in both athletic and military settings2. The findings of this research support extra sleep rather than restricted sleep as ideal after a concussion5. This is because many “housekeeping” processes within the brain and spinal cord only occur during deep sleep7. This finding is especially important for tactical athletes, as shift work schedules are not always conducive to optimal sleep patterns8, and research is demonstrating that sleep is one of the most crucial factors in recovery following a concussion9.
Q: Can I take acetaminophen or other painkillers when I have a concussion?
A: While you should always consult with a trusted medical provider before starting or stopping any medicine or supplement, and this guide is not to be considered medical advice, there is some evidence that NSAIDs (non-steroidal anti-inflammatory drugs) like naproxen sodium (Aleve®), ibuprofen (Motrin®), and others can be beneficial in relieving the symptoms of concussion. Common symptoms that can be treated with NSAIDs include headache, light or sound sensitivity, and pain with movement. While these drugs do appear to have a role in the recovery process, it is important to note that many protocols for return to sport or return to work require periods of time with no symptoms without the use of any drugs that influence pain. Therefore, while potentially useful in the early stages, especially if headaches are interfering with sleep, as sleep has been established as critically important in the recovery process, NSAIDs should not be relied upon for long term management of concussion symptoms.
Q: Do I have to stop going to the gym?
A: Staying physically active is one of the best things anyone can do for their long-term health10, and many tactical athletes are indeed required to maintain certain levels of physical fitness to remain on the job. However, after a concussion, a careful and graded approach to physical activity is recommended5. Guidelines generally advise individuals to avoid increases in blood pressure after a concussion, as increased blood pressure can increase symptoms and exert additional pressure on the central nervous system, interrupting the healing process. Activities like heavy weightlifting, or rapid changes in position of the head relative to the body (e.g., burpees or gymnastics) can all result in dramatic fluctuations in blood pressure and pressure in and around the brain, and so are best avoided during the rehabilitation process. Conversely though, ceasing all physical activity can likewise also delay the healing process, and light aerobic activity seems to have protective qualities regarding central nervous system health5. In general, activity should be maintained and progressed as tolerated; any physical exercise that does not produce or worsen symptoms should be encouraged. There is also some literature that training of the neck muscles may have a role in preventing concussions or the severity of concussions and given the established link between one concussion and subsequent concussions, training of the neck muscles after completing a return to sport or work protocol may be considered as well11.
Q: What can a Physical Therapist or Athletic Trainer do to help me?
A: Physical Therapists and Athletic Trainers are movement and rehabilitation experts. They are trained to follow research-backed guidelines on returning to sport or work after a concussion. They are also knowledgeable on the safe progression of exercise after a concussion and can help you get back to doing the things that are important to you after a concussion5. In cooperation with the full medical team, PTs and ATs can be thought of as your first-line resource for learning more about what concussions are and how to recover from one. They can evaluate the extent of your concussion symptoms, determine a treatment and rehabilitation plan, and help answer questions to guide you through the process from injury to returning to duty.
Q: Should I change the way I eat after a concussion?
A: There are some exciting advances in nutritional science regarding diet and concussion. Firstly though, there is no replacement for a performance diet. A performance diet is based on whole foods and includes an abundance of fruits and vegetables with minimal refined or processed food items. See Chapter 1 – EAT in the O2X Human Performance for Tactical Athletes book for more information on eating a performance diet. For returning from a concussion specifically though, like any injury, supplying the body with sufficient fuel to drive recovery is essential. The brain uses 20% of ingested calories and requires more than 40 nutrients12, so while physical activity levels will likely drop, a concussion should not be thought of as a good time to cut weight or calories. Sufficient fats, proteins, and micronutrients are all important for supporting recovery from concussion. Adequate hydration is also important. There are a few supplements and sports foods that have been identified in the scientific literature that may have a role in recovery. Beetroot juice has been studied for its nitrate content, which might reduce blood pressure even in people without high blood pressure13. This reduction in blood pressure and support of blood vessel health may also be beneficial. Creatine, perhaps once thought of as a body building supplement for increasing weight and muscle mass, may actually have important roles in the central nervous system, as well14 15. Studies have found creatine to be useful in several areas of brain research, including recovery from stroke and in the management of chronic nervous system diseases15. Again, while supplement use and safety should be checked with an expert prior to use, the above might serve as a beneficial starting off point when looking for ways to maximize the diet for recovery.
Q: Why can’t the brain heal just like a rolled ankle? There are nerves in the ankle too, right?
A: The reason why there are so many protocols and guidelines for managing concussion symptoms and returning those who have suffered a concussion to high level activity is because the brain is so complex and unlike most other tissues in the body. Essentially, the makeup of brain tissue and the presence of the blood-brain barrier makes the healing process slower, more gradual, and less complete than the example above of a rolled ankle. While ankle sprains also deserve specific and optimal recovery pathways, progress is usually more linear, and without the setbacks, obstruction to everyday life, and mystery that surrounds injuries to the brain. One reason for this difference is that injuries to the limbs can usually be assessed and measured by the rehabilitation team much more easily than the brain. Imaging the brain is very expensive, time consuming and requires highly specialized equipment like an MRI or CT (CAT scan) machine. Often, these technologies are still not able to differentiate between a brain that has suffered a concussion and one that has not1. As such, imaging is generally not recommended for concussion, unless a more catastrophic injury to the central nervous system is also suspected. As a result, subjective symptoms are the only guide for progressing through a concussion rehab protocol. What presents an additional challenge for the tactical athlete is that most of these protocols and guidelines were developed for sports or industrial settings, and do not consider the unique challenges faced in military, police, or firefighting service. Concussion protocols also generally restrict usage of screens or headphones to limit sound and light exposure that can aggravate symptoms. While these technologies have become key elements of how many of us spend our free time, they have also become essential components of work in many tactical professions, further complicating the rehabilitation process.
General Rules to Follow for Recovery
Nonetheless, some general rules apply regardless of where or how the concussion occurred, and regardless of what the rehabilitation goal ultimately may be:
- Get lots of sleep – as much as you can, especially while you still have constant symptoms. While these will be unique for everyone, common signs and symptoms include headache, changes in vision, sensitivity to light or sound, difficulty focusing, concentrating or problem solving, irritability or other changes in mood, decreased energy, and in some cases nausea, changes in smell or taste, and changes in balance or coordination.
- Eat a performance diet and stay hydrated: eat lots of fruits and vegetables, don’t restrict calories just because you aren’t moving as much, and talk to a trusted medical expert about pain relieving medications, sports food and supplements that can potentially enhance your recovery process.
- Continue to be physically active, but let symptoms be your guide: keep up with light aerobic activity that does not provoke or worsen symptoms. Things like going for a walk, slow steady cycling, rowing, and stretching are all important for maintaining both physical and mental health, as well as facilitating recovery. Just remember to stay within the guidelines prescribed to you by your medical team and progress gradually back to more intense exercise.
- Avoid screen time, loud sounds, and stimulants: while technology seems to be integrated into every aspect of our lives both at work and at home, minimizing exposure to electronics from both a light and a sound perspective may be an important part of the recovery process, and one of the most frustrating aspects of concussion rehab that sets it apart from other injuries. Cutting out the streaming or binge watching, avoiding headphone use, putting the smartphone away, and turning off the TV or computer can all be important steps in recovery. For the busy tactical professional, this can be the most challenging aspect of rehabilitation, but the use of screens should only be reintegrated when usage does not cause or worsen symptoms. Short “doses” of 10-15 minutes maximum can be a place to start, with increases of 5 minutes a week depending on symptom intensity.
- McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. British journal of sports medicine 2005;39(4):196-204.
- Helmick KM, Spells CA, Malik SZ, et al. Traumatic brain injury in the US military: epidemiology and key clinical and research programs. Brain Imaging and Behavior 2015;9(3):358-66. doi: 10.1007/s11682-015-9399-z
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- Brown BM, Rainey-Smith SR, Villemagne VL, et al. The Relationship between Sleep Quality and Brain Amyloid Burden. Sleep 2016;39(5):1063-68. doi: 10.5665/sleep.5756
- LyytikÄInen K, Toivonen L, Hynynen ESA, et al. Recovery of rescuers from a 24-h shift and its association with aerobic fitness. Int J Occup Med Environ Health 2017;30(3):433-44. doi: 10.13075/ijomeh.1896.00720
- Hoffman NL, Weber ML, Broglio SP, et al. Influence of Postconcussion Sleep Duration on Concussion Recovery in Collegiate Athletes. Clinical Journal of Sport Medicine 2020;30
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