Screens | Exercise | Sleep | Breaks | Anxiety & Depression | Diet | School & Work
by Joon Nah BScPT
Certified Vestibular Concussion Physiotherapist
updated Feb 23, 2021
Post Concussion Syndrome (PCS), also known as a chronic minor traumatic brain injury (mTBI), can result in significant, long-term symptoms and limit routine tasks and activities. Recovery can be even more problematic, as there are no concussion protocols that apply to everybody, rather rehabilitation is specific and personalized for each individual.
We recommend that everyone with post concussion syndrome work with a concussion professional, such as a vestibular physiotherapist so that your recovery is optimized. However, here we have compiled our top 10 general tips and advice that can apply to anyone who has suffered from chronic effects of a concussion.
1. The 2-Point Rule for Concussion Symptoms
Recovery from a concussion is centered on gradually increasing the stimulation you are exposed to, without over-stimulating yourself. This is a tricky balance to achieve and usually requires advice from a concussion therapist. However, generally speaking, when introducing an activity back into your daily routine, many use the 2-Point Rule.
You rate your current symptoms out of 10 (0 being no symptoms at all and 10 being the worst symptoms you can imagine). Then, you are allowed to continue your specific activity (going for a run, watching TV, typing on a computer) until your symptoms increase by 2 points, then you must stop.
For example, let’s say you are adding reading back into your routine and you rate your current symptoms as 3/10. Then you are permitted to continue reading as long as your symptoms stay within 2 points of this starting place(i.e 5/10 or less). If you reach 6/10, then you must stop reading.
2. Screen Time (phones, TVs, computers)
Computer, smartphone and television screens can be one of the most aggravating types of stimulation when we are recovering from PCS. It’s easy to overexpose our eyes (and brains) to the strain that screens cause and move backwards with our recovery. Here are some tips to help manage screen time properly:
- Most computers, monitors, newer TVs, and smartphones have nighttime settings that change the color tones on your screens from harsher blue ranges to calmer, soothing warmer tones. Set these so they are “ON” permanently.
- Use a physical anti-glare screen cover or a blue light filter on your monitor
- Ensure that your spaces are well lit when looking at a screen. Never watch a screen in a dark room.
- On computers and phones, increase the size of text and increase the distance of the screen from your face. You can adjust these sizes under your settings or search for “screen resolution”
- Breaks! Don’t wait for your symptoms to flare up to remind you to take a break. Set timers to take these proactively so that you stay ahead of your symptoms.
3. Exercise during Concussion Recovery
Generally speaking, exercising can be very beneficial for recovery from post concussion syndrome. Heart rate elevating exercise increases the blood flow to your brain, which speeds up the healing process. The movements related to exercising also helps trigger positive, normalizing nerve activity by the coordinating action of your arms, legs, neck and head as you move. Exercise also improves mood functions, reduces anxiety and depression, and can help with improving sleep.
It is recommended that:
- You walk daily. Walking activity is generally quite easy for concussed patients to tolerate and the movement patterns associated with it are great for recovery.
- Use care to gradually return back to physical activities. If you expect your heart rate to go up, then use a heart rate monitor to ensure that you are elevating your heart rate just a little more each session.
E.g. ride your stationary bike until your heart rate reaches 100 beats per minute (bpm) then adjust your speed so that it stays there for the rest of the exercise session. After 5 days of repeating this level of intensity, then allow your heart rate to go to 105 bpm.
- Avoid any activities where there may be a chance of hitting your head. (e.g. volleyball or skating for the first time). Suffering a second concussion while trying to recover from the first one can significantly delay your healing. Wait until you’re symptom free before attempting these sorts of physical activities.
4. Post Concussion Sleep Hygiene
Much of our recovery happens while we are sleeping. Particularly during Stage 4 sleep when breathing deepens, heartbeat slows, and brain wave activity is at its lowest. Sleep releases important hormones and allows cell repair to accelerate.
Tips on a more recuperative sleep:
- No screens (smartphones, TV, computer) in the last hour prior to bedtime.
- No naps during the day.
- Keep a regular sleep schedule, waking up at the same time each day (avoid sleeping in on weekends).
- Melatonin supplements, particularly if sunlight exposure has been limited (e.g. in the winter).
- Try using a weighted blanket while sleeping.
- Exercise! But not in the 90 minutes before bedtime.
- Often concussion come with tinnitus (ringing or other unwanted sounds in your ears). A white noise machine or phone app or even a nearby fan can help in creating a distracting sound and may soothe you into a faster, deeper sleep.
5. Brain Breaks
Properly utilizing brain breaks is the most important factor in a successful return to normal activities such as school, work and play.
What is a Brain Break?
It’s common to think of a rest or a break as physical timeout; lying down and closing your eyes. However, a brain break is more than just resting. It’s the ability to put your brain into a state where there is as low a level of neural stimulation as possible.
All activities cause your brain to be stimulated on some level. Working on your computer in a busy coffee shop creates massive levels of brain stimulation, and lying down thinking about what to cook for dinner creates small level of brain stimulation. A true brain break keeps stimulation from ALL sources at a minimum. This means a physical break, a cognitive break, AND a psychological break.
Why is brain rest important?
Your brain has a limit to how much stimulation it can tolerate before you overload its capacity and start reversing your post concussion progress. The more you do, the more the neural load on your brain builds up. A brain break allows this neural stimulation buildup to gradually reduce which then allows you to safely return to your activity again.
How do we get our brains to shut off?
Meditation is the key here. I strongly suggest to all of my patients, that they learn how to meditate. There are some excellent online resources, phone apps, even Netflix programs, that teach you how to meditate. Meditation is the best tool to learn how to quickly shut your brain off and give it the true “rest” that it needs before moving on to your next activity.
6. Anxiety/Depression with Concussion
The one group of factors that can take the most blame for delaying recovery and can cause post concussion symptoms to return is depression, anxiety, and poor stress management.
Optimal recovery and brain function requires a predictable and steady level of basic brain wave activity. Anxiety, depression and stress elevates the overall level of base neural activity as well they introduces large erratic waves in neural patterns.
I often use the analogy of building a tower of wood blocks on a boat. When stress, anxiety and depression are minimal, the ocean is calm and the boat is stable. It’s easy to build your wood block tower; the higher the tower, the better you feel. Stress, anxiety and depression represent a stormy ocean with larger and larger waves. Under such conditions, building your tower can get quite difficult.
Here some tips to help with managing these symptoms:
- Accept the fact that you may have an issue with anxiety and depression.
- Take your psychological symptoms seriously as they have a real physical effect on your brain function.
- Identify what your triggers are and reduce or eliminate as many as possible.
- Learn how to meditate. (see Brain Breaks above)
- Take on stress reducing activities like Tai Chi, Yoga, or enjoying your favorite calming music.
- Join the many mindfulness groups and communities that exist. Most municipal health departments have resources you can access.
- Get help from a professional. Cognitive behavioral therapy (CBT) from a social worker or psychologist; medication from a psychiatrist or physician can both be very helpful.
7. Concussion Diet Advice
Poor nutrition can have a negative effect on post concussion syndrome. What you eat and drink has direct changes to blood flow and composition, to hormone release and balance, to proper cellular activity, and ultimately to brain functioning. Here are some tips to consider:
- Stay hydrated by drinking lots of water and avoiding dehydrating fluids such as coffee, soda pop, and energy drinks.
- Be careful with caffeine. Besides its dehydrating effects, this stimulant can over-excite the neural pathways in your brain, lowering your tolerance to most of your usual daily activities.
- Eat on a regular schedule and don’t skip meals. Your body and brain need nutritional fuel on a regular cadence to ensure there are no gaps in your recovery.
- Some foods are known to make you more susceptible to headaches possibly through an inflammatory effect. Foods such as chocolate, aged cheeses, citrus fruits, highly processed foods, high sugar food and drink, preservatives such as nitrates, and high levels of salt.
8. Return to School and Work
For those with post concussion syndrome, getting back to school or your job, is typically your primary goal. Here are some things that can make the transition easier:
- Move your desk or work location. Find a quieter area, with less auditory and visual noise around you.
- Wear a hat to keep your visual field smaller and more focused, and to decrease the glare from overhead lighting.
- Use ear plugs or noise cancelling headphones to remove the significant distractions that sound can create.
- If you feel that your eye strain is increasing, try wearing polarized sunglasses to reduce visual stimulation. However, be careful to only wear these when you need them, as you still need some exposure to light. Additionally the more you wear your sunglasses, the more difficult it is to wean off them.
- Get used to using check lists. These can give your brain the structure it craves when your ability to organize is compromised.
- Your doctor or physiotherapist can help create your back to school or work transition plan. They can also provide the documentation you need for medical clearance to make implement these changes.
- EAPs. Many larger workplaces have Employee Assistance Programs that can offer you services to help you transition back to work and stay there. Best of all, EAP services are funded by employers.
9. Daily Activity & Symptom Log / Concussion Tracking
Without proper tracking of your symptoms and your activity, it’s difficult to understand what’s making you better and what’s making things worse. A daily log is an excellent way to follow your patterns for both yourself and to help your concussion physiotherapist with treatment planning. It’s also a useful tool to keep you on schedule with your home therapy program and avoid getting off track.
Your log would track items such as:
- Sleep Quality
- Memory / Brain Fog
- Screen Time in Minutes
- Therapy Exercises checklist
- General Exercise in Minutes
10. Setting Expectations with PCS
No one can tell you, on which day your post concussion symptoms will disappear for good. At times it can feel like you’re never going to get better. Unfortunately, this uncertainty causes stress, increases anxiety, and expands the clouds of depression. And as we’ve made clear, these factors themselves can prolong your recovery.
So what can we actually be certain about?
1) The vast majority of those with post concussion syndrome get better. It may take months, or in some cases years, but for the most part, PCS is not considered a permanent condition.
2) Patients don’t get better in a straight line. To clarify, you don’t improve by 1% each day, until 100 days later, you’re recovered. Rather, expect to get better in a wave-like pattern. You’ll improve for a period of time, then you’ll feel a little worse, then better again, then backtrack for a while. This up and down recovery curve is normal and still gets you to the finish line, though you don’t take the fastest way there.
3) It doesn’t matter how long ago your concussion occurred; there’s still an opportunity for improvement. Neuroplasticity of the brain starts the minute we are born and doesn’t stop until our final day. It’s the power of neuroplasticity that is the main driver of recovery from brain injury. This means that there’s always an opportunity for your brain to change if you can give it the right stimulus.
4) You can affect your own recovery. What you do during your rehabilitation has a direct impact on how quickly you get better. Adopt the tips we’ve provided in this article and learn more about Post Concussion Syndrome by clicking here. If you need some assistance to ensure you’re doing all you can, then contact a professional such as a vestibular physiotherapist with post concussion training.
Cornerstone Physiotherapy has vestibular physiotherapists trained and experienced in the treatment of post concussion syndrome. Convenient locations in Downtown and Midtown Toronto, North York, Markham and Burlington. Contact us today, and get us on your team.
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