Concussion Treatment
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Dr. van de Wall specializes in concussion management and has completed multiple continuing educations seminars on this topic. His most extensive training is the CCMI (Complete Concussion Management Inc) certification. The CCMI course is the most extensive concussion management coursework available in North America.
As the field of concussion research evolves, Dr. van de Wall continually updates his training to stay on top of the latest scientific evidence.
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A concussion is a mild traumatic brain injury. In mild traumatic brain injuries there is no permanent or irreversible damage, but symptoms and disability can nonetheless be high. Symptoms include headaches, nausea, vomiting, balance problems, dizziness, cognitive issues, emotional issues, and many more. In this state the brain is in an energy deficit, and consumes 20-30% more nutrients and energy while healing.
As you heal from a concussion, the two biggest concerns are that you don’t recover well (it becomes chronic), and that you suffer from a second head injury while the brain is vulnerable. In the case of a second brain injury, the consequences range from extending your recovery time by 2-6 months all the way to permanent brain injury in worst case scenarios.
As our brain heals, it is important to reduce risk of these two things by following a concussion protocol and wherever possible engaging in concussion rehabilitation.
Why Concussion Treatment?
Treatment can be helpful in two situations:
During the first 4 weeks after a concussion to help return to function or sport sooner and with less risk - Treatment can significantly reduce the risk of ongoing symptoms, and reduce the time someone is medically cleared to return to sport/work. Concussion clinics using up to date protocols have shown that the risk for chronic concussions decreases from 30-40% without treatment to 5% with treatment.
If symptoms are lasting after 4 weeks - Sometimes a concussion does not heal well on its own. Treatment is used to find and rehabilitate the source of ongoing concussion symptoms. The four areas of treatment are vision therapy, vestibular rehabilitation therapy, heart-rate specific aerobic exercise, and neck therapy. These treatments reduce concussion related symptoms, as well as improve daily function and quality of life.
How does Concussion Treatment work?
Acute Concussion Treatment
1-4 weeks post-concussion
Acute concussion treatment is about reducing risk once concussed and optimizing safe return to play timelines, specifically:
Reducing the risk of chronic symptoms and improving return to play timelines through early treatment and rehab
Reducing the risk of worsening brain injury or cumulative concussions when returned to soon through return to play testing
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An initial assessment for a new concussion includes:
Screening for signs and symptoms of medical emergencies, or need for medical referral.
Post-concussion symptom scoring.
Concussion-specific testing to confirm a concussion has occurred (ie. it's not just whiplash).
Head, neck, and neurological exam.
Treatment in the first four weeks includes:
Early concussion treatment targeting the neck, vision, vestibular, and autonomic systems. Treatment type varies with concussion presentation, and is usually more a simplified version of the treatment you would see for persistent concussion symptoms.
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Information on how much to rest vs participate in day to day activities.
Strategies to gradually increase activity levels while minimizing risk for flare up or slowing recovery.
Information on how to plan for returning to school, work, and sport following a concussion.
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Concussion-specific return to play testing is strongly recommended to make sure full healing has occurred after a concussion if attempting to return to play within the first 4 weeks.
Testing includes:
Visual function testing
Vestibular function testing
Exertional/physiologic heart rate testing
Cervical spine testing
Chronic Concussion Treatment
4+ weeks post-concussion
Chronic concussion treatment is about identifying source(s) of ongoing concussion symptoms, and applying targeted rehabilitation to help these areas of the brain heal and return to normal function.
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When concussion symptoms persist beyond 4 weeks (known as post-concussive syndrome, PCS), specific testing is needed to find the source(s) of ongoing concussion symptoms. Concussion symptom presentation can be subtyped into 4 broad categories, each with their own specific treatments.
The 4 most common concussion subtypes that cause the vast majority of chronic concussion symptoms include:
Visual dysfunction - difficulty with visual functions such as tracking, rapid eye movements, gaze fixation, convergence, etc.
Vestibular dysfunction - difficulty with static and dynamic balance, position changes, and vestibular reflexes.
Cervical dysfunction - whiplash or trauma to the neck causing concussion-type symptoms.
Exertional / physiologic dysfunction - dysregulated heart rate and blood flow mechanisms to the brain following a concussion that cause symptoms to flare when attempting to exercise or when heart rate is elevated.
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Vision therapy targets post-concussive visual dysfunction. Each exercise trains a specific eye function that may be problematic in isolation or in conjunction with another visual, vestibular, or neck function.
Common visual exercises include progressions of the following functions:
Eye tracking
Rapid eye movements
Convergence
Accommodation
Visual motion tolerance
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Vestibular therapy targets post-concussive vestibular dysfunction. Exercises given are testing dependent, and may include:
Static balance and dynamic balance training
Motion sensitivity / habituation exercises
Gaze fixation / adaptation exercises
Positional vertigo canal re-positioning maneuvers
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This treatment is for a post-concussive exertional tolerance, aka physiologic or autonomic dysfunction. This subtype is diagnosed through a heart-rate monitored treadmill or stationary bike test.
If the exertion tests are positive, treatment includes:
Aerobic exercise at the subthreshold heart rate determined on testing.
Graded progression of aerobic effort through higher heart rate zones.
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Neck manual therapy includes:
Neck joint mobilization.
Neck and shoulder girdle soft tissue therapy.
Neck rehabilitation includes:
Neck mobility, strength, and posture exercises.
Neck motor control retraining.
Neck proprioception / position-sense retraining.
Neck pain and headaches
Dizziness, vertigo, and balance problems
Exercise / exertion intolerance
Concussion symptoms treated:
Brain fog and fatigue
Concussion-related sleep, emotional, and cognitive difficulties
Visual function problems
Concussion Treatment Guide
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If you or someone you know recently had a head and neck injury and suspect a concussion:
Contact your medical doctor or nurse practitioner to get assessed and rule out other issues.
Go to the ER if you are concerned about abnormal concussion symptoms or other head injuries. Monitoring for concerning signs and symptoms in the first 24 hours after injury is always advised.
Consider contacting a concussion-trained rehab practitioner (usually a chiropractor or physiotherapist) if:
You would like to get treatment & protocols during the early stages of healing to reduce the risk of ongoing issues and help speed up recovery.
Your concussion symptoms persist beyond 2-4 weeks and are not going away on their own.
You want to return to a high risk sport before 4 weeks and want to be cleared for return to play safely to minimize risk of additional concussions.
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30-40% of concussion symptoms persist beyond 2-4 weeks. This can be normal for many people, but suggests that some concussion-specific testing and treatment may be needed to recover.
Reach out to a concussion rehabilitation practitioner - usually a chiropractor or physiotherapist with additional concussion rehab training - and consider doing an initial assessment to see if concussion treatment is right for you.
See the above drop down menu under "PCS Assessment" for information on what this looks like.
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Not sure if you need concussion treatment or something else?
Contact Dr. van de Wall's office (see contact info below) and inquire about concussion treatment.
If you have specific questions, leave your email and/or phone number to discuss your case before coming in to see if concussion treatment is a good fit for you.
If we don't think we can help, we'll try our best to refer you to someone we think can.
Interested in concussion treatment or have questions?
