Concussion Treatment and Recovery | Michigan Medicine

Recovery from concussion is a complex and dynamic process. During recovery it is critical to identify the factors responsible for symptoms and to develop a treatment plan targeting them. If recovery is not properly managed it can lead to unnecessarily prolonged recovery. Management of recovery should be individualized and directed by a health care provider with expertise in concussion care and who has ready access to treatment resources. 

Please note that reading information about concussion, including this web page or others, is not a substitute for appropriate care. A specialist should direct care for recovery from concussion.

Three Phases of Concussion Recovery

There are three phases of concussion recovery:

1. Acute symptomatic phase
2. Recovery phase
3. Recovered phase

The time spent in each phase is influenced by many factors and has individual variation.

Phase 1: Acute Symptomatic Phase

The acute symptomatic phase is defined as the time from injury, through maximum symptoms, to the beginning of when the symptoms resolve. Typically, this phase lasts less than three days. If you experience any of the following “Red Flag Symptoms during this phase,” you should go to the emergency room:

• Loss of consciousness for more than one minute
• Increasing confusion or inability to stay awake
• Repetitive vomiting
• Seizure or convulsion
• Severe or increasing headache
• Severe neck pain
• Weakness, tingling, or burning in arms or legs
• Persistent double vision or loss of vision
• Increasingly restless, agitated, or combative

In the first one to two days after suffering a concussion, near complete rest is important.

Even though symptoms during the acute symptomatic phase may be quite limiting, returning to light thinking and physical activities should start after the first couple of days.  

Examples of light thinking activity include:

• Watching TV
• Pleasure reading (if tolerated)
• Listening to music 
• Short periods of schoolwork

Examples of light physical activity include:

• Light chores around home 
• Short walks

During the acute symptomatic phase, it is typical that thinking and physical activity can make symptoms worse. Exposure to bright lights, loud sounds, and movement may also worsen symptoms. During the acute symptomatic phase, any activity that worsens symptoms should be avoided or limited. See Electronic Devices and Screen Time During Concussion Recovery (below) for information about screen time during recovery.

Management During the Acute Symptomatic Phase

During the first 24 hours you should avoid medications that can increase risk of bleeding. These include aspirin, ibuprofen (Advil), and naproxen sodium (Naprosyn, Aleve). During the first 24 hours acetaminophen (Tylenol) can be used for pain relief. After the first 24 hours, ibuprofen (Advil) and naproxen sodium (Naprosyn, Aleve) are generally more effective for pain relief, and are safe. In some patients, nausea and vomiting can be bothersome, and prescription medications can help.

Restful sleep is important in all stages of recovery from concussion. If getting to sleep or staying asleep is difficult, discuss this with your doctor for further recommendations. Sleep behavior techniques may be helpful as is the use of certain medications.

Throughout concussion recovery you should be sure to stay hydrated (60-80 ounces of water or non-caffeinated beverages per day), and eat normally.

Phase 2: Recovery

The recovery phase is characterized by:

• Lessening symptoms
• Ability to perform more intense thinking and physical activities without symptoms getting worse
• Gradual return to your preinjury state

During this phase it is common that symptoms will worsen with more thinking and physical activity.  

Gradual Return to Thinking and Physical Activity

After a 1-2 day period of rest, gradually increasing thinking and physical activity should be encouraged. During the recovery phase, symptoms should gradually improve to the point where you are symptom-free at rest, first with thinking activities, and then with physical exertion.

The amount of thinking and physical activity that is tolerated during recovery from concussion is dynamic and based on symptoms. Until recently, the recommendation had been to rest until symptom-free. New studies, including one performed at Michigan NeuroSport, suggest that limited exercise during the recovery phase allows for quicker recovery from concussion. 

Return to physical activity and exercise should be gradual and determined by your doctor. 

Examples of cardiovascular exercises that are started during this phase include use of a stationary bike or walking. Again, the specifics of the activity should be determined and guided by your doctor. Exercises that require bearing down, such as situps, pushups, pullups and weight lifting, should be avoided at first unless directed by your doctor, as they typically worsen symptoms.

Determining what type and how much activity is part of an individualized care plan that should be provided by your clinic. Accommodations may be needed during the transition to full-time school and work (see below).

Academic Accommodations Following Concussion

• Notify school of concussion
• Develop plan for gradual return-to-school demands
• Provide waiver of missed assignments or exams
• Plan to assist/support completion of missing assignments
• Provide rest time/breaks during school day
• Consider exemption from upcoming standardized tests
• Excuse activities requiring rigorous physical activity
• Reduce homework assignments
• Reschedule, coordinate or pace exams during times when the student is asymptomatic
• Negotiate timing of large assignments
• Assign a counselor
• Preferential seating for nose reduction and teaching monitoring
• Allow test-taking in a distraction-free environment
• Allow extended time for exams and assignments
• Using dedicated notetaker

Adapted from O’Neil JA, Cox MK, Clay OJ, et al. A review of the literature on pediatric concussions and return-to-learn (RTL): Implications for RTL policy, research, and practice. Rehabilitation Psychology: 2017;62(3):300-323

Management During the Recovery Phase

During the recovery phase factors that are causing symptoms should be sought and treatment plans put in place for their resolution. Common treatable causes of concussion-like symptoms include; neck injury, dizziness, lightheadedness, vision problems, difficulty with sleep, and new or worsening mood symptoms.  Continued follow up at a clinic with expertise in management of concussion during the recovery phase allows for an individualized recovery plan including, a prescription for exercise and referrals to optimize recovery.

During the symptomatic/recovery phase use of medications may still be necessary. Consistent scheduled medications used to treat headache should be discouraged, and reserved for severe headaches that limit activities. Consistent, prolonged use of medications to treat headache may result in medication overuse or rebound headache.

Medications for nausea may also be considered, if nausea is severe. During this phase nausea should significantly improve, and if it doesn’t, alternative explanations for it should be sought.

For sport-related concussion recovery, visit our Concussion in Athletes page.

Normal and Prolonged Concussion Recovery

Recovery is influenced by several important factors (see “Symptoms Associated With” list below), but age appears to be particularly important. Normal recovery for those younger than 18 is considered 30 days, and for those older than 18 is considered 14 days. A goal of recovery management it to avoid prolonged recovery, but 10-30% of those experiencing concussion can experience prolonged recovery.

The dynamic nature of concussion recovery requires follow-up with tailored management during each phase of concussion. Key milestones in the recovery process are return to learn, school, work, exercise, and sport. Each of these milestones is approached gradually from symptom-limited activity to full participation.

Symptoms Associated With (or Not Associated With) Prolonged Concussion Recovery

Factors associated with prolonged recovery:

• Initial symptom burden
• Female gender
• Age less than 18, with ages approximately 13-17 being at highest risk for prolonged recovery
• History of mental health issues
• Concurrent cervical involvement
• Convergence insufficiency

Factors not consistently assocated with prolonged recovery:

• History of migraine
• History of a neurobehavioral or attention disorder, i.e. ADHD or ADD
• Loss of consciousness

Adapted from Iverson GL, Gardner, AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine, 2017;51(12):941.

About Michigan Neurosport

The University of Michigan is one of only a handful of comprehensive programs in the country dedicated to the neurological concerns of athletes of all levels through our multidisciplinary NeuroSport outpatient clinic. Visit our Concussion in Athletes page or NeuroSport page for more information.

Patient Resources

• Concussion Patient Care Guide (NeuroSport)
  

Make an Appointment

To request an appointment or to get more information, please call 734-930-7400 and a team member will get back to you within two business days.

Electronic Devices and Screen Time During Concussion Recovery

It is important not to completely avoid use of electronic devices or exposure to screens unnecessarily. Restriction from email and social media can lead to social isolation and worsening of concussion-like symptoms. Use of electronic devices and social media during concussion recovery may be practiced as long as they do not make symptoms significantly worse. Computers, phones, TVs and social media can help avoid the complications of boredom and social isolation as well as their potential harmful consequences. Electronics use should be reasonably limited based on symptom worsening.

Concussion | Johns Hopkins Medicine

What is a concussion?

A blow or a jolt to the head can cause a concussion or traumatic brain injury (TBI). The injury keeps the brain from working normally. Symptoms of a concussion may last less than a day or may linger for months, or longer.

Millions of mild traumatic brain injuries occur in the U.S. each year, but most don’t require a visit to the hospital.

What are the causes of concussions?

Many concussions that require emergency treatment are because of falls, motor vehicle accidents, assaults, and sports injuries. Children, young adults, and older adults are at especially high risk for concussions and may take longer to recover after a concussion. People who have had concussions before are more likely to have them again.

What are the symptoms of a concussion?

These are symptoms of a possible concussion:

• Headache
• Vomiting or nausea
• Trouble thinking normally
• Memory problems
• Trouble walking
• Dizziness
• Vision problems
• Fatigue
• Mood changes
• Changes in sleep patterns

These symptoms may occur right away. But some may not start for weeks or even months after the injury.

How are concussions diagnosed?

To diagnose a concussion, your doctor will probably ask you a variety of questions. Be sure to say if you lost consciousness and report any other symptoms. The doctor will also want to know how the injury occurred and where you hit your head.

You may also be asked questions to test your memory and asked to do certain tasks to show how well your brain is functioning. Your doctor may also ask your friends or family questions about your symptoms and the injury.

Images of your brain using CT or MRI scans may be taken and evaluated.

How are concussions treated?

An important part of treatment for a concussion is getting plenty of rest, both sleep at night and naps or rest breaks during the day if needed. Your doctor will probably tell you to avoid certain physical activities and sports while you recover and may suggest medicine to take if you have a headache.

If your symptoms don’t go away in a few days or if they get worse, you may need to see a doctor who specializes in concussions.

Can concussions be prevented?

You can take a number of steps to help reduce your risk for a concussion or prevent it in your children:

• Wear a seat belt every time you’re in a motor vehicle.
• Make sure your children use the proper safety seat, booster seat, or seat belt.
• Never drive under the influence of drugs or alcohol. 
• Wear a helmet for activities such as riding a bike or motorcycle, playing contact sports, skiing, horseback riding, and snowboarding.
• Reduce your risk for falls by eliminating clutter in your home, removing slippery area rugs, and installing grab bars in the bathroom if needed, especially for older adults.
• Never work on a ladder if you feel dizzy or lightheaded. Alcohol can make you dizzy. Some medicines also can make you dizzy or affect your balance.
• Have your vision checked at least once a year. Poor vision can increase your risk for falls and other types of accidents.

Managing a concussion

After a concussion, your healthcare provider may decide to monitor you in the emergency room. When you’re released, the provider will want someone to stay with you at home for a day or 2 to keep track of your condition. Follow your healthcare provider’s directions about avoiding sports, physical education classes, and activities such as running and bicycling while you are recovering.

Limit activities that require you to concentrate heavily. This includes taking tests if you are in school or doing tasks at work that require intense focus. You may also need to take rest breaks during the day. As your symptoms go away, you may be able to go back to your normal activities. The time it takes to recover from a concussion can vary from weeks to months. In rare cases, symptoms can last for years.

If you have symptoms or problems that last more than 3 months, you may have a problem called postconcussion syndrome. Discuss this possibility with your doctor.

When should I call my healthcare provider?

Call your healthcare provider right away or go to the emergency room if you or someone else loses consciousness after a blow to the head or if any of these occur:

• Headache that gets worse and does not go away
• Weakness, numbness or decreased coordination
• Nausea or vomiting
• Slurred speech
• Feeling very confused
• Feeling very drowsy
• Convulsions or seizures

These could be signs of a serious condition that needs treatment right away.

Key points about concussion

• A blow or a jolt to the head can cause a concussion
• Symptoms such as headache, nausea, vomiting, dizziness, or trouble thinking can happen right away, or they may come on gradually over time.
• Call a healthcare provider right away or go to the emergency room if a person loses consciousness after a blow to the head.
• Getting plenty of rest is an important part of treating concussions.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

Treatment of concussion. Types and symptoms

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symptoms, diagnosis and treatment in Moscow

Concussion is a relatively mild and reversible brain disorder without organic damage. A similar condition occurs as a result of a traumatic brain injury: a strong blow, bruise or sudden movement of the head. In this case, the brain is strongly shaken and soft tissues, by inertia, hit the inner vaults of the skull.

A concussion provokes not only the appearance of unpleasant symptoms characteristic of a head injury, but also structural changes in the brain, leading to various complications. Therefore, even if there are mild signs, it is necessary to consult a doctor in order to protect your health from the development of pathologies when a vital organ is injured.

Clinical picture in case of concussion

Clinical manifestations are explained by a violation of neural connections between the brain stem and cerebral hemispheres, displacement of layers of nervous tissue, and deterioration of blood supply.

Macroscopic and histological changes in cells as a result of concussion were not detected.

In the first time after injury, the neurological status of patients may show nystagmus (involuntary eye movements), slight asymmetry of reflexes, mild meningeal symptoms.

Classification

Depending on the severity of the injury, concussion is of three types and is accompanied by the following symptoms:

1. Mild degree.
   The person is conscious, for 30 minutes the victim experiences a headache, dizziness, nausea and loss of orientation in space. After half an hour passes, the person’s condition returns to normal.
2. Medium degree.
   Consciousness is preserved, short-term memory loss is detected. All other signs are similar to a mild form of concussion.
3. Severe degree.
   The victim loses consciousness from several minutes to several hours. In such a situation, the person does not remember what happened before the CNS (central nervous system) injury. In addition, dizziness, nausea, disorientation in space and headache may remain for 2-3 weeks. Sleep is disturbed and appetite is reduced.

Causes of concussion

What circumstances cause this pathological condition in adults and children:

• domestic bruises;
• sudden head movement;
• traffic accidents;
• sports or work injury;
• blows received during street fights and under other criminal circumstances.

Concussion symptoms

There are 3 groups of signs of the disease:

Pathogenesis

As a result of an injury, the characteristic symptoms appear due to a malfunction of the nerve cells of the brain. Their nutrition is deteriorating, the layers of the brain tissue are shifting, there is no connection between the brain centers.

In a severe form of the lesion, blood vessels rupture and some areas are severely damaged. The main danger in such a situation is intracranial bleeding, resulting in additional tissue compression.

Which doctor to contact if you suspect a concussion

Patients with a traumatic brain injury should first see a traumatologist. The doctor will assess the severity of the damage, check the reflexes, and prescribe an x-ray of the skull. In the event of a serious injury, an additional consultation with a neurologist or neurosurgeon may be required.

If a patient has a concomitant injury with damage to the bones of the skull, dislocation or fracture of the cervical vertebrae, an emergency surgeon is needed.

Consultation with an otolaryngologist is required if there is bleeding from the ears or nose, damage to the nasal septum, or prolonged (more than a day) sensation of tinnitus.

If a contusion of the eyeball is suspected, the patient is referred to an ophthalmologist. If the patient does not get pain in the eyes, there is a decrease in vision, clouding or fuzziness of the picture, it is likely that TBI is accompanied by corneal edema or detachment of the iris.

How to identify a concussion

As a result of TBI, a person often loses consciousness for a period of several seconds to several minutes. Having come to his senses, he does not understand where he is, does not remember recent events and hardly distinguishes faces. In severe cases, it can fall into a coma.

Concussion causes severe nausea or vomiting. The victim turns pale, cannot focus his eyes. In the first hours after the injury, the pupils are excessively dilated or, conversely, narrowed. A patient with such symptoms should not be left without medical attention.

Features of concussion in children and the elderly

The clinical picture largely depends on the age of the patient:

babies	With a concussion, they rarely have a violation of consciousness, but regurgitation during feeding and bouts of vomiting become more frequent. The skin suddenly becomes pale, anxiety and difficulty falling asleep against the background of general lethargy and drowsiness are noted. Concussion symptoms at this age go away after 2-3 days.
Preschoolers and younger students	The pathological condition usually proceeds without loss of consciousness. The pulse becomes labile. Often observed horizontal nystagmus and reduced corneal reflexes. The child is on the mend after 2-3 days after the injury, while in adults the regression of symptoms occurs only on the 5-9th day.
Elderly and senile people	Primary loss of consciousness is rare, but severe disorientation in time and space is common. Patients complain of severe throbbing pain in the back of the head, dizziness, memory disorders. Symptoms last from 3 to 7 days.

Diagnosis

In case of a concussion, it is necessary to consult a doctor in order to prescribe timely treatment, if necessary, which will help prevent the development of complications. When diagnosing, the doctor takes into account all the circumstances of the incident, so both the patient and the witnesses of the incident need to be told as much information as possible.

An important role is played by the presence of injuries on the head, the psychological state of a person, alcohol intoxication and other related factors. When taking an anamnesis and examining the victim, the doctor checks the absence of anisoreflexia (unequal reflexes on the right and left sides of the body) and prescribes additional research methods: skulls.

In addition, the specialist, if necessary, refers the patient to a consultation with a neurologist. May also require:

• electroencephalography;
• echoencephalography;
• Doppler study of cerebral vessels;
• MRI of the spine.

In severe cases, a lumbar puncture is done as indicated by a specialist. This study makes it possible to determine the pressure, transparency, color and composition of the cerebrospinal fluid.

First aid for concussion

First of all, the victim should call an ambulance. Only a health worker can correctly assess the patient’s condition and the likelihood of serious complications. Late referral to a doctor makes diagnosis difficult.

The victim needs to be kept calm. If possible, the patient should be placed in such a way that the head is located above the body. A cold compress or ice pack can be applied to the injury for 5 minutes.

An unconscious patient should be revived. However, if this is not possible, it must be laid on the right side, bending the left arm and leg at an angle of 90 degrees.

In this way, you will prevent tongue retraction or choking due to uncontrolled vomiting.

Do not give painkillers or other medicines until the doctors arrive, as they will distort the clinical picture.

Treatment

Treatment for concussion consists of bed rest and prescribed medications. It is extremely important for the victim to be at rest and get enough sleep. Symptomatic therapy for the elimination of functional abnormalities in the brain includes the following types of medicines:

• sedatives;
• painkillers;
• psychotropic and hormonal preparations;
• means to eliminate insomnia and more.

Also, in some cases, an anesthetic injection at the site of attachment of the posterior cervical muscles, as well as manual therapy and physiotherapy, are prescribed.

Prevention

In order not to treat a concussion that has occurred, care must first be taken during situations that can lead to traumatic brain injury. When engaging in active sports, you need to use a protective helmet, and when driving in a car, buckle up. In winter, choose shoes with soles that reduce slippage during icy conditions or use special overlays.

Consequences and complications

If you do not treat in time and do not follow the recommendations of a qualified doctor, the following complications may develop:

• epilepsy;
• sleep disturbance;
• deterioration of hearing and vision;
• post-traumatic neurosis;
• vasomotor disorders, manifested by severe headaches, aggravated by physical exertion.

Forecast

The patient recovers completely if all doctor’s prescriptions are followed and in the absence of additional aggravating injuries. Some victims of concussion after the end of the acute period may experience a weakening of memory and attention. Headaches, irritability and depression, sleep disturbance and poor tolerance to loud sounds and bright lights may also appear.

All described post-traumatic symptoms can be observed from 3 to 12 months. In the future, unpleasant symptoms either completely disappear or are significantly smoothed out.