Recovery Roadmap: Manual Therapy's Crucial Role in Concussion Care
Introduction In the ever-evolving landscape of concussion management, the profound influence of manual therapy techniques on patient outcomes is indisputable. The nuanced practice of manual therapy has, at times, been…
It is well-established that a mild traumatic brain injury has a direct impact on mental health. Healthcare professionals should be aware of a concussion patient’s emotional & psychological symptoms, and…
After a head injury, patients can experience various common symptoms, including joint pain, headache, dizziness, nausea and fatigue. Concussions are largely an energy balance problem in the brain. This means activity-induced fatigue after sustaining a concussion is a very common symptom. It is a sign of this ongoing imbalance after a concussion.
How long do these concussion symptoms last?
Suppose you or your patients are experiencing fatigue after sustaining a concussion. First-line treatments should be implemented within the first 30 days. This will help close the energy balance gap and improve fatigue symptoms.
However, suppose their fatigue lasts longer than 3 months after sustaining the initial concussion. In that case, patients could be experiencing persistent concussion syndrome (1). If overly severe symptoms develop, this could be a sign of additional conditions like chronic fatigue syndrome or post-exertional malaise. Now they are facing long term effects of a concussion.
Continue reading this article to learn more about improving fatigue symptoms and the risk factors for developing chronic fatigue syndrome.
How does a concussion lead to a decrease in brain energy?
Check out our previous posts for a full explanation of the pathophysiology of a concussion here. Here is a summary:
During a mild traumatic brain injury, the brain’s movement with the skull will cause an over-activation of the neurons. This initial ‘excitation’ phase uses a lot of energy in the brain. In the following hours to days, there is a reduction in brain energy levels, commonly termed the ‘spreading depression’ phase.
After the spreading depression phase, the brain reaches a minimum of brain energy stores at approximately five days post-injury. Afterwards, energy levels are gradually restored to normal.
Studies show that energy recovery can take anywhere between 22 to 45 days post-injury. The major symptoms during this time include post-concussion fatigue.
How is post-concussion fatigue treated?
There is no gold-standard treatment for post-concussion fatigue. However, there are a variety of positive health behaviours that will each gradually improve fatigue symptoms.
Getting proper sleep
The 4 Ps of Prioritize, Pace, Plan and Position
Getting proper sleep
Getting proper sleep is essential for recovering from a concussion. It is an important time for the brain to recover after a traumatic injury. Lack of sleep also leads to anxiety, depression and worse outcomes in concussion patients.
For a complete article on sleep hygiene, please see our article here. A summary of good sleep habits include:
Maintain a consistent sleep schedule
Create a sleep- conducive environment (dark, cold, quiet, comfortable)
Avoid doing activities in bed other than sleeping (eating, watching TV, working, doing homework, etc.)
Stop all stimulating activities at least 30 minutes before bed (TV, video games, exercise, white light, etc.)
Proper nutrition plays a significant role in the recovery process following a concussion. A well-balanced diet ensures the brain receives the necessary nutrients to restore energy levels and regain full function quicker.
Foods rich in Omega-3 fatty acids, such as fish and walnuts, are particularly beneficial. They help to rebuild the brain’s cellular structure and enhance neuronal function. They also have anti-inflammatory properties, which can help reduce the inflammation induced by a concussion. Antioxidant-rich foods like berries, dark chocolate, and vegetables help neutralize harmful free radicals produced during the brain’s healing process. Protein-rich foods, including lean meat, dairy, and legumes, provide the building blocks essential for repairing damaged tissues and cells.
Finally, adequate hydration ensures proper blood flow and oxygen delivery to the brain, speeding up the healing process.
Implementing these nutritional strategies into your diet can significantly aid in speeding up recovery and reducing post-concussion symptoms.
Patients should avoid alcohol during their concussion. It affects brain healing, sleep and the increased risk of sustaining another concussion. Also, there is always the risk of alcohol compounding any mental health problems that occur after a mild Traumatic Brain Injury (mTBI).
Alcohol consumption before sleep can temporarily increase feelings of sleepiness because of its depressive effect on the brain. However, during sleep, it has been shown to decrease REM sleep, lead to increased waking during the night, and significantly diminish sleep quality. This leads to fatigue and reduced alertness the following day, subsequently, it takes longer to recover.
Regular exercise plays a crucial role in concussion recovery. It not only aids in restoring physical function and strength but also positively affects cognitive function and mood. Physical activity enhances blood flow to the brain, improving oxygen and nutrient delivery, which in turn supports brain healing and recovery.
Furthermore, exercise promotes the release of endorphins – the body’s natural painkillers and mood elevators. This can alleviate post-concussion symptoms such as headaches and depression. Regular exercise also improves sleep, which can aid in recovery from post-concussion fatigue.
Incorporating regular exercise into the recovery plan should be tailored to the individual’s symptoms and recovery progress. Strenuous exercise too soon after a concussion can exacerbate symptoms. Always consult with a healthcare provider before starting any exercise program post-concussion.
Stress management is crucial to a good treatment plan. High stress levels can exacerbate post-concussion symptoms such as headaches, fatigue, and difficulty concentrating. High stress levels can also make it hard for the nervous system to relax to the point of sleep.
Cognitive behavioural therapy (CBT) and meditation effectively manage stress following a concussion. A mental health provider conducts CBT to assist individuals in changing unhelpful thought patterns and behaviors. This can lead to a reduction in anxiety and depression symptoms that often accompany a concussion. It reinforces positive coping mechanisms and aids in managing the emotional impact of the injury.
Meditation promotes relaxation and mindfulness and is something a patient can do independently or with a professional. It aids in reducing anxiety, improving mood, and boosting one’s ability to focus and concentrate. Meditation is particularly beneficial to relieve symptoms such as anxiety, irritability, and difficulties with concentration and memory.
There are also a variety of support groups available for those with persistent symptoms. They can be a good resource for patients for additional support through their concussion recovery alongside their healthcare team.
The 4 P’s of Post-Concussion Fatigue
The 4 P’s of Post-Concussion Fatigue are Plan, Pace, Prioritize, and Position. These are practical guidelines for patients not to overwhelm their brains with too many activities and worsen concussion fatigue.
Prioritize your time and energy. Decide on the important things you must do and focus on those first. You should identify crucial tasks you need to do versus those you can postpone, delegate, or eliminate.
This helps conserve energy for what’s essential and prevents unnecessary energy expenditure. One way to break down activities is by asking yourself the following questions:
Is this urgent? Do I have to do it today?
Do I need help? Can I ask someone to help me or do it for me?
Do I have to do it at all? Can it wait until I feel better?
Pacing is about controlling the speed and intensity of activities to prevent sudden spikes in energy demand. This can cause worsening symptoms and fatigue. It is about balance between continuing to do as much of your everyday activities as possible without overloading your brain.
Plan to take breaks. Remember to change your task or take a break as symptoms worsen.
Try to break tasks down into smaller steps or stages so that you take a break.
Adjust activities as needed into more manageable pieces. For example, if you are to go out with family, go for only a part of the day.
Planning means arranging your day to handle routine tasks and reserving high energy for mentally demanding ones.
Planning for regular rest breaks during tasks that take an extended time.
Intersperse high-energy activities with lower-energy ones to maintain a reasonable energy level throughout the day.
Plan and organize your day to ensure you’re doing work or chores when you feel rested and have the most energy. If you have more energy in the morning, do the most challenging task then.
Spread heavier or harder tasks over the week, not just one day if needed. Try to alternate between physical tasks like folding laundry to tasks that get you thinking, like using the computer.
Try to make time in your day for things that bring you happiness and give you energy. For example, socializing with friends or getting back into a hobby. Setting small goals can help you build up to what you want to do.
Have a backup plan as fatigue can sometimes happen at the most inconvenient times. It is important to have a backup plan for when you feel exhausted. For example, make dinners ahead or have someone else shop for you. Have a backup child-care plan for times when you are not feeling well.
Position refers to being aware that different locations and methods of doing activities can contribute to increasing concussion symptoms and fatigue. For example, using good body posture and ergonomics to reduce physical stress and strain. Good positioning can also involve arranging tasks and environments to minimize unnecessary physical effort.
Think about the things around you and how your posture can affect your energy level. Doing things like standing for too long or sitting in a hunched position while working on the computer can tire you. Changing between various positions and locations can help minimize overloading any system.
Noisy and distracting places can also make it hard to concentrate and will use up more energy, leading to increased fatigue. Use sunglasses to block out light, earplugs to block out sounds, or a shopping list to help you stay focused.
Completing high-energy tasks in comfortable or familiar environments can also reduce fatigue levels. For example, using work-from-home to transition back into a busy or noisy office environment.
When does “regular” post-concussion fatigue become chronic fatigue syndrome?
Fatigue is a very common and expected symptom after sustaining a concussion because of the subsequent lack of brain energy. Therefore, increased physical or mental activity can cause increased fatigue. This usually resolves itself as brain energy recovers over the following 30(ish) days.
However, this fatigue becomes pathologic when there is a reduced capacity to continue the activity even after adequate rest (2). Especially when it lasts past the expected timeline for recovery of brain ATP levels. For these patients severe fatigue prevents them from completing their everyday activities, no matter how much they sleep and rest. This is when normal post-concussion fatigue becomes chronic fatigue syndrome (CFS) or systemic exertion intolerance disease (SEID).
Not everyone with a concussion will get chronic fatigue syndrome. But for those who do, it can be challenging to return to school, work, sports, and other daily activities.
About 33% of mTBI patients will likely experience fatigue, reduced physical activity, and social limitations at the 6-month mark (3). Another study found that after 5 years, 73% were still suffering from fatigue after a TBI, affecting their everyday lives (4).
Why do some post-concussion syndrome patients develop chronic fatigue syndrome?
It is unknown why mTBI can predispose people to develop chronic fatigue. However, it includes multiple factors that are biological, psychological, and social.
Research also suggests that the circuits of the basal ganglia, amygdala, thalamus, and frontal cortex play a role in chronic fatigue. These brain areas and their integration are essential for regulating behaviour, motivation, learning, planning, emotional regulation and other cognitive functions (5). It is unknown if concussion can predispose to these changes in some patients, but it is an area of ongoing research.
Treatment of Chronic Fatigue Syndrome/ Systemic Exertion Intolerance Disease
Just like fatigue that is present after a concussion, there is no gold standard treatment for CFS/SEID. The recommendations are very similar to those for acute fatigue.
However, this is now the time that you should refer your patient to other healthcare providers to ensure that all body systems are addressed.
Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is a complex and multifaceted condition that can manifest differently in each individual. It is essential to establish a healthcare team comprising a variety of professionals, such as a medical doctor, a psychotherapist, an occupational therapist, and a rehabilitation specialist. The main goal for CFS/SEID patients is to gradually increase activity tolerance in personal, work and social settings.
Other testing that may be worth investigating can include:
Blood tests (hormone levels, ESR, CRP, rule out other systemic diseases, etc)
Exercise tolerance tests
Psychological evaluation, etc.
In conclusion, fatigue is a common and treatable symptom most patients will experience after a concussion. There is no gold standard treatment for post-concussion fatigue. However, tailoring a treatment plan using positive health behaviours can improve sleep problems and fatigue after physical or mental activity.
Using a combination of good sleep hygiene, proper nutrition, avoiding alcohol, regular exercise, stress reduction, and the 4 Ps can help your patient get back to normal activities.
McInnes K., Friesen C.L., MacKenzie D.E., Westwood D.A., Boe S.G. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE. 2017;12:e0174847. doi: 10.1371/journal.pone.0174847.
Johansson B., Rönnbäck L. Long-Lasting Mental Fatigue after Traumatic Brain Injury—A Major Problem Most Often Neglected Diagnostic Criteria, Assessment, Relation to Emotional and Cognitive Problems, Cellular Background, and Aspects on Treatment. Trauma. Brain Inj. 2014 doi: 10.5772/57311.
Stulemeijer M., van der Werf S., Bleijenberg G., Biert J., Brauer J., Vos P.E. Recovery from mild traumatic brain injury: A focus on fatigue. J. Neurol. 2006;253:1041–1047. doi: 10.1007/s00415-006-0156-5.
Olver J., Ponsford J.L., Curran C.A. Outcome following traumatic brain injury: A comparison between 2 and 5 years after injury. Brain Inj. 1996;10:841–848. doi: 10.1080/026990596123945.
Chaudhuri A., Behan P.O. Fatigue in neurological disorders. Lancet. 2004;363:978–988. doi: 10.1016/S0140-6736(04)15794-2.
Dr. Steven Murray is a chiropractor located in downtown Toronto, Canada at Back in Balance clinic with an active living and rehabilitation-based practice. He has a special interest in working with all people of all athletic abilities to reach their fitness and wellness goals. Dr. Murray completed his undergraduate and Master’s degree in Exercise physiology at McGill University. He also completed his Doctor of Chiropractic degree at Canadian Memorial Chiropractic College. Dr. Murray treats a variety of spine related conditions, but also has a special interest in treatment of acute and chronic concussions, along with running- related injuries. In practice, he uses his previous experience in research to provide patients with the most up-to-date evidence-based treatment, so his patients receive a proven treatment plan that is tailored to their specific needs.