Yoga

Can yoga help with my concussion recovery?

Yoga can be a great source of exercise or mindful movement for people with a concussion. There is something to be said for connecting your mind, body and spirit as you go through the recovery process. And as far as yoga is concerned in the concussion population, Love Your Brain Yoga (LYBY) is a tremendous organization and resource to learn how you can integrate yoga into your recovery regimen today.

Concussion Recovery

How long does it take to recover from a concussion?

Recovery from a concussion is individualized and assessed on a case-by-case basis. Predicting recovery from a single concussion is challenging, given the unique nature of the injury. Recovery is measured by ongoing progression through the graded step-wise protocol of increasing exposure to school, physical activity, work, and social life. Progression is not based on time but based on your response (symptoms and performance) to the rehab protocol.

We know that on average school-aged students take approximately two to four weeks to fully return to all activities. Each concussion is unique – don’t compare one person’s recovery to another’s. Healing from a concussion is a process that takes patience. Rushing back to activities can make symptoms worse and recovery longer.

What can I do to recover from a concussion?

Since a concussion is a form of traumatic brain injury, it is important that individuals modify their lifestyle and activities to promote brain recovery. This includes:

• Adequate amounts of rest
• Adequate amounts of sleep
• Adequate nutrition and not skipping meals
• Keeping well hydrated
• Avoiding activities that significantly worsen symptoms
• Avoiding situations that can be stressful
• No alcohol and recreational drugs
• Strictly avoiding situations that can place the person at risk of future head injuries or concussions
• Stay engaged. Do not isolate yourself and avoid social interactions (i.e., cocoon).

After a concussion, am I at risk of future concussions?

The vast majority of people who suffer a single concussion recover and go on to live normal lives. However, individuals who have suffered even one concussion are at risk of suffering further concussions that may occur with less force and may require longer periods of time to recover. Multiple concussions or incomplete recovery can be a risk factor for deterioration in performance (e.g., school, work), depression, and anxiety – it is therefore important that students avoid concussions and report them immediately when they do happen.

Exercise Progression

General Principles

Each stage of exercise should be performed without symptom production either during or after (within an hour or so) exercise.

If a stage of exercise does produce symptoms, then the next session should the patient has to “go back” to the last stage that did not produce symptoms, and subsequently progressed with caution, after a day or two of asymptomatic exercise.

By Whom

Ideally, such an exercise progression should be supervised and monitored by a qualified health professional. However, patients may “supervise” their own progression if needed, so long as they understand both the principles involved and the specifics.

How often to exercise

Sessions in an exercise progression after concussion are typically once daily. In some cases (either severe injuries with prolonged symptoms, or mild injuries with fleeting symptoms) the frequency of these sessions may be reduced (to several sessions per week) or increased (to twice daily) as may be appropriate in the clinical judgement of a supervising health professional.

How quickly to progress

This is not a time-based process; instead, it is based on successfully reaching “milestones”. Each stage is commenced only after the last stage has been completed successfully. There is no “correct” rate of progression so long as the previous stage has been successfully passed.

In the mildest cases with the quickest recovery, an athlete may potentially progress from one stage to another on the same day (if doing two sessions of exercise that day).

In severe or prolonged cases, it is generally prudent to perform exercise successfully (without symptoms or exacerbation) for at least several sessions before progressing to the next stage.

Stages of Exercise Progression

Rest

Goal: Reduction of symptoms/attainment of asymptomatic state

Description: No physical activities that raise HR above resting rate. Should perform non-vigorous isometric stabilization exercises for the neck.

Re-Introduction of Stressors

Goal: Establish capacity for cardio-respiratory exertion without symptom production (or symptom exacerbation if performing progression despite persistent symptoms).

Description: Stationary bicycle (no head movement) with the progression of intensity or duration (not both concurrently in one session).

• 15 minutes @ 120 bpm – increase duration to 30 minutes @ 120 bpm
• 30 minutes @ 140 bpm
• 30 minutes @ 140 bpm – 1-minute maximal sprints every 5 minutes (@ 5, 10, 15, 20, 25 min)

Low-Level Stress

Goal: Establish capacity for at least 30 minutes per day of sport-specific movements that involve progressively greater acceleration of the head without symptom production (or exacerbation)

Description: Sport-specific movement that is most relevant to a patient’s function, with gradual progression of both intensity of exercise and magnitude of head acceleration, individualized as appropriate. At this stage, there should be no “cognitive burden” where drills require them to make decisions or concentrate on a task other than basic movement. No resistance training.

Intermediate Stress

Goal: Establish that at least 30 minutes per day of sport-specific training (stage 3) with additional cognitive and visual tracking burdens and body-weight resistance exercises do not produce or exacerbate symptoms.

Description: Continue with the intensity and duration of sport-specific drills reached in stage 3, but now add an element of thinking or decision-making, such as ball or puck-handling, shooting, passing, positional play, execution of set plays, and so on. Also, add 15 minutes per day of body-weight floor exercises such as planks, push-ups, squats, lunges, sit-ups, box jumps, and so on – progress these from less intense (e.g. planks) to more intense (e.g. box jumps). Do not hold your breath.

Submaximal Stress

Goal: Establish freedom from symptoms in situations that simulate all aspects of normal training, except for the risk of collision.

Description: Sport-specific drills should involve increased complexity in simulating game situations. Increase duration toward normal daily training load for this sport. Resistance training may now use additional weights or machines as would be typical of training programs in your sport. Heavy resistance exercises may involve the Valsalva manoeuvre (breath-holding during very heavy lifting, which increases intracranial pressure).

Full Physical Activity / Sport

Goal: Unrestricted activity without symptom production.

Description: Full participation in sports.

Sleep Hygiene

Why is sleep so important after a concussion?

Early after a concussion in the first few days, changes in sleep and wakefulness are routinely experienced by almost everyone. This is normal. The brain and the body need extra sleep to recover. During the first week to ten days, allow yourself to sleep and nap as needed! The structures in your brain responsible for sleep and day-time wakefulness are located at the base of your skull/upper spine and are quite vulnerable during concussion.

What is “Sleep Hygiene”?

Supporting healthy sleep and day-time wakefulness should always begin with addressing behaviors and the environment. This is called “sleep hygiene”.

Part of sleep hygiene involves having a clear schedule/routine and trying to stick to it daily. Go to bed and get up at the same time each day, even on weekends if possible. (If this is difficult, try to keep it within ½ hour either way.) Not only will this help your sleep, but it will help all aspects of your life.

What are suggestions for sleep hygiene at night?

• Make sure it’s quiet. If you have noisy roommates, noises from the street etc., wear ear plugs and use a white noise maker.
• Create a cool dark environment
• Use a humidifier if needed.
• Do NOT have a digital clock beside the bed!
• Try not to have your laptop in your bedroom room (or tv) and turn off all electronic devices an hour before sleep.
• Use dim out or black-out curtains or try an eye mask.
• If getting up to use the bathroom, try not to turn on the overhead light; use a night light. Do NOT look at a clock.
• Keep stress out of the bedroom. For example, do not study, work or pay bills there.
• Try to go to bed at the same time every night and set your alarm for the next day.
• Avoid Caffeine, nicotine, alcohol and sugar for five hours before bedtime (Limit caffeine in general)
• Follow a bedtime routine. For example, put out your clothes for the morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.

What are daytime suggestions for improving sleep?

• Set an alarm to try to wake up at the same time every day. I like the Philips SmartSleep Sleep and Wake-up Light Therapy Lamp, with Sunrise Alarm and Sunset Fading Night Light, White.
• Include meaningful activities in the daily schedule. If screens are required, try putting the screen on “night mode” and use Blue Blocker glasses or Theraspecs. (Both are available for purchase online) Theraspecs may also help with headaches.
• Limit screen time in general.
• Exercise every day as tolerated but do so at peak energy times and stop at least 2 hours before bed.
• Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime (like Toronto), consider trying light box therapy. (Philips Blue light).
• Avoid napping for more than 30 minutes. More than this will disrupt nighttime sleep. Also, try not to nap after 4 pm in the afternoon.

How do screens disrupt my sleep?

• All computer screens (and smartphones, iPads, tables etc.) emit blue light which is stimulating to the brain. It can also be irritating to the eyes and can trigger headaches. Most importantly, it can disrupt sleep.
  Put your screen in night mode, reduce the overall brightness, try blue blocker glasses or TheraSpecs (rose-tinted).
• Turn off your devices an hour before sleep. Do not look at them after you’ve gone to bed as the blue light will stimulate your brain to wake up.
• Blue light from screens will also cause your brain’s natural melatonin in levels to drop.
• Melatonin is a neurotransmitter in your brain that is involved in regulating sleep. It’s also important to know that the melatonin you can purchase to take by mouth is NOT a sleeping pill, it is to help regulate the sleep-wake cycle.

Vision

What is vision?

Vision is not just about seeing clearly at a distance (“20/20). There are two aspects of vision that work together of a regular basis:

Seeing fine details = central or focal vision.

Information about our surroundings, where we are in space, where objects are relative to us, and how we would like to move through space = peripheral or spatial vision. This includes interplay of vision, body position, posture, and the balance system.

Why does concussion disrupt vision?

Over 50% of our brain is dedicated to vision and vision processing, and 80% of all sensory processing in the entire body is directly affected by information coming in from the eyes. Thus, it is not surprising that a concussion affects the visual system in some way.

What is vision difficulty?

Vision difficulty is not limited to “seeing double” or “blurred vision”, it could be things problems with peripheral vision (i.e., at the sides), or discomfort in busy environments. These issues can impact daily function, including work, social, and recreational activities.

What are common symptoms if you have trouble with vision?

Symptoms can vary from individual to individual, and can include any of or a combination of the following:

• dizziness
• headaches
• difficulty with reading, computer work, and/or scrolling on a phone (can also include losing one’s place or re-reading the same line)
• blurry vision
• double vision
• balance and depth perception issues
• light sensitivity
• motion sensitivity
• discomfort in crowded or busy areas; bothered by busy patterns
• reduced sense of where body is in space and reduced confidence navigating through space
• impaired ability to process visual information
• memory issues: difficulty recalling what was read, or seen

What can I do to get better if I have these problems?

Completing rehabilitation exercises can be helpful. This can be accomplished with consistent completions of at-home exercises and even regular in-clinic visits to reinforce and challenge skills. The best results are seen with patients who are motivated, dedicated, and compliant. If symptoms persist evaluation and treatment by an optometrist specializing in neuro-optometric rehabilitation may be warranted and could occur additional strategies such as specialized glasses with coloured tints, partial lens occlusion, etc.