Acute Concussion Care: Essential Steps to Take After Injury

When someone sustains an acute concussion, it can be frightening and uncertain for everyone involved. Despite overwhelming evidence opposing the advice to “sit in a dark room” or “just wait it out,” many healthcare providers still commonly give it. However, recent research has shown that there are several proactive steps you can take at home to support recovery. While it's crucial to seek medical care and follow your doctor's recommendations, there are additional strategies you can consider to aid the healing process.

Before reading this article, we recommend checking out our article, "Simple Guide to a Not So Simple Concussion." This guide provides foundational information that will complement the insights shared here. This article will discuss several actions you can take with your doctor or at home to support acute concussion care, all backed by recent research. Please remember this is educational advice and not a substitute for medical advice. Always consult with your healthcare provider before implementing any new strategies.

Acute concussions are like the match that start a fire in the brain

The first days after sustaining a concussion are the most vulnerable. Although an acute concussion might seem like a singular event, it’s more akin to a spark that starts a fire. This metaphor of a concussion being a fire burning in the brain can help you understand the urgency and the need for immediate care. We will be using this metaphor throughout this article to explain the various stages of a concussion and the corresponding care needed. 

Concussions are neurological injuries triggered by biomechanical forces exerted on brain tissue, and they can continue to "burn" for two days up to 2 weeks. During this period, it’s crucial to understand what is happening to promote healing and prevent further injury. It is most effective to break down an actue concussion’s underlying mechanisms into excitotoxicity, impaired glucose utilization, oxidative stress, swelling and altered blood flow, inflammation, and changes in functional connectivity and efficiency. We will briefly discuss these and paired interventions to address each.

It is imparitive that one must consult with their personal doctor before implementing these educational topics.

Excitotoxicity

Acute concussions create excitoxicity

When injured, neurons primarily do one of two things: enter a state of hibernation or die. When they die, they release glutamate, a neurotransmitter that causes surrounding cells to become overstimulated. This overstimulation leads to spontaneous neural activity, often presenting as “seeing stars” when it occurs in the brain's visual areas, “ringing your bell” in the auditory regions, and nausea or dizziness in the vestibular areas. If these neurons become too overstimulated and cannot sustain their function or lack essential fuel such as oxygen and glucose, they, too, may die. This process can initiate a catastrophic cascade of cellular damage, exacerbating the injury.

What can we do to combat this process? 

First and foremost, after a healthcare provider has identified an acute concussion, the individual should be given physical, cognitive, and emotional rest. We don’t want to add any more fuel to the fire. Initially, they might feel fine as their neural pathways are “burning” in the initial minutes to hours, but symptoms may appear once the fire begins to burn out. Rest is essential during the first 24-48 hours following a concussion. This period allows you to gauge whether symptoms worsen, plateau, or improve. During this time, watch for severe symptoms that require immediate emergency care, such as:

  • Agitation or irritability
  • Vomiting more than three times
  • Severe headache or neck pain
  • Confusion or disorientation
  • Difficulty walking or talking

If any of these symptoms occur, seek emergency care immediately. However, after the first few hours, if there are no severe symptoms, allow them to sleep as needed. There is an old myth that when someone sustains a concussion, they should not be allowed to sleep. This is not true. Ensuring plenty of rest can aid the healing process. Sleep is one of the most important things someone with a concussion should do. It is advised that they be checked on regularly while sleeping to ensure that they have not vomited, and are breathing normally. You, as a caregiver, play a crucial role in this. You may want to wake them every few hours to ensure that they are responsive and check for signs of worsening symptoms. Ask them simple questions and assess their speech and cognitive status (remembering that they were just sleeping)

Magnesium Supplementation

Magnesium for Acute concussions

Some research suggests that Magnesium L-threonate, a form of magnesium, has shown potential benefits in addressing excitotoxicity associated with acute concussions. It helps reduce excitotoxicity in concussions by stabilizing neural activity and protecting neurons. Magnesium plays a critical role in regulating neurotransmitter release and preventing excessive stimulation of neurons. After a concussion, magnesium levels in the brain can decrease, leading to increased vulnerability to excitotoxic damage. The potential benefits of Magnesium L-threonate offer hope for a smoother recovery process.

Magnesium L-threonate is particularly effective because it can cross the blood-brain barrier more efficiently than other forms of magnesium. Its availability allows it to replenish magnesium levels in the brain more effectively, helping to:

  1. Inhibit Excessive Glutamate Release: By restoring magnesium levels, Magnesium L-threonate helps inhibit the excessive release of glutamate, a neurotransmitter that can overstimulate neurons and lead to excitotoxicity.
  2. Protect Neurons from Overstimulation: Magnesium acts as a natural calcium channel blocker, preventing excessive calcium influx into neurons, which can trigger cell death. This protective effect helps maintain neuronal integrity and function.
  3. Enhance Synaptic Plasticity: By improving magnesium levels in the brain, Magnesium L-threonate supports synaptic plasticity, essential for cognitive function and recovery after brain injury.
  4. Reduce Inflammation and Oxidative Stress: Magnesium L-threonate has anti-inflammatory and antioxidant properties, which can help mitigate secondary damage caused by inflammation and oxidative stress after a concussion.

Altered Glucose Transportation

After a concussion, the brain's need for fuel is dramatically increase, but it's ability to transport glucose (sugar) into the brain cells is disrupted. Glucose is the brain's primary energy source, and when it's not adequately transported, brain cells don't get the energy they need to function and heal. This situation is similar to diabetes, where the body struggles to manage sugar and it accumultates outside the cells. What do people with diabetes avoid? That's right, sugar. Therefore, individuals who sustain an acute concussion should avoid sugars and carbohydrates during the acute healing process.

So, what should they eat? Accumulating evidence suggests that ketones are the preferred fuel for the brain when it is injured. Our bodies can produce ketones from fats and obtain them through supplementation. In theory, this should save brain cells from dying of starvation and also reduce excitotoxicity. Understanding the role of ketones in brain recovery can help you make informed dietary choices post-concussion. 

Oxidative Stress

Oxidative Stress and Acute concussions

Oxidative stress occurs when there is an imbalance between the production of harmful molecules called free radicals and the body's ability to neutralize them with antioxidants. After an acute concussion, the injury to brain cells leads to an increased production of these free radicals. When there are too many free radicals, they can damage brain cells, leading to inflammation and further injury. This process is known as oxidative stress. Managing oxidative stress is crucial because it helps reduce additional damage and supports the brain's healing process.

Blood Flow Alterations

After a concussion, the brain experiences significant changes in blood flow. Typically, blood delivers essential nutrients and oxygen to brain cells, but a concussion disrupts this process. Immediately following the injury, there can be a period of reduced blood flow (cerebral hypoperfusion), which means the brain isn’t getting enough oxygen and nutrients to function correctly.

This decrease in blood flow can lead to symptoms like dizziness, headaches, and cognitive difficulties. As the brain attempts to heal, blood flow regulation can become erratic, leading to periods of both low and high blood flow and swelling. These fluctuations can contribute to ongoing symptoms and complicate the recovery process.

Brain MR images plot the average cerebral blood flow (left panel) and gray-matter volume fraction (right panel) for athletes with and without a history of concussion. Red arrows denote areas where concussed athletes showed significantly lower blood flow and gray-matter volume. Images courtesy of Nathan Churchill, PhD, and St. Michael's Hospital.

These brain MR images plot the average cerebral blood flow (left panel) and gray-matter volume (right panel) for athletes with and without a history of concussion. Red arrows show where concussed athletes showed lower blood flow and brain tissue volume. Images courtesy of Nathan Churchill, PhD, and St. Michael's Hospital.

Proper blood flow is crucial for delivering the nutrients and oxygen the brain needs to repair itself. Disrupted blood flow also impairs the removal of waste products, potentially leading to increased oxidative stress and inflammation.

Inflammation and Swelling 

After a concussion, the brain's natural response to injury includes inflammation and swelling. Inflammation is the body's way of protecting itself by removing damaged cells, irritants, and pathogens. However, in the brain, inflammation can be a double-edged sword.

When an acute concussion occurs, immune cells in the brain, known as microglia, become activated. These cells release inflammatory molecules called cytokines to help repair the injured brain tissue. This response can lead to swelling as fluids and immune cells accumulate at the injury site. While this process is necessary for healing, excessive or prolonged inflammation and swelling can cause additional damage to brain cells and tissues.

Swelling in the brain, known as cerebral edema, can increase pressure within the skull, leading to symptoms such as headaches, nausea, vomiting, and altered consciousness. Chronic inflammation and swelling can also interfere with the brain's ability to recover and may contribute to prolonged post-concussion symptoms.

Managing inflammation and swelling is crucial for supporting brain recovery. 

3 Problems, 3 Solutions

There are many ways to directly manage oxidative stress, blood flow, and inflammation without negatively affecting healing after an acute concussion. Treatments such as transcranial photobiomodulation, low-pressure (1.3-1.5 ATA) hyperbaric oxygen therapy, methylene blue infusions, and autohemotherapy with ozone have shown promise. However, these treatments can be costly, and a physician must perform them.

We have identified three synergistic methods that are very effective and can performed at home with minimal equipment: the consumption of molecular hydrogen, omega-3 fatty acids, and light aerobic exercise. According to medical literature, non-steroidal anti-inflammatory (NSAID) medications, such as ibuprofen and aspirin, are not advised after a concussion. These medications carry the risk of bleeding and can dampen the healing process.

Molecular Hydrogen

Molecular hydrogen (H2) has shown promise as a therapeutic agent in the early stages of concussion recovery. Its unique properties can provide several benefits that support the brain's healing process:

  1. Antioxidant Effects: Molecular hydrogen is a potent antioxidant that can selectively neutralize harmful free radicals, reducing oxidative stress. After a concussion, oxidative stress can damage brain cells and exacerbate inflammation. By scavenging these free radicals, molecular hydrogen helps protect brain cells from further injury.
  2. Anti-Inflammatory Properties: Molecular hydrogen can help reduce inflammation in the brain. In the aftermath of a concussion, inflammation can cause swelling and additional damage to brain tissue. By modulating the activity of pro-inflammatory cytokines, molecular hydrogen can help control and mitigate this inflammatory response.
  3. Neuroprotection: Research suggests that molecular hydrogen can protect neurons and other brain cells from damage. This neuroprotective effect is crucial in the first days following a concussion, when the brain is most vulnerable to secondary injuries.
  4. Improved Blood Flow: Molecular hydrogen may help enhance cerebral blood flow, ensuring brain cells receive adequate oxygen and nutrients. Proper blood flow is essential for healing and recovery after a concussion.
  5. Support for Mitochondrial Function: Mitochondria are the powerhouses of cells responsible for energy production. After a concussion, mitochondrial function can be impaired. Molecular hydrogen supports and improves mitochondrial function, aiding energy production and overall cellular health.

For a more in-depth discussion on the role of molecular hydrogen in concussion, please read our article, "The Incredible Benefits of Molecular Hydrogen for Concussion and Beyond"

Omega3’s: EPA/DHA for Concussion Recovery

Omega3s and Acute concussions

In supporting brain health and recovery after an acute concussion, both EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) play crucial roles. The optimal ratio of these omega-3 fatty acids can vary, but a commonly recommended ratio is approximately 3:2 or 2:1 of EPA to DHA. You can find these ratios on the back of commercially available supplements. This balanced ratio ensures that the brain receives the benefits of both fatty acids.

Anti-Inflammatory Benefits: EPA is particularly effective at reducing inflammation by decreasing the production of pro-inflammatory cytokines. An adequate amount of EPA helps manage the inflammatory response following a concussion, reducing swelling and further damage.

Neuroprotective and Structural Support: DHA is a major component of neuronal membranes and is essential for maintaining the integrity and function of brain cells. It provides neuroprotection and supports cognitive function, vital during concussion recovery.

Combined Effects: A balanced ratio meets your anti-inflammatory and neuroprotective needs. EPA helps control inflammation and improve blood flow, while DHA supports neuronal health and repair.

A study published in Frontiers in Neurology recommended omega-3 supplementation in the range of 2-4 grams per day, with a balanced ratio of EPA and DHA, to support recovery from traumatic brain injuries, including acute concussions. Another study published in the Journal of Pediatrics suggests that a combined dosage of 1000-2000 mg of omega-3s (EPA + DHA) daily can benefit children with traumatic brain injuries. Splitting the dosage between EPA and DHA can ensure an appropriate balance of EPA and DHA.

Sources: Omega-3 supplements, such as fish oil, often provide this balanced ratio. Additionally, consuming foods rich in omega-3s, such as fatty fish (salmon, mackerel, sardines), flaxseeds, and walnuts, can help achieve the desired intake. These Omega-3 fatty acids also maintain a ketogenic state because they are high in fats (ketones) and low in carbohydrates (sugar).

Wait… Exercise in the Days Following an Acute Concussion?

Exercise for Acute concussions

Dr. John Leddy and his colleagues have conducted pioneering research on the role of mild, sub-symptom threshold exercise within 48 hours of sustaining a concussion. Their work has demonstrated that carefully monitored physical activity can provide significant benefits in managing inflammation, blood flow, swelling, oxidative stress, and mental/emotional well-being.

  1. Inflammation: Leddy's research suggests mild exercise can help modulate the inflammatory response after a concussion. By engaging in controlled physical activity, the body’s immune system can balance the release of pro-inflammatory and anti-inflammatory cytokines, which helps reduce overall inflammation without exacerbating symptoms.
  2. Blood Flow: One of Leddy's critical findings is that mild exercise can improve cerebral blood flow. After a concussion, blood flow to the brain can be disrupted, leading to various symptoms. Sub-symptom threshold exercise helps enhance blood circulation, ensuring brain cells receive adequate oxygen and nutrients, which is crucial for healing and recovery.
  3. Swelling: Although swelling in the brain (cerebral edema) can be a concern after a concussion, Leddy's studies indicate that light exercise, performed within safe limits, does not increase intracranial pressure. Instead, it can support the lymphatic system in removing excess fluids, helping manage swelling, and reducing pressure on brain tissues.
  4. Oxidative Stress: Mild exercise has been shown to enhance the body's antioxidant defenses. By increasing the production of endogenous antioxidants, sub-symptom threshold exercise can help neutralize free radicals and reduce oxidative stress, which is a common consequence of concussion and a contributor to further brain injury.
  5. Mental and Emotional Status: Leddy's research highlights the psychological benefits of mild exercise for individuals recovering from a concussion. Physical activity, even at low intensity, can improve mood, reduce anxiety, and alleviate symptoms of depression. Exercise promotes the release of endorphins and other neurotransmitters that support mental and emotional well-being, providing a sense of normalcy and control during recovery.

A physician should ultimately decide whether someone with an acute concussion (or any person) should commence an exercise program. After the initial rest period, resuming low-intensity physical activities may benefit you if a physician approves. Doing gentle activities can expedite recovery if you do them carefully and incrementally. These forms of exercise will not overstimulate the brain and should keep heart rates below a symptom threshold.

  • Walking Around the House: Begin with simple activities like walking around your home.
  • Short Walks: Take short walks of up to 15 minutes. Set a timer for 7 minutes to turn around and head back.
  • Stationary Bike: While walking is preferred, sometimes location, weather, and other circumstances prevent the ability to go for walks. An alternative can be using a stationary bike and starting with minimal exertion (a 1 out of 10 exertion) for up to 15 minutes.
  • Monitoring Symptoms: Use a symptom scale from 0 to 10 to track any changes. If symptoms increase by 2 points or more, stop the activity and rest until symptoms return to baseline. You can try the activity again later, reducing the duration by 25%.
  • Progression: Once you can walk for 15 minutes without symptom exacerbation, increase the duration to 20 minutes while maintaining the same intensity. Gradually, you can increase the intensity of the walks by walking slightly faster, ensuring your heart rate stays below 120 bpm. Those over 40 who smoke, have a family history of heart conditions or have documented heart conditions should consult their doctor before starting any exercise regimen.

Concussion Rehabilitation

Twenty years ago, treating acute concussions was unfathomable. The approach was one of two: "rub some dirt on it" (AKA shake it off and get on with your life) or just wait for it to get better. Afterall, how do you "treat" the brain? Once again, understanding the mechanism of injury in concussion is so important. It's also important to know how acute concussions differ from persisting concussions; there's a fundamental and critical difference - one (in my opinion) should not be "rehabilitated," and the other must be. This all comes down to network remodeling and altered connectivity.

Treating Acute Concussions vs. Persisting Concussions

The injury process resulting from an acute concussion is fairly homogeneous, meaning the outcomes are similar across different cases. Each person who experiences a concussion will go through some degree of excitotoxicity (excessive neuron stimulation), impaired glucose utilization (difficulty using glucose for energy), oxidative stress (imbalance between free radicals and antioxidants), swelling and altered blood flow, inflammation, and changes in functional connectivity and efficiency within the brain.

However, when concussions become persistent, the outcomes become heterogeneous, with each case resulting in a relatively different outcome. So, what causes the shift from acute to persisting concussions? The answer lies in neurological remodeling, also known as neuroplasticity. During the acute phase, the injury process decreases function in groups of neurons (hubs), forcing other hubs to work harder.

Confused? Let’s use an analogy involving airports and bad weather to explain.

Imagine Denver has a terrible winter, beginning with a blizzard accumulating 5 feet of snow in 48 hours, shutting down the airport for 2 days, followed by 2 weeks of daily snow, in which only 10 flights per day can get in and out of the airport (this represents a singular acute concussion and its healing process). Flights from Seattle to Kansas City might have to reroute through Los Angeles instead. The same rerouting happens for flights destined for Phoenix and Salt Lake City. This increased traffic affects LAX, causes delays, and even impacts food availability in the airport. This scenario mirrors what happens in the brain during a concussion, leading to sensory overload, fatigue, confusion, and cognitive dysfunction.

Now, if Denver and LAX is impacted for weeks, DIA might cut staff and supplies, and LAX might adapt by hiring new staff, building a new terminal, and increasing its food supply. In the brain, this remodeling is called neuroplasticity. But what happens when the snow in Denver melts? Denver has been closed and cut back staffing for so long, and LAX has become very efficient at handling the increased traffic, so passengers may never book a flight through Denver, even though it’s open again.

When a busy travel weekend like the Fourth of July comes around, nobody books flights through Denver because they forget it is open, causing delays and issues at other airports, and those that do fly through Denver have a terrible experience due to staffing issues. Similarly, after a concussion heals, this "bad" plasticity leads to inefficiencies in all brain areas. People may feel fine during rest or trivial activities but struggle with stress, challenging tasks, heavy cognitive demands, lack of sleep, or even getting out of bed.

This remodeling creates the transition from acute concussion to persistent concussion. In the acute phase, therapies that we discussed should be implemented to support brain cells, chemistry, blood flow, and inflammation to prevent remodeling. If remodeling does occur, individualized, targeted, immersive rehabilitation becomes necessary.

I have seen hundreds of patients with acute concussions who initially appeared to need treatment, but once their brain was supported, normal function re-established within 1-3 weeks, and they never needed further treatment. However, I have also seen thousands of patients with persisting concussions whose lives had been devastated by this remodeling process, requiring intensive efforts to restore their normal functioning.

Other important factors of recovery:

Stay Connected: Maintain social connections through phone calls or short visits, but avoid overwhelming the person.

Professional Support: If anxiety, depression, or other emotional issues arise, seek support from a mental health professional.

Patience and Understanding: Recovery from a concussion can be a slow process. Being patient and understanding with your loved one as they navigate their recovery is essential. Encourage them to take things one day at a time and celebrate small victories along the way.

Long-Term Considerations

Follow-Up Care: Regular follow-up appointments with healthcare providers are essential to monitor progress and adjust the recovery plan as needed. Keep track of symptoms and share any changes with the doctor.

Gradual Return to Normal Activities: Gradually reintroduce normal activities as symptoms improve. Always do this under the guidance of a healthcare provider to avoid setbacks. You should reintroduce activities in the following order:

  • Light Physical Activity: Begin with light physical activities such as walking or gentle stretching.
  • Cognitive Tasks: Gradually increase cognitive tasks like reading or working on a computer.
  • Total Return to Activities: Once cleared by a healthcare provider, gradually return to complete daily activities, including work or school.

Awareness of Persistent Symptoms: Many individuals experience persistent symptoms, known as PPCS (persisting post-concussion symptoms). These symptoms can include headaches, dizziness, and cognitive difficulties that last for weeks to years. If symptoms persist beyond 30 days, seek further medical evaluation and treatment from a fellowship-trained concussion specialist like Dr. Antonucci.

Educating Yourself and Others

Stay Informed: Stay current with the latest research and recommendations on concussion management. Reliable sources include medical journals, reputable health organizations, and concussion specialists.

Educate Family and Friends: Share what you've learned with family and friends to help them understand the importance of proper concussion care. Educating those around you can create a supportive environment for the person recovering from a concussion.

Recovery from an acute concussion requires careful management and support. Understanding the proactive steps you can take at home and recognizing the importance of medical guidance can help ensure a smoother recovery process for yourself or your loved one. If your provider approves, implementing these recommendations might prevent you from needing our care.  

While we mainly treat persisting post-concussion symptoms, If you have any questions or need personalized advice, we are here to help. Schedule a free consultation with us to discuss your concerns and receive expert guidance tailored to your needs. Our team is dedicated to supporting you every step in your journey to recovery. Contact us today to book your consultation and take the first step towards comprehensive concussion care.

Updated 7/3/2024: Incorporated "Concussion Rehabilitation" by the request of a reader

Dr. Antonucci
Dr. Matthew Antonucci
Doctor | Educator | Researcher
Dr. Antonucci is an experienced chiropractic neurologist, board certified in functional neurology and multiple sub-specialties, a researcher, and an international lecturer, currently seeing patients out of Minneapolis, MN. He trained extensively under Prof. Frederick R. Carrick, maintains an active private practice with licenses in multiple states, and has provided breakthrough neurorehabilitation and performance training to thousands of patients. He consults with several NFL and NHL franchises on performance training and concussion. His work has been featured on ESPN, Sports Illustrated, CBS, Fox News, and more. He has delivered more than 11,000 hours of presentations, both nationally and internationally, on behalf of the Carrick Institute. Most importantly, he is a loving husband and the father of five amazing boys, whom he hopes to inspire to follow in his footsteps.

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