The Realms of Concussion

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It’s National Concussion Awareness Day! Below are the five realms of concussion symptoms, the various tests we run at SPARCC to evaluate for them, and the treatment options for each. You can also check out Dr. Mo’s post on concussion symptoms and treatment options.

Somatic realm

The somatic realm deals with “sensations” such as headaches, neck/shoulder pain, and nausea. While often the headache is the first symptom of concussion and the last to resolve, sometimes we will use medications to help control and prevent headaches (amitriptyline, topiramate, and gabapentin are a few of the more common ones we use). Some of the medications we use have beneficial side effects or additional benefits, including grogginess to help with sleep onset, and can help in the setting of underlying emotional symptoms. Zofran can be used for nausea. Additionally, physical therapy, massage, acupuncture and topical anti-inflammatories can help with headaches and neck pain.

Sleep realm

Particularly early on in concussion people have a tendency to be very tired, require napping and sleeping many hours at night (10-14 or more isn’t unheard of). Some people have broken sleep, which decreases the quality of sleep and makes them feel more tired the following day (similar to those with sleep apnea, for example). For those patients who continue to have significant symptoms and start to fall into “post concussion syndrome“, they begin to experience more insomnia, having trouble falling asleep and returning to sleep when awake. We start to discourage napping after the first couple of weeks because naps will promote sleep onset insomnia.

Occasionally we will use medications, like trazodone to help with sleep, or over-the-counter (OTC) melatonin. Exercise is also the best way of inducing deeper stages of sleep and mental and physical recovery with sleep. In our clinic, we also perform Active Rehabilitation, which allows us to progressively challenge patients to increased intensities of exercises (advancing every 1-2 weeks), and making sure that there is no flare of symptoms or evidence of POTS or dysautonomia.

Cognition realm

Patients frequently suffer cognitive complaints, which could be central (neural pathways being temporarily dysfunctioned) or could result from visual/eye fatigue or acute flare of somatic symptoms, like a headache. To improve cognitive recovery we recommend the phone app called Peak, or online resources like Luminosity that have brain games. We often use ImPACT as a neurocognitive test to evaluate for cognitive problems, including reaction time, processing speed and memory. There are some medications that can be used, typically first line with stimulants to improve cognitive function while the patient returns to baseline. We have also incorporated the use of EEG (electroencephalogram) to assess for cognitive deficits by measuring the electrical activity of the brain.

Vestibulo-ocular realm: balance and vision problems

Often in the setting of concussion, the neural pathways of vision and eye control are affected, which can be even worse when there is whiplash associated with the original injury. We have vision testing (oculomotor testing) here in the office, as well as components of our physical exam that test for vision deficits. Patients who are not progressing may need an evaluation with neuro-optometry, and may ultimately require prism lens glasses, or binasal blocking glasses to decrease symptoms of concussion and promote nerve recovery. Often vision therapy is a big component of working with neuro-optometry.

Mood/Emotional realm

While some people have anxiety, depression or mood disorders at baseline, others have none or minimal complaints until they are concussed (including symptoms of ADD/ADHD). There are some medications that we use or will start to engage psychology, psychiatry, or cognitive behavioral therapy to help manage symptoms until the patient is recovered.


By Dr. Jon Minor