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Concussion and Return to Gaming

News reporter gets hit with skateboard (GIF)If you’ve recently gotten hit in the head and are wondering what to do next, you’ve come to the right place! While it is unlikely that you managed to get a concussion during your normal gaming activities, but we all live in the real world where anything from riding in a car, biking, skateboarding, PE, basketball, soccer or any number of activities can result in a concussion.

What is a Concussion?

First off let’s talk about what a concussion is. The American Association of Neurological Surgeons defines concussion as a “Clinical syndrome characterized by immediate and

transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma.”1

All that is to say, getting hit in the head or even having your head shaken by something as simple as hitting a pothole too hard, can cause a chemical disturbance in your brain that can affect many of the functions we use during gaming.

So next we are going to talk more about what kinds of issues you may experience after a hit to the head. This is a long list of symptoms to look out for after some kind of head trauma and we will break down each section below. If you experience any of these symptoms after a concussion you will need to see a Medical Doctor (M.D.) as soon as possible for an official diagnosis.

Physical Symptoms with a Concussion and Gaming Applications

So the first category we will talk about is physical symptoms. These issues affect your major senses and are probably the main things you will notice if you have experienced a concussion. With headache being the big one. But don’t forget even if you don’t have a headache right away it’s still possible to have a concussion so stay mindful of the rest of these issues as well.

Cognitive Symptoms with a Concussion and Gaming Applications

Next we will talk about cognitive symptoms. These are the symptoms that are most likely to affect the mental skills that are necessary during gameplay. If you have noticed your skills during gameplay (aiming, actions per minute, reaction time, game sense/situational awareness) have been off since receiving a blow to the head. You should see a M.D. (Medical Doctor) for a concussion evaluation. 

Emotional Symptoms with a Concussion and Gaming Applications

The next category is the emotional component. This is an area that may be more noticeable by your teammates, but with some self awareness you can recognize these symptoms in yourself as well. You or your team may be noticing that you are getting saltier/sadder than normal when you lose. Or abnormally excited / hysterically laughing when winning. This may be a sign that it’s time for you to be evaluated for a concussion. It’s important to try to take a step back and listen to what people are telling you if they are noticing something off about you. There is no shame is recognizing a condition that can be managed by a medical professional. 

Sleep Symptoms with a Concussion and Gaming Applications

The last category of symptoms we will discuss is sleep. Sleep is such an important aspect of our lives and CRITICAL for high level performance in gaming. If your sleep/wake cycles are off, it will have a big impact on your ability to play well. 

Intro of Plan for Return to Gaming After Concussion

Once again the first step after receiving head trauma is to get evaluated by a physician so they can make sure you don’t have anything more dangerous going on inside your head like a fracture, brain bleed or a central nervous system injury. 

If and when you are diagnosed with a concussion and want to return to gaming, you will most likely be given instructions to rest and may or may not get much more information than that. 

Background of Plan for Return to Gaming After Concussion

As medical professionals we used to believe the best way to recover from a concussion was just to stop all activity until the kinds of symptoms listed above went away. The research has shown us however that this approach puts players at a disadvantage because it doesn’t challenge the systems in the brain that we need to fully recover.

The Consensus Statement on Concussion in Sport—the 5th international conference on concussion in sport held in Berlin, October 2016, is essentially a big conference where medical professionals of all kinds (Medical Doctors, Physical Therapists, Neuropsychologists, etc.) come together and come up with the best guidelines to manage head injuries. After the conference a document is written outlining everything they discussed and the latest one has provided medical professionals with an updated phased return to play plan, that gradually incorporates things like aerobic exercise and coordination drills to help speed recovery and return players to sport safely.2

Timeframe of Plan for Return to Gaming After Concussion

This return to activity plan on average takes about 7 days but this is highly dependent on the player and how he or she progresses.

This plan should not be performed without supervision or consultation from a licensed rehabilitation medical professional that specializes in sports injuries such as a Physical Therapist, Athletic Trainer, Chiropractor, etc. This plan is modeled after the current best standard to guide concussion recovery and it is important to find a medical professional that can help monitor your progression through it, but we are giving you an overview here of what you can expect to go through when working with a trained professional.

Precautions/ Considerations of Plan for Return to Gaming After Concussion

if you are an esports professional trying to return to competitive play quicker than 7 days a specialist Neuropsychologist (a special kind of doctor that focuses on the mental and physical components of the brain) is also necessary to provide an evaluation.3

This is a full list of reasons why a specialist Neuropsychologist should be involved in your rehab.

  • Where an accelerated return to sport (<7 days) is planned
  • In cases of delayed recovery (>1 month)
  • In complex cases (eg, athletes with a history of multiple concussions)
  • For athletes with pre-existing conditions (eg, ADHD, Depression, Anxiety)
  • In decisions regarding athlete retirement for the season or career

The plan we are showcasing below is a modification of the return to activity guidelines specific for gamers and doesn’t include the typical stage 5 return to contact sports

*Now we will discuss this return to play plan in a step by step way.

Pre-Stage: Plan for Return to Gaming with a Concussion

After you have been diagnosed with a concussion the old rules of no activity still apply for at least 24 but up to 48 hours. This means no screen time, no exertion, sunglasses for light exposure, and maybe earplugs or noise cancelling headphones to limit sound input. It’s important to take this day off to give your brain a chance to set itself up for a successful, fast return to play.

Stage 1: Plan for Return to Gaming with a Concussion

After the 24-48 hour rest phase we want to gradually get you moving around the house and your community again. You may still need to wear sunglasses when going outdoors or wear earplugs/noise cancelling headphones when going outside. This is the phase where we can start gradually reintroducing screen time and gaming starting at 5 minutes and building up tolerance slowly. We recommend a 5 min on to 1 hour off ratio with the on time increasing by 5 minutes every time. Note: this is true for all of these steps but if you experience a worsening any of the symptoms listed above while increasing your gaming it’s time to go back to the previous step and try again the next day.

Stage 2: Plan for Return to Gaming with a Concussion

This next phase is all about really getting moving again. Cardio training is incredibly important for restoring a lot of the process in your brain that help to keep your brain supplied with the right amount of blood and pressure it needs to work properly. You are going to want to start with slow walking and move up to cycling at a medium pace. Running in this phase can cause a lot of up and down motion of the head and is not recommended here. The goal is to increase your heart rate slowly but not overdo it. You can continue with the progression of gaming from where you left off in the previous phase as well.

Stage 3: Plan for Return to Gaming with a Concussion

 is where we want to progress the cardio exercises to include running. It is important to make sure that your running form is smooth and that there isn’t any unnecessary jarring of your head while you run. At this point you should be able to tolerate at least a partial gaming session without increasing your symptoms. This is true of all gaming sessions but even more important in this case: make sure you are taking consistent breaks during your session.

Stage 4: Plan for Return to Gaming with a Concussion

  1. General motor coordination
    • Motor coordination can be broken down into several pieces and your rehab professional will know how to test for and improve these areas, but we will list them here and give you an example exercise for each one just so you know what to expect. These can be performed with eyes open and eyes closed and/or increased speed.
      • Alternate or reciprocal motion
        • Alternating palms up/down
      • Movement accuracy in space
        • Finger to nose
      • Over/under shoot target (Hypo/Hypermetria)
        • Finger to target
      • Speed of movement
        • Touching targets quickly that light up
      • Smoothness of movement
        • Circle or figure 8 with hands
      • Interlimb Coordination and alternate motion
        • Palm up/palm down, opposite actions between each hand
      • Intralimb Coordination and alternate motion
        • Palm up/palm down, same action of each hand
  2. Mechanical skills (Peripheral/fine motor coordination)
    • This is the coordination of small muscles, in movements involving the synchronisation of hands and fingers with the eyes and is the foundation we build a lot of game specific mechanical skills on such as (flicking, aiming, pressure aiming, tracking, consecutive clicks, coordination of clicking and movement – more on this in a future article -) that are critical to instinctively call on during gaming. It is a good idea to keep track of your scores in these activities before your injury so you know how much you need to progress to get back to your previous level of performance. These are some examples of ways to train mechanical skills in different games.
      • Shooters
        • KovaaK’s FPS Aim Trainer
        • Aim Hero
        • OSU
      • MOBA/ MMOs
        • Mobalytics Proving Ground
        • Actions Per Second
      • Fighting Games
        • Training Mode Combos
  3. Esports Specific Coordination
    • This is the highest and most complex form of coordination because it combines all of the above mechanical skills and requires you to apply them in the environment of the game. Because of all the variables present this can be hard to replicate while also giving you an objective score that you can use to see if you are improving or not. Some good ways to train esports specific coordination include:
      • Shooters
        • Offline Bot Matches
        • Zombies
      • Fortnite
        • Buildcap 90s for time
        • Edit Courses for time
        • No Build Deathmatch
        • Zone Wars
        • Turtle Wars
        • 1v1
        • MOBAs
        • Bot/AI matches
        • MMOs
        • Rotation Training Dummies (DPS/HPS/TPS for time)
        • World of Warcraft – Proving Grounds
        • Fighting Games
        • Bot Matches

During Stage 4 resistance (weightlifting) exercise should also begin and progressed based on standards of strength and conditioning. This is important to stress the systems of the body that control blood flow to the brain under stress.

Stage 5: Plan for Return to Gaming with a Concussion

Stage 5 is the full return to pre-injury gaming levels. This is where you can integrate competitive game play and progress towards your preinjury rankings. It is important to continue to perform the training drills from all the previous steps to increase your chances of success in this way.

Additional Strategies for Return to Gaming After Concussion

Gaming by nature is a stressful activity on the brain due to the sensory input both from the ears and the eyes. You may find you have to significantly modify how you are playing while progressing through these stages. Lowering the volume on your game and switching your monitor to night mode (which changes the frequency of light to cause less eye strain) may be necessary to aid in the recovery process.

Gaming Glasses for Return to Gaming After Concussion

There is some research that has shown that athletes post-concussion responded well to utilizing gaming glasses designed to filter the light entering their eyes and it has helped with the symptoms associated with concussion.4

Summary for Return to Gaming After Concussion

In summary a concussion is a serious injury that requires the attention of medical professionals working together to help an athlete return to play safely and quickly. Not everybody responds the same and it is important to have input from qualified rehabilitation professionals as you progress along this journey.

1. Surgeons AAoN. Concussion. Neurosurgical Conditions and Treatments 2019; https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Concussion.
2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847.
3. Patricios JS, Ardern CL, Hislop MD, et al. Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations. Br J Sports Med. 2018;52(10):635-641.
4. Lynch JM, Anderson M, Benton B, Green SS. The gaming of concussions: a unique intervention in postconcussion syndrome. J Athl Train. 

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