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from fear-avoidance to progress: the psychology of concussion recovery
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if avoidance persists, your tolerance to day-to-day stimuli reduces, and your concussion symptoms can start to flare even with small everyday tasks.
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after a concussion, it is normal to fear symptoms. many people start to avoid things that feel uncomfortable or bring on symptoms, such as screens, stores, restaurants, and exercise. avoidance does help you feel safe in the short term, but prolonged avoidance leads to unhelpful behaviours and habits.1,8
in fear avoidance, when uncomfortable or painful sensations in the body are felt, the nervous system interprets them as dangerous. this creates a fear and anxiety response that unintentionally causes more avoidance and more fear. this negative feedback loop adds to emotional strain, psychological distress and leads to increased concussion symptoms2, 3, 7. the opposite outcome of what is wanted and desired. if avoidance persists, your tolerance to day-to-day stimuli reduces, and your concussion symptoms can start to flare even with small everyday tasks.
to move out of the fear avoidance feedback loop and into progress is the “goldilocks” plan: not too hard, not too easy, but just right, and adding a little more each time4-6. this kind of plan will help you gradually build tolerance to uncomfortable and feared symptoms through exposure. here is a helpful study. one group was told to stop the exercise as soon as symptoms arose. the other group was told to keep going until symptoms rose by a small amount, and then stop. the group that continued exercise despite a small rise in symptoms got better. the group that always stopped early when symptoms rose did not get better. this study shows that gradually expanding exercise tolerance not only rebalances autonomic nervous system function and improves blood flow, but also functions as a gentle exposure to uncomfortable and feared symptoms and helps your system to learn and adapt. this lowers fear and builds confidence6.
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how do you practice the goldilocks plan without overdoing it? well, you plan, pace, and reflect. pick one area, like walking, or grocery shopping. start below your threshold for the onset of symptoms. for example, if going into a grocery store and walking down an aisle causes you to feel a significant rise in symptoms (beyond 3-5 points on a distress scale), you have gone too far. start with a small exposure, such as walking into the grocery store and standing at the top of an aisle for a few minutes. once symptoms rise between 3-5 points, exit the store safely and take a few breaths. see how you feel later that day and the next morning. if you are okay, add a little bit more time to your next grocery store visit. if your symptoms really flared up a lot, modify your approach. next visit, try less time, or a less busy store, or even bring a support person with you to help you work through your fear and anxiety.
one thing to keep in mind with this method, is not to fear a small, short symptom increase. the evidence shows that mild symptom rises during activity are usually brief and do not slow recovery when you stay under your symptom limit. and the benefits are substantial, as you are teaching your nervous system that the world is safe again. with repeated exposure, your symptoms gradually dissipate and your recovery time improves; fear reduces, and you no longer feel the need to avoid activities.4,5
if you try this out and your fear remains high, or if the goldilocks plan feels overwhelming for you, please reach out for added support. speaking with a health coach, therapist, or clinician can help you tailor this approach to meet your needs. they can help you set goals, break tasks into small, manageable steps, and celebrate wins. recovery is not a straight line, and that is okay. keep moving forward, and over time, the challenges that feel heavy today will become lighter.
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melinda krynen hill, med, mph, rp is a registered psychotherapist and canadian certified counsellor (ccc). hill is also a co-founder of the concussion fix program.
references
- abramowitz, j. s., tolin, d. f., & street, g. p. (2001). paradoxical effects of thought suppression: a meta-analysis of controlled studies. clinical psychology review, 21(5), 683-703.
- gatchel, r. j., neblett, r., kishino, n, ray, ct. (2016). fear-avoidance beliefs and chronic pain. journal of orthopaedic & sports physical therapy, 46(2), 38-43
- gilliam w, burns jw, quartana p, matsuura j, nappi c, wolff b. interactive effects of catastrophizing and suppression on responses to acute pain: a test of an appraisal x emotion regulation model. j behav med. 2010 jun;33(3):191-9.
- grool am, aglipay m, momoli f, et al. association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. jama. 2016;316(23):2504-2514.
- leddy jj, haider mn, ellis mj, willer bs. early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. jama pediatr. 2019;173(4):319-325.
- mercier lj, mcintosh sj, boucher c, joyce jm, batycky j, galarneau jm, burma js, smirl jd, esser mj, schneider kj, dukelow sp, harris ad, debert ct. evaluating a 12-week aerobic exercise intervention in adults with persisting post-concussive symptoms. front neurol. 2024 dec 24;15:1482266. doi: 10.3389/fneur.2024.1482266. pmid: 39777319; pmcid: pmc11703733.
- patricios j, ardern cl, schneider kj, et al. consensus statement on concussion in sport: the 6th international conference on concussion in sport–amsterdam, october 2022. br j sports med. 2023;57(11):695-711.
- picavet hs, vlaeyen jw, schouten js. (2002) pain catastrophizing and kinesiophobia: predictors of chronic low back pain. american journal of epidemiology. dec 1;156(11):1028-34.
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