Post-Concussion Syndrome BY DAVID COPPEL Over the last decade, sport-related concussions have fatigue, irritability, sleep disturbance and sensitivity to become an important focus within the general sports inju- light and noise may continue over the next few days. Oth- WHAT CAN COACHES DO? ry and sports medicine field. Clinical and research studies SIGNS AND SYMPTOMS • Make sure student-athletes who sustain a concus- er symptoms seen on post-concussion symptom checklists According to the Diagnostic and Statistical Manual regarding this form/context of mild traumatic brain injury sion are immediately removed from play and that include attention and concentration difficulties, slowed of Mental Disorders – 4th edition (DSM-4) – an individu- have increased geometrically as its position as a public they do not feel pressure from the coaching staff to processing, distractibility, memory problems, slowed visu- al with post-concussion disorder experiences objective health concern elevated and the Centers for Disease Con- return to play before fully recovered. Communicating al tracking or vision problems, balance disturbance, and declines in attention, concentration, learning or memo- with team members before the season about con- trol and Prevention (CDC) became involved. ry. The individual also reports three or more subjective anxiety or depressed mood. Typically, depressed mood or cussion safety, and verbally reinforcing the impor- The CDC has compiled guidelines and resources for symptoms, present for at least three months: tance of concussion safety throughout the season health care providers, coaches, parents and athletes re- • Becoming fatigued easily are important ways to encourage student-athletes garding concussions. Great progress has been made in • Disordered sleep to feel comfortable reporting concussion symptoms WHAT CAN ATHLETIC • Headache understanding and managing sport-related concussions, to medical personnel. • Vertigo TRAINERS DO? especially in terms of: • Student-athletes who are experiencing post-con- • Make sure coaches are appropriately educated • Irritability or aggression on little or no provocation • Incidence and prevalence of sport-related concus- cussion syndrome may feel isolated from their team about concussion safety and post-concussion • Anxiety, depression, or affective liability sion at all levels of sports participation, and from their normal social roles. These chang- syndrome. Talk to them explicitly about the role they • Changes in personality • Delineating acute symptoms and sideline man- es can manifest in mental health issues, such as can play in creating a team culture that encour- • Apathy or lack or spontaneity depression, that are not a direct consequence of the ages symptom reporting and early detection of agement, The symptoms result in a significant impairment in • Describing the general course of recovery for initial injury. Be in touch with your student-athletes concussions. For some coaches, it may be useful functioning, which can include impairment in social to emphasize the negative athletics performance most athletes, and during their recovery period, communicate that and occupational functioning. consequences of continued play while symptom- • Identifying risk factors or modifiers associated with they remain valued team members, and encourage help-seeking from relevant medical professionals, atic, and the long-term athletics consequences if a prolonged recovery and/or persistent symptoms. including mental health professionals as appropriate. student-athlete sustains an additional impact while Expert reviews of available scientific evidence have still symptomatic. resulted in a series of consensus or position statements ATHLETICS CONSEQUENCES • Be aware that student-athletes who are experiencing that have guided concussion definitions, evaluation, man- • Student-athletes who experience post-concussion complexity emerges when symptoms are delayed or pro- post-concussion syndrome may experience other agement and return-to-play guidelines. syndrome will likely miss games and practices longed, or when symptoms are not specific to concussion, related mental health issues as an indirect conse- The current definition of concussion is a brain injury over a prolonged period. Those who return to play but instead are temporally related to the concussive event quence of this injury. Screen and refer student-ath- involving a “complex pathophysiological process affect- while symptomatic and sustain an additional injury or experienced/perceived as having been brain-injury re- letes to mental health professionals as appropriate. • Ensure that your athletics department has a protocol ing the brain, induced by mechanical forces.” Concussion are at risk of magnified neurologic consequences. lated. Due to the range of symptoms (physical, cognitive, To minimize the net amount of time that a student- for helping student-athletes experiencing post-con- has a number of described features: emotional) and the individual factors influencing recov- athlete is held out of practice and competition, cussion syndrome manage their academic demands • Concussion may be caused by either a direct blow early detection and removal from play, and en- ery, a multidisciplinary management approach is often in- during the recovery process. If your school has a to the head, face, neck or elsewhere on the body suring that the student-athlete does not return to dicated. Physicians, athletic trainers, neuropsychologists, policy for academic accommodations and support with impulsive force transmitted to the head. play before it is medically indicated, are critical academic advisers, physical therapists and clinical/sport during the concussion recovery process, make sure • Concussion typically results in the rapid onset of risk-reducing behaviors. psychologists all play roles in clarifying symptoms and that your student-athlete is aware of this policy and short-lived impairment of neurological function providing support. that all relevant stakeholders in its implementation that resolves spontaneously or may evolve over The strong desire and motivation of some athletes to are engaged in supporting the student-athlete. If minutes or hours. ers or neuroradiological findings have been delineated, return to play provides the opportunity for these motiva- your school does not have such a policy, work with other stakeholders at your institution to develop • Concussion may result in neuropathological chang- although the research continues in these areas. tional factors to be manifest in symptom reporting. Since and implement one. Additional information about es, but the acute clinical changes largely reflect a The neuro-pathophysiology of sport-related concus- tracking self-reported post-concussion symptoms over recommendations for managing academic demands functional disturbance rather than structural injury. sion has been described in terms of changes in brain time (typically with checklists) is the main aspect of man- during the concussion recovery process is available • Concussion results in a graded set of clinical symp- metabolism and evidence of temporary metabolic-based agement, some athletes will minimize or report resolved in Marcia Ridpath’s article in Chapter 3. toms that may or may not involve a loss of con- vulnerability to secondary injury. Typically, concussion symptoms in order to be seen as “symptom-free” and be- sciousness, and resolution of clinical and cognitive events produce physical, cognitive and emotional/neuro- gin the return-to-play protocol or be cleared. Knowing symptoms typically follows a sequential course, behavioral symptoms that are generally most severe in the athlete and his or her baseline or pre-injury function- anxiety levels improve as the physical symptoms resolve, with some cases having prolonged symptoms. the acute post-injury timeframe (one to two days) and ing can be crucial in evaluating post-injury symptom re- but it is important to assess and intervene if these emotion- Diagnosing concussion may be complicated in some then reduce/resolve over subsequent days and weeks. ports and presentations. al issues persist. instances, as most do not involve a loss of consciousness Recent consensus guidelines indicate that 80-90 per- Acute sport-related concussion signs may include loss While most sport-related concussions (concussion or overt neurological signs, and impact on functioning cent of concussions resolve in seven to 10 days, some- of consciousness, headache, dizziness and alteration of symptoms) resolve over days and weeks (most within can be quite mild and temporary. No consistent biomark- times longer for children and adolescents. The diagnostic mental status (confusion or fogginess). Headache, nausea, three weeks), a subset of sport-related concussion patients THE BIG INJURY (AND SMALL ONES, TOO) • CHAPTER 4 - 76 - MIND, BODY AND SPORT MIND, BODY AND SPORT - 77 - CHAPTER 4 • THE BIG INJURY (AND SMALL ONES, TOO) Post-Concussion Syndrome BY DAVID COPPEL Over the last decade, sport-related concussions have fatigue, irritability, sleep disturbance and sensitivity to become an important focus within the general sports inju- light and noise may continue over the next few days. Oth- WHAT CAN COACHES DO? ry and sports medicine field. Clinical and research studies SIGNS AND SYMPTOMS • Make sure student-athletes who sustain a concus- er symptoms seen on post-concussion symptom checklists According to the Diagnostic and Statistical Manual regarding this form/context of mild traumatic brain