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Sabrine Semper

Independent Research GT

Mr. Eckert

05 March 2020

Post Concussion Syndrome: ​How Prolonged Symptoms of Concussions Can Have Long-term

Effects on Student-Athletes

When discussing head injuries, concussions are most likely the first thing to come to

mind. Most (no specific number) patients will recover from minor traumatic brain injury within

7-14 days. However, 10-30% of people will have prolonged mTBI symptoms (Hugentobler).

Merriam-Webster’s Dictionary defines a concussion as “a stunning, damaging, or shattering

effect from a hard blow; ​especially​: a jarring injury of the brain resulting in disturbance of

cerebral function”. As well as concussions, greater cerebral dysfunction can also be closely

related to Post Concussion Syndrome. Chapter 17 of The ​Handbook of Clinical Neurology

defines Post-concussion syndrome as, “a heterogeneous condition consisting of a set of signs and

symptoms in ​somatic​, cognitive, and emotional domains” (Dwyer). Allowing PCS the possibility

to affect more than just the chemistry of our brain. As compared to a broken elbow, damages to

the brain in this manner are grossly harder to detect, but why is this condition treated less

significant than said broken elbow? Concussions need to be taken more seriously than how they

are treated at this time, especially with the adolescent athletes who are taking on strenuous

activity with school work and sports. Acquiring post-concussion syndrome could present both

clinical and mental complications involving the patient. Cerebral dysfunction ranges from

complete loss of consciousness to disorientation and an inability to pay attention, making both
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concussions and post-concussion syndrome even harder to diagnose and even harder to treat. The

patient themself could be unaware of their own injury or unwilling to participate in the prolonged

recovery time. The risks of post-concussion syndrome are so underestimated due to the fact that

we know so little about the brain, that the way we treat, diagnose, and detect a concussion or

lingering/prolonged symptoms is insufficient. Even research has proven that some of the go-to

treatments we have for an mTBI can lead to severe symptoms of Post-Concussion Syndrome that

not only affect the physical but the mental well-being of the patient. Impairment of one or

several of the many specific functions that the brain contributes to is also possible with

post-concussion syndrome, and there is no true way to prevent a patient from having PCS unless

proper interventions are taken at its early stages of an mTBI to ensure the patient’s condition

may not worsen. Many patients suffering from an mTBI are subject to contracting

post-concussion syndrome due to the lack of knowledge on how to treat concussions; therefore

patients suffering an mTBI and their doctors should further their knowledge on up to date

treatments for concussions, consider the patients work and school life, and impose incentives for

proper treatment for anyone suffering a concussion.

From the collective research, one could conclude the simple definition of Post

Concussion Syndrome (PCS) is the persistence of concussion symptoms beyond the normal

course of recovery. The recovery of a concussion patient is crucial to their development and

future growth, but the recovery process is different to each patient looking at other factors that

may impede their recovery process, “In most people, symptoms occur within the first seven to 10

days and go away within three months. Sometimes, they can persist for a year or more. The goal

of treatment after a concussion is to effectively manage your symptoms” (Mayo Clinic). The
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persistence of symptoms past the normal course of recovery could affect not only future growth

but also have the possibility of future mental impairment, especially when focusing on the brain

of a developing student-athlete. In this case, the focused patients’ brain is not yet fully developed

yet having to endure a serious brain injury and what may follow as well as environmental

stressors from their age range. Severe depression; feelings of severe despondency and dejection,

is one of the many possible and sometimes most common symptoms when acquiring PCS,

“Although they do not have a straight correlation [this is only present in some studies],

depression or any mental health issue can impede the recovery of the patient recovering from an

mTBI” (Jorge). This is also sometimes the most dangerous symptom because many topical and

internal stressors personal to the patient can contribute to the severity of their depression. There

is a combination of neuroanatomic (The branch of anatomy that deals with the nervous system),

neurochemical (relating to chemical processes occurring in nerve tissue and the nervous system),

and psychosocial factors (relating to the interrelation of social factors and individual thought and

behavior) that are responsible for the cause of depression; that could also contribute or be the

effect of the initial injury. Yet, depression must happen at a certain frequency of injury in order

to connect it to the effect of an mTBI, and other prolonged symptoms to connect the brain injury

to PCS, meaning that the severity of the patient’s mental state is taken into account to decide the

severity of their injury. As of April 2019, The National Institute of Mental Health reports that

about 3.2 million 12- to 17-year-olds have had at least one major depressive episode within the

past 12 months (Lohmann). Not all were the cause of concussions, but mental health in teens is

becoming more and more of an epidemic and how the situation is approached will determine the

future of the children.

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Post Concussion Syndrome can be commonly overlooked since it's not as clear cut of a

diagnosis as a broken bone. This can leave room to possibly misdiagnosis or a compromised

interest of the patient wanting to return back to their sport and not giving correct of sufficient

information for the doctor to correctly diagnose their injury, “One of the first challenges in

responding to sports-related concussions is to recognize that a player may have sustained a

concussion and therefore should be removed from the activity for further evaluation. As

discussed in ​Chapter 1​, although previous generations of athletes were encouraged to “shake it

off” and return to play” (IOM). A lot of times, with an mTBI, there is a temporal bone fracture

which is how most doctors who don’t entirely understand the brain will diagnose their patients’

concussion severity. Yes, by discovering said, “broken bone” in the skull and directly connecting

it to a brain injury is a way of…., it should not be a method of diagnosis. With temporal bone

fractures, there is such a wide spectrum of severity and diagnosis that could correlate to other

injuries, “Temporal bone fracture (TBF) has been reported to occur in about 30% to 70% of

cases of skull fractures in patients with head trauma. TBFs have been extensively studied

because of their severity and emergency nature” (Kong). This method is extremely inefficient

because if one were to look at brain injuries the way they look at any other physical injury, their

diagnosis and treatment plan will be completely different than what is needed for the patient to

recover. Comparing the severity of fractured skull bones leading to discoveries of further head

injury versus a brain injury involved with a temporal bone fracture should not be treated with the

same severity because of how complex the brain is. The same level or possibly and even worse

brain injury may be present in a brain without a temporal bone fracture than one with a clear

temporal bone fracture.

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Although Post Concussion Syndrome is not easily identified by a specific set of

symptoms, researchers have found that frequent drilling headaches, light, and sound sensitivity,

and memory issues have a significant connection to possible PCS. The term Post Concussion is

very seclusive in the title but in true definition requires an entire assessment of the patient's

initial injury to determine these prolonged symptoms. Because the most common symptom is

subjective symptoms like headaches that vary doctors are very quick to recommend that solely

rest will induce the fastest recovery possible for the patient without assessing any other

symptoms or how different variations of headaches may progress in the patient.“Post-concussion

headaches can vary and may feel like tension-type headaches or migraines. Most often, they are

tension-type headaches. These may be associated with a neck injury that happened at the same

time as the head injury” (Mayo Clinic). Although some tension-type headaches may be caused

by a neck injury a blow or disruption to the brain can also be further injured by not addressing

other not normally suspected symptoms like lack of hand-eye coordination or lack of sleep.

Which can either be solved with specific treatment plan and recovery process given to the patient

or diagnosed rest and recovery, “A number of studies in recent years have focused on eye-hand

coordination (EHC) in the setting of acquired brain injury (ABI), highlighting the important set

of interconnected functions of the eye and hand and their relevance in neurological

conditions.”(Rizzo). These symptoms are what lead other physicians into the new method of

easing athletes and patients back into their daily routines and activities little by little still

including lots of rest to ensure no ability and movement is lost.

This boiling pot of prolonged symptoms could also lead to mental health issues like

depression induced by the frustration of a speedy recovery and other stressors. Through
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extensive research, it has become evident that Post Concussion Syndrome is the cause of cerebral

dysfunction, while “[​Some] experts believe post-concussion symptoms are caused by structural

damage to the brain or disruption of the messaging system within the nerves, caused by the

impact that caused the concussion”(Mayo Clinic). Due to the great number of possibilities that

one can attain cerebral dysfunction, structural damage or disruption to the brain from the initial

injury of a concussion, researchers have found more connections from the initial injury to the

prolonged symptoms and to possible depressive states after said injury.

Unsurprisingly, there is a significant correlation between lifetime concussions and

depressive symptoms. According to the Medicine and Science in Sports and Exercise, “[the

study’s] findings suggest a possible link between recurrent sport-related concussion and

increased risk of clinical depression. The findings emphasize the importance of understanding

the potential neurological consequences of recurrent concussion”(Guskiewicz). One of the

biggest risks of Post Concussion Syndrome is the mental state of the patient since it is very

possible for the chemistry of the brain to change and alter during the initial injury or recovery

phase of the concussion. Although this is a possibility, there is still not enough research to

confirm just how much the biochemical chemistry of the brain may shift especially on

still-developing brains like minors. “The mechanism of interaction between the pathophysiology

of concussion or mild TBI in these players and the lifetime risk of depression is unclear”

(Guskiewicz). Many doctors stick to what they know and do not choose to take into

consideration the possibility of a shift in the mental health of their patients because there is not

enough research out there yet and said the patient becomes subject to misdiagnosis. The

misdiagnosis of PCS is common since concussions are often overlooked by doctors who
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undresses or prescribe the wrong treatment for said injury. The most common form of

“treatment” given by a doctor could be lots of rest, and isolation, in a dark quiet room for the

majority of their prolonged recovery time. Most doctors’ first response/diagnosis for a

concussion is to “take it easy and it will be better in a few weeks” but this is only the case for so

many, (Griffith). This form of treatment could be hurting the patients more than helping because

every recovery process is different and for some, this could cause unintended restlessness which

could put more stress on the brain than intended. In some patients, this may even be the cause of

their depressive symptoms during their time of recovery because the patient may be so worried

about getting back into their routine that they become agitated, restless, and start to lose sleep

which is the opposite of the intention for this form of recovery. In response to these situations,

some may even prescribe unneeded antidepressants to the patient which could greatly alter the

brain chemistry of the patient even more rather than present a quick solution. This is the result of

an uninformed doctor and because the medical community knows so little about the brain, this is

a huge and very common risk to the well being of the patient.

As far as improving the interventions one may use now to better the majority consensus

of concussions could help many who are suffering across the country. Even addressing some

common misconceptions around the definition of PCS and concussions has shown some promise

in this goal. In one study, a group of doctors consulted through interviews with career athletes to

address how many concussions they have possibly had and some that they might have not even

known they have had. ​When the interviews were concluded, the athletes' histories were

significantly greater after reading them the current definition of concussion, compared to the

reporting when no definition was provided (Robbins). This was thought to improve the number
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of athletes who are seeking treatment to self-report concussions by explaining the severity and

the impact that an untreated concussion may have. ​If both doctors and patients can possibly

identify warning signs and symptoms of concussions they can start to be taken as seriously as it

already should be without the fear of the doctor misdiagnosing. Addressing misconceptions with

patients and doctors not only an advocate but can also help revise the broken understanding of

what concussions may be in the medical field (Morton). As discussed previously, the most

popular treatment among the medical community is the “Darkroom Treatment”, one may

conclude that ​Dr. Micky Collins believes that there are physiological reasons why some may feel

anxious or depressed following a concussion. This treatment ​not only challenges but stresses the

patient as well as creating major challenges for enhancing efforts at community re-entry. Instead,

he recommends that patients with an active anxiety level prior to the injury to be treated in a

more active way.​ While rest is still an important part of recovery, he recommends that the patient

should not sit alone in quiet dark rooms like many other doctors (Collins). His Patients are eased

back into their daily lives then sheltered from it completely then reintroduced all at once. In

addition to this revised rest and recovery plan, Every patient should undergo a mandatory

psychiatric evaluation post-concussion or mTBI. “Future research should use comprehensive,

integrative models of depression that include demographics, biologic, and psychosocial factors;

enhanced functional neuroimaging techniques; controlled studies of psychopharmacologic and

other interventions; and prospective designs with long-term follow-up” (Rosenthal). The best and

safest bet, to ensure that no patient of a head injury is greatly suffering from a change in their

mental health, every patient of head injury should also undergo a psychiatric evaluation and
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concomitant treatment if required to ensure the attainment of neuroanatomical intact and overall

productive and qualitative life.

Those who suffer an mTBI heighten their chances of experiencing symptoms closely

related to Post-Concussion Syndrome could greatly affect the patients’ life more than one may

think. With the limited knowledge in the medical field on brain development after injury, proper

care, testing, and treatments are scarce. Reevaluating the true definition of a concussion or of the

post-concussion syndrome will lead to doctors and researchers changing and adapting their

research, practice, and teachings. Or, by addressing common misconceptions around the

definition of PCS and concussions can improve the reliability of athletes’ self-reporting (seeking

treatment) concussions. This will not only improve the patients’ self-reporting awareness but

allow doctors and coaches to be able to know and recognize the symptoms of PCs in a possible

patient and recommend they seek treatment. Changing and further developing the practices of

doctors treating patients with PCS will make family, friends, coaches, teachers, and patients

more socially, emotionally, and physically aware of the recovery process and how it may differ

from patient to patient. As the treatments and practices change, so will the stigma and

misconceptions of concussions, recovery, and surviving post-concussion syndrome and the

mental disadvantages that come with it.

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Works Cited

“Anxiety/Mood Trajectory of Concussion.” Performance by Micky Collins, ​YouTube,​ YouTube,

15 June 2015, www.youtube.com/watch?v=L0fbfjA7tX4.

Barlow, Karen Maria, et al. "Epidemiology of Post Concussion Syndrome in Pediatric Mild

Traumatic Brain Injury." ​Official Journal of the American Academy of Pediatrics,​ vol.

126, no. 2, 22 Apr. 2010, pp. 374-81. ​AAP News and Journals Gateway​,

doi:10.1542/peds.2009-0925. Accessed 12 Dec. 2019.

Dwyer, Brigid, and Douglas I Katz. “Post Concussion Syndrome.” Handbook of Clinical

Neurology, vol. 158, Elsevier B.V., 2018, pp. 163–178.

Griffith, Cara. "The Ugly Truth about Concussions." 2 Feb. 2016. ​Youtube​,

uploaded by TEDx Talks, 2 Feb. 2016, www.youtube.com/watch?v=-WadcoPE0m8.

Accessed 22 Oct. 2019. Lecture.

Guskiewicz, K. M., S. W. Marshall, J. Bailes, M. McCrea, H. P. Harding Jr, A. Matthews, J. R.

Mihalik, and R. C. Cantu. Recurrent Concussion and Risk of Depression in Retired

Professional Football Players. Med. Sci. Sports Exerc., Vol. 39, No. 6, pp. 903–909,

2007.

Hugentobler, Jason A et al. “PHYSICAL THERAPY INTERVENTION STRATEGIES FOR

PATIENTS WITH PROLONGED MILD TRAUMATIC BRAIN INJURY

SYMPTOMS: A CASE SERIES.” ​International journal of sports physical therapy​ vol.

10,5 (2015): 676-89.

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Institute of Medicine (IOM) and National Research Council (NRC). 2014. Sports-related

concussions in youth: Improving science, changing the culture. Washington, DC: The

National Academies Press.

JORGE, R. E., R. G. ROBINSON, S. V. ARNDT, S. E. STARKSTEIN, A. W. FORRESTER,

and F. GEISLER. Depression following traumatic brain injury: a 1-year longitudinal

study. J. Affect Disord. 27:233–243, 1993.

Kong, Tae Hoon et al. “Clinical Features of Fracture versus Concussion of the Temporal Bone

after Head Trauma.” ​Journal of audiology & otology​ vol. 23,2 (2019): 96-102.

doi:10.7874/jao.2018.00339

MORTON, M. V., and P. WEHMAN. Psychosocial and emotional sequelae of individuals with

traumatic brain injury: a literature review and recommendations. Brain Inj. 9:81–92,

1995.

Rizzo, John-Ross et al. “The Intersection between Ocular and Manual Motor Control: Eye-Hand

Coordination in Acquired Brain Injury.” ​Frontiers in neurology​ vol. 8 227. 1 Jun. 2017,

doi:10.3389/fneur.2017.00227

Robbins, Clifford A et al. “Self-reported concussion history: impact of providing a definition of

concussion.” ​Open access journal of sports medicine​ vol. 5 99-103. 7 May. 2014,

doi:10.2147/OAJSM.S58005.