How to avoid post-concussion syndrome: sometimes rest means rest!

206982_1037539872681_50_nWESTBOROUGH, MA September 9, 2014 As athletes begin playing fall football, soccer, field hockey, fall baseball, and even cross-country they may experience concussion. Concussion is defined as a traumatic brain injury that results from a force being applied to the skull.  The resulting energy exchange causes the brain to move, often dramatically, in the skull sometimes by striking one side of the head and a point directly opposite causing injury. A concussion is thought of as an invisible injury because no outward signs of injury can be seen most often. What really happens is a sudden release of excitatory neurotransmitters and a change in the cellular permeability. This results in an energy mismatch and decreased cognitive efficiency. Postconcussion Syndrome (PCS) is diagnosed when symptoms last longer than expected.  In general, the brain is effected for 7-10 days after concussion.  PSC impacts approximately 5-10 percent of cases of concussion and these patients can have symptoms for weeks or months. How can an athlete minimize his or her chance of getting post-concussion syndrome?

Remove athlete from highly stressful surroundings

The truth is that athletes exhibiting prolonged symptoms are at risk for a second injury during the period of recovery making it very important to fully rest following concussion. By doing so the athletes lessens the chance of second impact syndrome – a potentially life threatening swelling within the brain. Athletes who are recovering from a second or third concussion must expect to recover over a longer period or time.  “Prolonged symptoms like headaches, irritability, and fatigue may be a signal that the brain has not returned to its normal equilibrium after injury”, according to Michael Sefton, Ph.D. who published a blog on the topic in May 2014.  It is particularly important to minimize physical and cognitive exertion following brain injury including concussion.  Most people now recognize that student athletes should not return to competitive play until symptom free for 7-10 days and after they have completed a well designed return to play protocol.  But some fail to take the need for the need to rest seriously.

Rest has become the treatment of choice – that includes both physical and cognitive rest.  This is a hard sell to many athletes including the professionals.  In fact, there is a growing literature that suggests people recovering from concussion must completely shut down – meaning no text messaging, no video games, no web surfing, and no loud rock concerts!  A 16-year old female athlete was recovering slowly from a moderate concussion.  Her symptom profile remained high after 3 weeks time.  The post-injury testing revealed a marked decline in her short-term memory and processing speed.  She seemed to buy into my prescribed rest including a shorter day in school and a reduced work load.  Just when I thought I had helped her understand the need for rest both she and her mother asked whether I thought it would be okay that she attend a 2 day rock concert scheduled for later in the week.  There are trade-offs for everything but rest means rest and the excitement and chaos associated with most rock shows would probably has tripped the exertion meter and given her another headache.

There is clearly a subset of athletes who may be prone to PCS including chronic headaches, poor concentration, emotional lability, and other physical and cognitive symptoms.  Some believe those with pre-existing anxiety and depression may be more at risk of having a protracted course after concussion.  For these athletes a short course of psychotherapy that offers both education and supportive counseling may mitigate the sequelae of postconcussion symptoms.  There is also a subset of cases that may be at greater risk of recurring headaches when a history of migraine headaches is reported.  For these athletes, a coordinated interdisciplinary approach to treating the migraine is a must while assuring the athlete is getting the needed rest to fully heal.

School Reentry

If complete rest is the key for athletes recovering from concussion at what point can a student athlete return to class?  The answer to this question lies in the current symptom profile and individual conditions within the school setting.  Meanwhile, it is well established that student athletes suffering from the effects of PCS are eligible for academic support under Section 504 of the Rehabilitation Act of 1973.  This law affords students with specific physical disabilities accommodations so that they may succeed in school. This might mean a shorter school day during initial recovery coupled with reduced assignment load, deferred testing until recovery is complete, rest breaks, changing classes 5 minutes before or after the bell, and others.  In some cases, physicians order complete neuropsychological testing for students with symptoms lasting over 30 days – especially those with a history of academic vulnerability.  School psychologists, nurses, and adjustment counselors are key personnel in the school reentry team and can do much to reduce the risk of school related failure due to postconcussion syndrome due to concussion.

Michael Sefton, Ph.D.

Sefton, M. (2104) Prolonged symptoms signal delayed healing. blog: May 4, 2014 taken September 9, 2014


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