Bulletin

Bulletin vol. 32 no. 1 | 21 Prolonged Recovery/Persistent Symptoms The most common symptoms that may continue to linger after a concussion include headaches and emotional symptoms. Preexisting history of headaches/migraines are predictors for prolonged recovery following a SRC (Davis et al., 2007). Research also indicates that preexisting conditions such as ADHD, learning disorders, or mental health diagnoses may also influence the recovery period (CDCC, 2018). Continued evaluation of an athlete with persistent symptoms is vital during the recovery process and may include symptom checklists, neurological exams, vestibular assessment, and balance testing. A comprehensive neuropsychological evaluation may be administered to athletes with cognitive and emotional symptoms to assess attention, executive function, memory, processing speed, and/or emotional difficulties. During the evaluation period, health care professionals also provide concussion education as it relates to the physical, cognitive, and emotional triad, which is vital during the recovery period. Intervention The optimal treatment approach is a multimodal intervention that targets four key domains simultaneously – the individual, family, school or work, and athletics/activities (Kirkwood et al., 2008). At both the individual and the family level, psychoeducation on symptom treatment and recovery is key. Education may also be provided at the school for student athletes, as the school system will also have mandated protocols for a gradual return to activity/athletics. Employers may need to be informed of any accommodations that may be needed for individuals returning to work. Dr. Didehbani is the lead neuropsychologist at the Parkland Outpatient Psychiatry Clinic and Assistant Professor of Psychiatry at UT Southwestern Medical Center. Dr. Siebenmorgen is a pediatric neuropsychologist at Children's Medical Center Dallas and assistant professors at UT Southwestern. As the individual makes the graduated return back to school, work, and daily activities, increased awareness is placed on their emotional adjustment as well as repeat injury prevention. Commonly, accommodations can be provided to assist with the graduated return, with the understanding that accommodations will slowly be removed as symptoms improve. For school and work, this can include breaks for concentration difficulties and/or headaches, extra time for makeup work, dimmed lights on electronic devices or complete assignments without such devices, and avoidance of loud atmospheres like the lunch or break room. For return to physical activity, this may include initial rest, but returning to light aerobic exercise as soon as possible. If there is no increase in symptoms during light aerobic exercise, more intense exercise may be attempted and gradually increased as long as symptoms do not persist. The key is continue with as much activity that does not increase or intensify symptoms – all of which can occur with the written authorization of a medical professional. Targeted interventions for specific symptom relief may include medication management for headaches, sleep, and/or mood in isolation or in combination with other therapies including vestibular and behavioral modifications. What is CTE? Recent media coverage on contact sports in professional athletes has highlighted the potential long-term consequences of concussions and/or repeated hits to the head. Abnormal findings following autopsy of some athletes' brains have been labeled chronic traumatic encephalopathy (CTE), which is characterized by abnormal tau protein deposits in the brain. CTE can only be diagnosed by an autopsy of the brain and cannot be diagnosed in a living person. It is important to note that abnormal tau proteins in the brain are also found in people with neurological disorders and are not unique to CTE. Research on CTE has primarily focused on the brains of deceased professional athletes with retrospective examination of behavioral symptoms and limited information on other potential contributing factors such as substance abuse or history of mental illness. There is also no current research to link youth contact sport participation with a risk for CTE and current prevalence rates are unknown at this time. For more information on CTE, please visit the Sports Neuropsychology Society's CTE Fact Sheet. Other Resources More comprehensive and up-to-date information on mTBI, including sports-related mTBI can be found in the Report to Congress: The Management of Traumatic Brain Injury in Children, National Center for Injury Prevention and Control (2018), CDC Heads Up program, and the Berlin Consensus Statement (2017). Important Note Concussions can occur during any sport at any level and it is important to monitor potential signs and symptoms of a concussion. Every state now has concussion laws that mandate proper evaluation and return to play guidelines for a suspected concussion in student athletes. Please visit your individual state laws for your specific guidelines. Overall, sports provide athletes with healthy exercise habits and life lessons of teamwork, confidence, and respect with minimal risk for injury. So, play it safe!

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