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The Psychiatric Aspects of Sports Related Concussion and Mild Traumatic Brain Injury

Within the last few decades, medical experts have discovered the potential short- and long-term effects of concussions, and how clinicians can better treat them.

The Psychiatric Aspects of Sports Related Concussion and Mild Traumatic Brain Injury

Estimated watch time: 51 mins 

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Presentation Materials:

Presenter, Alex Strauss, M.D. is Board Certified by the American Board of Psychiatry and Neurology (ABPN) in both Psychiatry and Child & Adolescent Psychiatry. He received his Doctor of Medicine (M.D.) from Northwestern University School of Medicine in Chicago, Illinois. He completed his Adult, Child and Adolescent residency and fellowship at Western Psychiatric Institute and Clinic (WPIC), (#12 Top Psychiatry Hospital U.S. News and World Report 2017) a part of the University of Pittsburgh School of Medicine. At WPIC, he served as the chief resident for education and the chair of the academic, administrative, clinical educator track. During his time at WPIC, he received comprehensive training in the assessment and treatment of all varieties of psychiatric illness. He is a partner at Centra, Clinical Assistant Professor in the Department of Psychiatry at Rutgers Robert Wood Johnson Medical School and Consulting Sport Psychiatrist for Temple University Athletics. He has expertise in the use of psychiatric medication and psychotherapeutic techniques for the treatment of all age groups. He also has a special interest in the treatment of concussion and psychiatric illness in athletes.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Alex Strauss is board certified by the American Board of Psychiatry and Neurology in both psychiatry and child and adolescent psychiatry. He received his doctor of medicine from Northwestern University School of Medicine in Chicago, Illinois. He completed his adult, child and adolescent residency and fellowship at Western Psychiatric Institute and Clinic — and No. 12 top psychiatry hospital by U.S. News and World Report in 2017. At WPI, he served as the chief resident for education and the chair of the academic administrative clinical educator track. During his time at WPI, he received comprehensive training in the assessment and treatment of all varieties of psychiatric illness. He is a partner at Centra, clinical assistant professor in the Department of Psychiatry at Rutgers Robert Wood Johnson Medical School and consulting sports psychiatrist for Temple University athletics. He has expertise in the use of psychiatric medication and psychotherapeutic techniques for the treatment of all age groups. He also has a special interest in the treatment of concussion and psychiatric illness in athletes. Welcome, Dr. Strauss, and we are so excited to have you speak for us today. 

Dr. Strauss:
Well, thank you so much, and I really appreciate the invitation. I am very fortunate that we get to talk about a very important topic to me, and hopefully, you guys can ask questions. We’ve got a small group, so just type some questions into the chat during the presentation and we’ll go from there. I don’t have control of the slides, so I will ask that they move forward. The topics that I want to focus on today are defining what a concussion is, ‘cause I know it’s different from what I had thought. And then get into kind of what post-concussive syndrome looks like and really focus — since I am a psychiatrist — on the psychiatric aspects of it. And then go into the treatment that’s involved in the post-concussive syndrome.

So, I dunno if you guys know these folks or what they all have in common, but you can probably guess that it’s related to a concussion. We have in the upper left hand, Ben Roethlisberger, still the quarterback for the Pittsburgh Steelers, which is where I trained. In the upper right, Eric Lindros, whose career was ended prematurely due to concussion, Tim Tebow in the lower right — we got a video of him having one of his concussions in the presentation today. And Max Conradt out of Oregon, who was a player who ended up having multiple concussions before his concussion healed, leading to laws in Oregon that have spread across the country in terms of approaches to sports and concussion management. 

Max’s Law that I briefly referred to here came out of Oregon and required coaches and school athletics teams to receive training on how to recognize a concussion and the proper medical treatment. I’m here in New Jersey, and we’ll talk a little bit about what they’ve done as well, but really, around 2010, which is when I was finishing up my training, concussion became very big — and the appropriate management of it.

In New Jersey, the policies included training for parents and guardians, as well as the athletes, the coaches, the athletic trainers and any physicians employed by the school. They really made a big push — and have continued to do so — to say that understanding concussion and being able to assess for it is extremely important for anyone involved in athletics. What I hear a lot from coaches and other parents and folks is, “I’ve had a concussion and I was fine, so what’s the big deal? Why is this such a big deal right now?” It used to be in the news a lot in terms of what was going on with athletes. Obviously, things have changed a little bit in the news lately, but for the NFL, it was a very big thing and spread across the country. So, what does it mean to have a concussion and why is it important?

First of all, when you look at the literature on concussion, there’s no clear consensus on a diagnosis or exactly what makes a concussion a concussion. There’s no uniform definition. Multiple terms are used in the literature. We see a concussion, and then we also see the term “mild traumatic brain injury,” and that affects how people are treated who’ve had these head injuries. So, this was an interesting study that came out of the journal Pediatrics in 2010, and the quote, “My child doesn’t have a head injury, he only has a concussion.” And what’s fascinating about this is that, in the literature and in reality, concussion and MTBI or mild traumatic brain injury are the same thing. But if someone was labeled to have a concussion, they’d be discharged earlier from the hospital, returned to school or sports earlier than if they were given the diagnosis of a mild traumatic brain injury. And obviously, that’s going to impact these people’s future, especially if you think back to someone like Max, who was put back into athletics, had a repeat concussion and then had serious brain injury for the rest of his life.

The CDC has also come up with the definition of concussion, and it’s a traumatic brain injury. That’s a bump or a blow or a jolt to the head or the body where the brain moves rapidly back and forth. If you think about it, the brain is actually floating within the skull, so you don’t even necessarily need to hit your head on something. You could have a whiplash-type injury, and that would mean the brain would bounce back and forth against the skull, and that can cause a concussion. The traumatic brain injury has to interrupt the normal functioning of the brain. You’re going to experience something that you either can see or feel, or other people can see. It’s deemed mild because it’s not life-threatening; there are more moderate or severe concussions, and those are situations where people lose a lot of functioning, at least early on — may be unconscious for 24 hours. There’s a whole thing called the Glasgow Coma Scale, in which things are defined in terms of mild, moderate and severe, but these are all mild. So pretty much, you don’t have any major neurological findings following a concussion.

Highlighting the 1997 definition from Neurology, which is any trauma-inducing alteration in mental status that may or may not include a loss of consciousness. This is going back to — it could be a whiplash injury. You don’t have to, like, hit your head. Your head just has to move, and you have to not either be thinking right or feeling right. Some sort of change in your mental status — your balance is off, your vision is off. Something is changed after you have a traumatic event that impacts your head.

So, why do we care? Who does this happen to? Over one million people. Every year, up to three million people a year have concussions, and being a child/adolescent psychiatrist, I am often in the greatest age group of where these occur. They occur with really young kids, zero to four, and then with your teenagers, 15 to 19. I focus a lot on sports, but the highest rate occurs in motor vehicle accidents or other accidents which can occur at really high velocity. I want to show a little news story so you guys can hear a little bit about how a parent thought about a concussion, and a doctor. 

News Video:
“And I went up to kick the ball, kind of hot, and I got knocked off and my head hit first. And then I landed on the ground.” But minutes later, Jacob Singer was back in the game. He didn’t black out, so he didn’t think twice. Neither did his coach or his parents. “I was always under the impression that you have a concussion if you get knocked out. He was not knocked out.” But the next day, Jacob’s seemingly minor sports injury sidelined him from everything. “I had really bad headaches, like, migraines.” A trip to Dr. Richard Hyman brought a startling diagnosis: a serious concussion. One that kept Jacob out of school for two weeks and away from the sport he loves even longer. “I fear I would have missed that five or 10 years ago.” But thanks to research being done right here in Ohio by Akron doctor Joe Congeni, pediatricians are learning that as many as 80% of concussions have gone undiagnosed, especially those that occur during sporting events. The problem — kids are sent right back in, and a second brain injury and could have lifelong, even deadly consequences. “A lot of people that have chronic headaches for the rest of their life were people that had multiple concussions when they were young.” 

Recent research shows multiple concussions could also lead to hyperactivity disorders, learning disorders, depression and a rare but deadly condition known as second impact syndrome — a reality that shocked even doctors, “My jaw dropped open and I’m looking at page after page and saying to myself, ‘Wow, I haven’t been handling this right for the last 35 years.’ Which is why Dr. Congeni is trying to spread the word that a child doesn’t have to take a direct blow to the head to suffer a concussion. He calls it a silent epidemic that parents, coaches and doctors need to take more seriously. “When it comes to the possibility of a brain injury, there’s no place to tough it out.” A lesson learned the hard way by this parent whose son was put on complete brain rest — no TV, no schoolwork, nothing in order for his bruised brain to heal. “Jake slept pretty much for four days straight.” But today, Jacob’s back in the game, and on the sidelines, his mom is now on the defensive. “Now I know if my kids hit their head, I’m not just going to say, ‘Oh, you’ll be fine.’” 

Dr. Strauss:
I think what’s interesting is that video’s from about 10 years ago, and the treatment’s even changed from then. Keep that in the back of your head as you listen to that video and what we talk about in terms of management today. We don’t know exactly what happens in terms of concussion, but the theory is that you’re getting a rotational force and strain on the axons. These are the wires within the brain that are communicating to the different areas. If you start to stretch them or twist them, you can let in different types of chemicals, which is what the other slide was talking about, and that can lead to damage. There’s no way to see this damage on your standard MRI or CT scan that you’d typically get if you were to go to an emergency room or an imaging center; you can only see this damage with a special diffusion tensor imagery. That’s a specialized MRI, and that’s really only used in research at this point. The damage that is done following a concussion is typically not something that you can ever see, so it’s really more about what are the symptoms that people are experiencing. This is a video of a more standard concussion. 

News Video:
No. 1 Florida losing its quarterback, Tim Tebow, last night in Kentucky after a blow to the head, carted off the field exhibiting symptoms of a concussion. Tebow was hospitalized overnight. espn.com injury analyst and licensed physical therapist Stephania Bell with more on Tebo’s injury. “Every concussion represents a brain injury, and for that reason needs to be treated seriously. In football, concussions happen when a player’s head makes contact with another player or the ground. And in Tim Tebow’s case, he took a series of hits from the front, from the back and the ground, which all led to a concussion. To return to football, Tebow will need to be completely symptom-free at rest, and will then be gradually returned to activity while being clearly monitored for any return of symptoms. Unfortunately, when it comes to concussions, we never know how severe they are until we see how long it takes someone to recover.”

Dr. Strauss:
What I really liked there in terms of what Stephania Bell said was that the concussion severity is typically based not on the actual hits or, as we said, not even the hit, but what it’s based on is the recovery. Really, a severe concussion is only determined after you understand that you’ve had a prolonged recovery. Someone could have a really severe hit like Tim Tebow right there and be able to be back on the field the next week, and somebody else could be in a car accident at 10 miles per hour and have long-term symptoms that could last weeks or months. So, the more severe concussion is really based on how long people aren’t feeling well. 

When we look at the idea of having a head injury and a concussion, typically, we’re looking at the initial phase. What do people notice? If somebody hit their head, the first kind of signs that you start to see are issues with memory loss, appearing dazed or confused, clumsily moving, being slow to answer questions, having behavioral personality changes. Only rarely do we end up seeing anything on a CT scan or people losing consciousness or someone having a seizure. What you see these days is that you’re watching a football game, and one of the players looks wobbly after a play. When they’re going into the tents and being analyzed by the team physician, what they’re really looking at is what does their memory look like? Are they able to track and follow? That’s how they’re determining whether or not this person had a concussion or just some other type of injury.

Now, symptoms are the things that people experience themselves. Sometimes, after a concussion, people don’t have any symptoms. And then other times, when people do have symptoms, they typically fit into four symptom clusters. One are the cognitive symptoms, and that’s where you kind of have fogginess, difficulty concentrating, memory difficulties, finding you get tired when you try to do different things that require brain function. The most common symptoms are more the somatic ones, so that’s the headache occurring. Up to 78% of people who have gotten dizziness, up to 50% nausea, light and sound sensitivity. A lot of people have sleep difficulties, falling asleep, staying asleep, too much sleep, too little sleep. You heard in the video — the kid slept for four days. And then mood disruption, which is another major area and fits into the majority of the psychiatric components, which is the irritability, sadness and anxiety.

When the concussion research first came out — and a lot of it was done in Pittsburgh, and development came out as a result of NFL and other sports — the focus was very much on, “When can I play again?” And the saying that came out was, “When in doubt, sit them out.” When they started to learn about the effects of multiple concussions and having concussions when people aren’t healed, they really focused on not having people return to play. So, you weren’t supposed to return to the practice of the game, and you really needed monitoring and medical evaluation and then a step-wise process to be able to get back to play. That included intact neurocognitive functioning. 

New Jersey came out with their own rules and they said, for at least children and adolescents, you needed to be removed from your game or practice. But then you also had to be symptom-free for an entire week before even initiating a return to play protocol. So, anybody who had a concussion in the state of New Jersey — once this law got passed, they weren’t going to return to play for at least two weeks because you had to wait that first week and then have the standard week-long return to play protocol. If symptoms were to return during that, you’d have to pause the protocol and then advance as tolerated. The real purpose of this was to really make sure that people weren’t returning too early.

The other thing that was put into law by Christie in December of 2010 was that you also had to have a licensed health care provider trained in the evaluation and management of concussion provide the clearance. You could no longer get clearance from your coach or your athletic trainer; I mean, you could get it from your trainer, but you couldn’t get it from your coach or your parent. You had to get a health care provider who’s trained in concussion management to get you back onto the field.

So, what did this mean? It meant that if you were on the sideline and you were parents or you were a kid in the game, you should stop playing. If you had any symptoms of concussion and go seek medical evaluation, then you needed to be symptom-free before you’d even think about returning. And then exercise and make sure that you could tolerate general light exercise, heavier exercise, and that your thinking and neurocognition were back. And then you can get back to play. You’re really looking at, as we talked about, not having any signs or symptoms of a concussion before you put yourself at risk for another concussion.

Ultimately, people were like thinking most of these kids are not professional athletes, but they are professional students. What developed was this concept of “return to learn” and the idea that we can’t have kids returning to sports before they’re able to return to school, but school can be really challenging as well. The idea of trying to focus in a classroom — or if you have vision difficulties, trying to look at a board, look down, take notes — all of these things can be really difficult. And oftentimes, I find in practice, kids who had no difficulty in school before a concussion — all of a sudden, their grades drop and they don’t even know why, but they’re not able to remember things or aren’t able to take notes or they’re getting headaches. What they’ve really worked on is kind of a return-to-learn program as well. Which is to say, we’re going to rest a little bit, but then what we’re going to do is really gradually get back into the cognitive activities, the homework activities. Get into school part-time, then full-time, increase the school workload and then get back into full-time school. And it’s very much modeled after the idea of the return to play.

I’ve mentioned a number of times “neurocognition.” For those of you who aren’t familiar, neurocognition refers to kind of the way in which you are able to pay attention to things, concentrate, remember things, process information, how you perform and how quickly you’re able to perform, your reaction time. This can be tested by neuropsychologists, and it has been — people do IQ and other types of educational testing, performance testing, which can be paper and pencil and computerized. And that is the way that it used to occur. But in concussion, they’ve developed kind of short-term, McDonald’s versions of neuropsychological testing. The one that I was trained in and the one that’s been used by the NFL and NHL and things like that is called the ImPACT testing. What it is is about a 20-minute computerized test, and it looks at those neurocognitive functions. Typically, for athletes starting in middle school, you’ll do the testing before you start sports, and then if you have a concussion, you’ll repeat the testing, and that’ll be the judge to see if you can get back to your baseline level. So, they’ll know kind of where you started at with your memory and attention and processing speed. And then if you have a concussion, they’ll test it again. If you’re not able to get back to your baseline neuro functioning, then what they’re going to do is have you test every week as you’re symptom-free to see when your brain gets back. It’s just another tool to assess for recovery of concussion.

So, how long does recovery take? When we’re looking at athletes, typically, recovery is going to occur in seven to 10 days. The younger the athlete, the longer it can take. When you’re looking at elementary and middle schoolers, it could take up to 28 days or four weeks. When you’re looking at professional athletes, sometimes it only takes three to five days, and that’s how you can have a concussion on a Sunday, go through the whole protocol and be back to play the next Sunday. Now, 80% or more of athletes are going to recover spontaneously within three weeks. Really, what I focus on in my practice are the people who do worse, and there are some predictors in terms of who might do worse. If you had a learning disability ahead of time, if you’ve got younger age, if you’ve had prior concussions, if you have amnesia at the time of the head injury, if you have migraines or have a family history of migraines, or if you’re an over-exerter — one of those people who can’t rest at all and just wants to go right back to doing everything full throttle.

The thing that we really worry about is the repeat concussions. Athletes are at increased risk, obviously, because they’re putting themselves into a situation where they have that risk of a concussion. It’s six times more likely if you had loss of consciousness when you had your initial concussion. The greatest risk is in the first week to 10 days, which is where things like the laws in New Jersey came out to say, “We’re not even going to let you get back on the field — at most — for the 14 days. Longer recovery often occurs after repeat concussions. Maybe the first one, you bounced back within a couple of days, but then the next one takes a couple of weeks, and then the next one takes a couple of months, and that’s when things can start to get a little scary.

The thing that was talked about in one of the videos, and Max Conradt and the law in Oregon was based on this kind of second impact syndrome, and that’s the idea that having a second head injury before recovery from the first head injury — even if the second injury is minor — can lead to significant concerns of permanent brain damage, death, brain swelling and things along those lines, and kids may be at increased risk. One of these huge things that we’re trying to avoid with all this concussion education and these laws of preventing people from returning to play is to prevent this idea of having people with second impact syndrome. You don’t hear about too much second impact syndrome like you did 10 or 20 years ago. Now, here’s a video of an athlete who had so many concussions he actually retired early. 

Video:
Lindros and Stevens have battled like this over the years, the power forward against the power defense for the NHL. Another look at it — he catches him right there. The head snaps back, and Lindros was escorted off the ice. Stevens’ shoulder is the one that always makes contact first, the shoulder. 

Dr. Strauss:
That brings up the question of retirement, and I deal with this a lot in my practice as well. There’s an emotional toll to retirement, and all athletes are going to retire at some point. But when you’re retiring due to concussion, it’s typically before you feel like you’re ready to retire. It’s often important to include mental health in the management of that and really think about the pros and cons of continuing to get back out onto the field. One proposed criteria is having three concussions in a year or three months or more of symptoms. But I definitely see plenty of people who do return to sports after that, and there really is no clear plan in terms of who has retirement and who doesn’t or when it occurs.

We’re going to talk a little bit about long-term effects that can happen post-concussion. These can lead to more permanent neurocognitive deficits, psychiatric problems and the scary chronic traumatic encephalopathy, the CTE, studies that have come out of the head injuries of NFL players, as well as the research and movie with Will Smith, “Concussion,” talking about chronic traumatic encephalopathy.

So, chronic traumatic encephalopathy. If you look it up and read about it, I think they studied over a hundred brains from the NFL, and all but one of them had signs of chronic traumatic encephalopathy. And this was originally termed dementia pugilistica, and where you saw it in earlier years was in boxers who had continued and repeated brain trauma. They’d have memory disturbances, behavioral difficulties, and Parkinsonism, where they have difficulties with movement, speech, gaits and other neurodegenerative conditions. Estimates of at least 17% of people who have repetitive, mild traumatic brain injury could develop this, but it’s extremely difficult to really understand how much repetitive brain trauma, severe or not so severe, will lead to chronic traumatic encephalopathy — and if there’s other factors, like substance use or other things that get involved in brain damage that you often see in professional athletes or fighters or things like that.

Let’s talk a little bit about post-concussive syndrome, ‘cause this is what I deal with the most in my practice. Also, it’s not completely clearly defined, but the Diagnostic Statistical Manual in 1994, the DSM-IV, did have kind of the concept of having three or more symptoms from those symptom clusters of the physical symptoms or the psychiatric symptoms or the attentional symptoms or the sleep symptoms lasting three or more months, and then causing impairment and decline of function. And these are — the majority of the people that end up in my office are people who have these types of prolonged symptoms following a head injury. Again, that’s in a percentage of people that’s maybe 10%, 20% of people who have concussions.

The development of the neuropsychiatric complications can occur in about 20% of people after they’ve had a traumatic brain injury. Even with no past psychiatric history, the increased rates can be up to 2.8 times the risk of somebody who did not have a head injury. If you had a past psychiatric history of illness, you have an even greater risk of psychiatric illness following head injury. So, what you’re seeing is people who never had psychiatric illness developing it and people who have had it with it worsening.

These are the most common. So, cognitive deficits or things that look like ADHD occur in 25% to 70% of folks; depression, 25 to 50% of people; and anxiety, 10% to 77%; and sleep problems, 30% to 70%. We see agitation and aggression in maybe three out of 10, but you definitely see that more in the more moderate and severe. There’s also a three-times incidence of suicide. You see increased substance use, and this can go both ways in terms of “people who have head injuries may go towards using substances,” but you also see that substance use increases your risk of having a traumatic brain injury. We also see, rarely, things like psychosis or OCD, personality changes, dementia, mania as part of a bipolar spectrum, stress disorders and apathy. But really, the things that I see in practice are the focus and attentional concerns, depression, anxiety, sleep difficulties and then the substance use. And suicide definitely pops its head, unfortunately.

I wish that we had a “treatment be gone,” a “concussion be gone” machine. That we could just kind of put it on their head and fix their concussion, but unfortunately, that does not exist. And the treatment of post-concussion is very multidisciplinary in nature with many different aspects, due to the wide range of symptomatology that people experience.

What I want to do is run through a little bit on each of these treatment modalities — the collaborative care, the education, the rest, the accommodations, sleep, relaxation, vestibular therapy, physical therapy, cognitive rehab, occupational and speech therapy, psychotherapy and medications. For folks who have post-concussive syndrome — and again, this is folks who have symptoms of concussion that are lasting for many weeks to many months — what they’ve really found is that if you work in a collaborative way with things like cognitive behavioral therapy, case management, medication as needed, there’s a significant improvement over just kind of getting the usual care of going to the emergency room and being sent home or going to your pediatrician and being told to rest. What we really try to do is get folks who’ve had concussions and have prolonged symptoms into care with providers who really know what they’re doing and multiple providers to address the needs that each individual has.

Education, support and guidance is also really important. It’s not uncommon for people to come in who’ve had a concussion — their first concussion — and be terrified that they’re going to get chronic traumatic encephalopathy or things along those lines. What we noticed is that increased anxiety and fear really increases the symptoms and prolongs the symptoms. The sooner that people can be told about the fact that 80% to 90% of them are going to get better within a couple of weeks, and that it’s okay to have these symptoms. That 70% plus are going to have headaches and 70% plus are going to have sleep issues — this is all normal, and the body typically recovers as well. If you can decrease that stress, that anxiety, people often have less symptoms and get better quicker.

This is a big thing that has changed over the course of the last decade of my work in the area. When I was initially practicing the focus — and some people called it cocoon therapy, where you put somebody into a dark room and lock them away after a concussion and wait for their symptoms to go away. So, you’d see all these teenagers who weren’t allowed to have phones and weren’t allowed to go to school and weren’t allowed to go to sports. They would just be in a dark room for days or weeks or months at a time. And the symptoms generally, over time, would go away, but what often developed was depression and anxiety and other things that you’d imagine from isolating these kids from their school and their friends and their sports and everything that they were used to. Over time, they actually realized that that was the case, as I was noticing in my practice, and the guidelines have changed. Now, rest is not recommended for any more than 48 hours. You’re really looking at no more than two days of rest. And really, the goal is to kind of get up and get moving as tolerated early on, as you would do with any other type of musculoskeletal injury. And you still, in the first couple of days, maybe you’re not going to be texting and doing TV and video games and things like that.

But then you’re going to really start to follow that return-to-learn protocol very, very quickly and really get people back into reading and into the school setting, even if they’re continuing to have symptoms. You may not get them back to exercise and sports right away — or intensive exercise, I should say — but you want to get them back walking and moving and things like that.

And as I said, typically, people — 80% to 90% — they’re going to get back in a week or two. So, you’re really only looking at a small percentage who, after a little rest and a little return on a lighter scale, aren’t going to be doing better. The ones who have the prolonged symptoms — you really need to make sure that they’re still able to engage in life as tolerated.

Sleep I find to be extremely important in pretty much all areas of life, but in concussion, it gets all messed up. And oftentimes, the picture that I see are people who never had sleep problems before. They have a concussion; all of a sudden, they sleep for multiple days in a row. Lots of sleep, which is totally fine, but then their sleep schedule gets messed up. And obviously, this occurs more if you put people on rest and they don’t have to go to work or school or things like that. They don’t have any reason to get up and they don’t have a schedule of things to do. One of the first things that I do when I meet with somebody is really follow and track their sleep patterns, and then really focus on normal sleep hygiene, as well as different techniques to help them sleep. Maybe even getting into cognitive behavioral therapy — insomnia, if need be — to really work on getting their sleep structured. Because if they can get a good, clean sleep during the night and be awake during the day and not be taking naps, oftentimes, that’s going to lead to improvement in all areas of post-concussive syndrome.

As I said previously, anxiety can often be a factor that leads to these prolonged symptoms. If anxiety is a factor, I’ve often used analyzing, relaxation strategies, deep breathing, progressive muscle relaxation, visualization, meditation — all of these things help to decrease the post-concussive syndrome and improve brain recovery. 

More and more, we’re seeing that there are visual and balance issues that frequently occur post-concussion. Sometimes, people are really good at picking those up, and sometimes, not so much. And as I said, it could be as simple as kids are getting headaches because they’re trying to look at a board and then write down their notes or things along those lines. Vestibular functioning can be abnormal in 90% of youth following a concussion. Getting to a vestibular physical therapist who understands post-concussion and is able to do a comprehensive evaluation and then work on appropriate treatment to get the vestibular system back into place can be extremely beneficial for a lot of the difficulties in a lot of the physical symptoms. So, you can be getting nauseous or dizzy, not because necessarily it has to do with your brain in respect to it being hit; it has to do with your eyes and the way in which they’re not tracking the world appropriately.

Now, physical therapy in a non-vestibular way is often beneficial because a lot of folks get deconditioned as they’re resting following a head injury. If you look at the New Jersey law, you’re not going to be able to get back to sports for at least two weeks. People who are high-intensity athletes often will get deconditioned over that period of time. And then, as you’re getting back into sports, you’re starting to get symptoms that you never had before because you were in good shape. And now, you’re starting to get your heart racing or you’re getting headaches, or you’re getting nauseous because you’re out of shape, and people contribute those to concussion when actually, it’s just getting back into shape. So, getting to a good physical therapist who can help to associate, “This is normal. This is healthy. We’re going to start off on the bike and move our way to the treadmill, and then we’re going to start doing some more sports-specific things. We’re going to track your heart rate.” That can help people confidently get back to the physical activity they were doing before their concussion.

As I was mentioning before, upwards of 70% of people can have an ADHD-like picture following concussion, where memory, focus and attention becomes an issue. Cognitive rehabilitation has ways in which they’re able to assess for and then help people learn different approaches to addressing these cognitive deficits that they have. In addition, oftentimes, occupational therapists can be used more times for the more moderate or severe head injuries, but also for the more mild ones, and they can help to evaluate gross and fine motor deficits. Are you having difficulty with writing? Are you having difficulty with being able to tie your shoes or zip your coat or things along those? And then figure out ways to address that and teach activities of daily living strategies to help with those things.

Speech therapy doesn’t only deal with speech, but also deals with strategies to help with attention, concentration, study skills and organization. Sometimes, you see folks who never had difficulties before and can benefit from learning. Sometimes, they had them before and then they got worse and it kind of pushed them over a threshold, and now they’re struggling more academically than they ever were before. Getting to a speech therapist or academic support can really help people get on track.

Psychotherapy, which is one of the big things that I do, has been shown to be effective post-concussion in post-concussive syndrome, and I would agree with this. Basically, there’s a lot of, as I said, depression, anxiety and also just kind of automatic negative thoughts and other things that people come up with that aren’t necessarily true — cognitive distortions that come into play. And sitting down and kind of working through what’s going on and what people believe about their injury and what they believe about their recovery can often lead to improvement.

The other thing that cognitive behavioral therapy is good for are headaches and migraines. And this is just showing a couple of studies. I know that, oftentimes, when people go to the doctor, they’re put on medications for headaches. But this demonstrates that in children, adolescents with recurrent headaches and migraines — again, a very common post-concussive symptom — you can get significant improvement just by doing cognitive behavioral therapy with these kids and helping them understand their headaches and what might trigger their headaches and what might make them better and what pain means to them can all be extremely beneficial. And not using any type of medication to treat the headaches.

When you’re working with kids, you can’t forget about their families. If you think about it, a lot of the folks that are having these head injuries, as we talked about, are in their 15- to 19-year-old years when they’re separating from their parents, and they’re starting to get their driver’s permits and driver’s license and go off and do their own things. And oftentimes, a head injury really changes that because now, all of a sudden, they might be home more. They might not be able to drive for a little bit. They can’t play sports. That can really mess up the dynamic and the independence that a lot of these kids have had. And oftentimes, working with the family on thinking about how the prolonged symptoms of post-concussion have affected them and ways to return to normalcy and independence can be extremely beneficial in the healing process of post-concussive syndrome.

Finally, being a physician and prescribing medications, I want to talk about medications and the use of a post-concussion. First, there’s no medications that are FDA-approved to treat anything — neuropsychiatric consequences of traumatic brain injury. Almost all of the literature is on adults, and if you look at it and look around the country, there’s a ton of different medications that have been used with variable success.

The approach that I’d recommend and what’s really been shown to, I think, make the most sense is understanding that the brain may be more fragile following a head injury. So, you really want to not use medication if you don’t have to. You want to really wait for those symptoms to go away. And then if you need to initiate any medication, you really want to start with very low doses of medication and only increase slowly, as tolerated, watching out for anything that could be a side effect or people getting worse. A big thing that I see in my practice is people not discontinuing medications that don’t work, so people add medications on top of medications, and that’s not good in any type of psychiatry — but definitely not in head injury. You want to watch out for seizure threshold, although I’ve never seen a seizure in a concussion, and you definitely want to watch out for side effects, especially the anticholinergic side effects. And that is actually common with over-the-counter medication. 

Typically, people would take things like a ZzzQuil or Benadryl to go to sleep at night, and those have significant anticholinergic side effects. What that does is, other than make you tired, it can make you groggy in the morning. It can also lead to cognitive difficulties, so you can have difficulties with memory and attention and concentration associated with these medications. You have been listening to the talk that that happens with concussion too. All of a sudden, you’re not sleeping well, and you’re feeling like you’re having memory problems and you start to take Benadryl every night or ZzzQuil every night and you start sleeping better and you get even more cloudy. And the reason that that’s happening is not because your concussion is getting worse, but it’s because you’re taking ZzzQuil every night. As I said, mixing drugs — not a good idea — so you really want to limit any type of drug interactions in anybody.

Just to summarize, and then we can open it up to questions for the last couple of minutes if there are any. Again, there’s over a million concussions each year in the United States, and many are going undiagnosed, although that’s fewer now with all the education that’s out there. Most youth are going to recover within two to four weeks, and it’s really only 10% to 20% that are going to go on to have any type of chronic problems or post-concussive syndrome. And really, only about 2% are going to have any symptoms beyond a year. Treatment is going to require a multidisciplinary approach, and I highly recommend if you’re a treatment provider or a family member or someone who’s had a concussion, get a good multidisciplinary team together and really address this, not just with one doctor or one therapist. Really work as a team, and we’re able to really get even some of the most challenging long-term cases better with that model. Again, thank you so much for coming out today. If you guys have any questions, please feel free to put them up in the chat box.

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

The medical community’s understanding of concussions is still evolving rapidly, with some of the largest breakthroughs occurring relatively recently. In this presentation, Alexander S. Strauss, M.D., DFAACAP, FAPA, explains more about the history of mild traumatic brain injury (concussion) and chronic traumatic encephalopathy (CTE), how it affects people and ways that clinicians can better treat patients with concussions.

After watching this presentation, the viewer will:

  • Understand how concussions are viewed now versus in the past
  • Know the differences between types of concussions, how they affect different age groups and how they can lead to CTE
  • Be aware of how treatment has evolved and what the best treatment practices are today

Presentation Materials:

Presenter, Alex Strauss, M.D. is Board Certified by the American Board of Psychiatry and Neurology (ABPN) in both Psychiatry and Child & Adolescent Psychiatry. He received his Doctor of Medicine (M.D.) from Northwestern University School of Medicine in Chicago, Illinois. He completed his Adult, Child and Adolescent residency and fellowship at Western Psychiatric Institute and Clinic (WPIC), (#12 Top Psychiatry Hospital U.S. News and World Report 2017) a part of the University of Pittsburgh School of Medicine. At WPIC, he served as the chief resident for education and the chair of the academic, administrative, clinical educator track. During his time at WPIC, he received comprehensive training in the assessment and treatment of all varieties of psychiatric illness. He is a partner at Centra, Clinical Assistant Professor in the Department of Psychiatry at Rutgers Robert Wood Johnson Medical School and Consulting Sport Psychiatrist for Temple University Athletics. He has expertise in the use of psychiatric medication and psychotherapeutic techniques for the treatment of all age groups. He also has a special interest in the treatment of concussion and psychiatric illness in athletes.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Alex Strauss is board certified by the American Board of Psychiatry and Neurology in both psychiatry and child and adolescent psychiatry. He received his doctor of medicine from Northwestern University School of Medicine in Chicago, Illinois. He completed his adult, child and adolescent residency and fellowship at Western Psychiatric Institute and Clinic — and No. 12 top psychiatry hospital by U.S. News and World Report in 2017. At WPI, he served as the chief resident for education and the chair of the academic administrative clinical educator track. During his time at WPI, he received comprehensive training in the assessment and treatment of all varieties of psychiatric illness. He is a partner at Centra, clinical assistant professor in the Department of Psychiatry at Rutgers Robert Wood Johnson Medical School and consulting sports psychiatrist for Temple University athletics. He has expertise in the use of psychiatric medication and psychotherapeutic techniques for the treatment of all age groups. He also has a special interest in the treatment of concussion and psychiatric illness in athletes. Welcome, Dr. Strauss, and we are so excited to have you speak for us today. 

Dr. Strauss:
Well, thank you so much, and I really appreciate the invitation. I am very fortunate that we get to talk about a very important topic to me, and hopefully, you guys can ask questions. We’ve got a small group, so just type some questions into the chat during the presentation and we’ll go from there. I don’t have control of the slides, so I will ask that they move forward. The topics that I want to focus on today are defining what a concussion is, ‘cause I know it’s different from what I had thought. And then get into kind of what post-concussive syndrome looks like and really focus — since I am a psychiatrist — on the psychiatric aspects of it. And then go into the treatment that’s involved in the post-concussive syndrome.

So, I dunno if you guys know these folks or what they all have in common, but you can probably guess that it’s related to a concussion. We have in the upper left hand, Ben Roethlisberger, still the quarterback for the Pittsburgh Steelers, which is where I trained. In the upper right, Eric Lindros, whose career was ended prematurely due to concussion, Tim Tebow in the lower right — we got a video of him having one of his concussions in the presentation today. And Max Conradt out of Oregon, who was a player who ended up having multiple concussions before his concussion healed, leading to laws in Oregon that have spread across the country in terms of approaches to sports and concussion management. 

Max’s Law that I briefly referred to here came out of Oregon and required coaches and school athletics teams to receive training on how to recognize a concussion and the proper medical treatment. I’m here in New Jersey, and we’ll talk a little bit about what they’ve done as well, but really, around 2010, which is when I was finishing up my training, concussion became very big — and the appropriate management of it.

In New Jersey, the policies included training for parents and guardians, as well as the athletes, the coaches, the athletic trainers and any physicians employed by the school. They really made a big push — and have continued to do so — to say that understanding concussion and being able to assess for it is extremely important for anyone involved in athletics. What I hear a lot from coaches and other parents and folks is, “I’ve had a concussion and I was fine, so what’s the big deal? Why is this such a big deal right now?” It used to be in the news a lot in terms of what was going on with athletes. Obviously, things have changed a little bit in the news lately, but for the NFL, it was a very big thing and spread across the country. So, what does it mean to have a concussion and why is it important?

First of all, when you look at the literature on concussion, there’s no clear consensus on a diagnosis or exactly what makes a concussion a concussion. There’s no uniform definition. Multiple terms are used in the literature. We see a concussion, and then we also see the term “mild traumatic brain injury,” and that affects how people are treated who’ve had these head injuries. So, this was an interesting study that came out of the journal Pediatrics in 2010, and the quote, “My child doesn’t have a head injury, he only has a concussion.” And what’s fascinating about this is that, in the literature and in reality, concussion and MTBI or mild traumatic brain injury are the same thing. But if someone was labeled to have a concussion, they’d be discharged earlier from the hospital, returned to school or sports earlier than if they were given the diagnosis of a mild traumatic brain injury. And obviously, that’s going to impact these people’s future, especially if you think back to someone like Max, who was put back into athletics, had a repeat concussion and then had serious brain injury for the rest of his life.

The CDC has also come up with the definition of concussion, and it’s a traumatic brain injury. That’s a bump or a blow or a jolt to the head or the body where the brain moves rapidly back and forth. If you think about it, the brain is actually floating within the skull, so you don’t even necessarily need to hit your head on something. You could have a whiplash-type injury, and that would mean the brain would bounce back and forth against the skull, and that can cause a concussion. The traumatic brain injury has to interrupt the normal functioning of the brain. You’re going to experience something that you either can see or feel, or other people can see. It’s deemed mild because it’s not life-threatening; there are more moderate or severe concussions, and those are situations where people lose a lot of functioning, at least early on — may be unconscious for 24 hours. There’s a whole thing called the Glasgow Coma Scale, in which things are defined in terms of mild, moderate and severe, but these are all mild. So pretty much, you don’t have any major neurological findings following a concussion.

Highlighting the 1997 definition from Neurology, which is any trauma-inducing alteration in mental status that may or may not include a loss of consciousness. This is going back to — it could be a whiplash injury. You don’t have to, like, hit your head. Your head just has to move, and you have to not either be thinking right or feeling right. Some sort of change in your mental status — your balance is off, your vision is off. Something is changed after you have a traumatic event that impacts your head.

So, why do we care? Who does this happen to? Over one million people. Every year, up to three million people a year have concussions, and being a child/adolescent psychiatrist, I am often in the greatest age group of where these occur. They occur with really young kids, zero to four, and then with your teenagers, 15 to 19. I focus a lot on sports, but the highest rate occurs in motor vehicle accidents or other accidents which can occur at really high velocity. I want to show a little news story so you guys can hear a little bit about how a parent thought about a concussion, and a doctor. 

News Video:
“And I went up to kick the ball, kind of hot, and I got knocked off and my head hit first. And then I landed on the ground.” But minutes later, Jacob Singer was back in the game. He didn’t black out, so he didn’t think twice. Neither did his coach or his parents. “I was always under the impression that you have a concussion if you get knocked out. He was not knocked out.” But the next day, Jacob’s seemingly minor sports injury sidelined him from everything. “I had really bad headaches, like, migraines.” A trip to Dr. Richard Hyman brought a startling diagnosis: a serious concussion. One that kept Jacob out of school for two weeks and away from the sport he loves even longer. “I fear I would have missed that five or 10 years ago.” But thanks to research being done right here in Ohio by Akron doctor Joe Congeni, pediatricians are learning that as many as 80% of concussions have gone undiagnosed, especially those that occur during sporting events. The problem — kids are sent right back in, and a second brain injury and could have lifelong, even deadly consequences. “A lot of people that have chronic headaches for the rest of their life were people that had multiple concussions when they were young.” 

Recent research shows multiple concussions could also lead to hyperactivity disorders, learning disorders, depression and a rare but deadly condition known as second impact syndrome — a reality that shocked even doctors, “My jaw dropped open and I’m looking at page after page and saying to myself, ‘Wow, I haven’t been handling this right for the last 35 years.’ Which is why Dr. Congeni is trying to spread the word that a child doesn’t have to take a direct blow to the head to suffer a concussion. He calls it a silent epidemic that parents, coaches and doctors need to take more seriously. “When it comes to the possibility of a brain injury, there’s no place to tough it out.” A lesson learned the hard way by this parent whose son was put on complete brain rest — no TV, no schoolwork, nothing in order for his bruised brain to heal. “Jake slept pretty much for four days straight.” But today, Jacob’s back in the game, and on the sidelines, his mom is now on the defensive. “Now I know if my kids hit their head, I’m not just going to say, ‘Oh, you’ll be fine.’” 

Dr. Strauss:
I think what’s interesting is that video’s from about 10 years ago, and the treatment’s even changed from then. Keep that in the back of your head as you listen to that video and what we talk about in terms of management today. We don’t know exactly what happens in terms of concussion, but the theory is that you’re getting a rotational force and strain on the axons. These are the wires within the brain that are communicating to the different areas. If you start to stretch them or twist them, you can let in different types of chemicals, which is what the other slide was talking about, and that can lead to damage. There’s no way to see this damage on your standard MRI or CT scan that you’d typically get if you were to go to an emergency room or an imaging center; you can only see this damage with a special diffusion tensor imagery. That’s a specialized MRI, and that’s really only used in research at this point. The damage that is done following a concussion is typically not something that you can ever see, so it’s really more about what are the symptoms that people are experiencing. This is a video of a more standard concussion. 

News Video:
No. 1 Florida losing its quarterback, Tim Tebow, last night in Kentucky after a blow to the head, carted off the field exhibiting symptoms of a concussion. Tebow was hospitalized overnight. espn.com injury analyst and licensed physical therapist Stephania Bell with more on Tebo’s injury. “Every concussion represents a brain injury, and for that reason needs to be treated seriously. In football, concussions happen when a player’s head makes contact with another player or the ground. And in Tim Tebow’s case, he took a series of hits from the front, from the back and the ground, which all led to a concussion. To return to football, Tebow will need to be completely symptom-free at rest, and will then be gradually returned to activity while being clearly monitored for any return of symptoms. Unfortunately, when it comes to concussions, we never know how severe they are until we see how long it takes someone to recover.”

Dr. Strauss:
What I really liked there in terms of what Stephania Bell said was that the concussion severity is typically based not on the actual hits or, as we said, not even the hit, but what it’s based on is the recovery. Really, a severe concussion is only determined after you understand that you’ve had a prolonged recovery. Someone could have a really severe hit like Tim Tebow right there and be able to be back on the field the next week, and somebody else could be in a car accident at 10 miles per hour and have long-term symptoms that could last weeks or months. So, the more severe concussion is really based on how long people aren’t feeling well. 

When we look at the idea of having a head injury and a concussion, typically, we’re looking at the initial phase. What do people notice? If somebody hit their head, the first kind of signs that you start to see are issues with memory loss, appearing dazed or confused, clumsily moving, being slow to answer questions, having behavioral personality changes. Only rarely do we end up seeing anything on a CT scan or people losing consciousness or someone having a seizure. What you see these days is that you’re watching a football game, and one of the players looks wobbly after a play. When they’re going into the tents and being analyzed by the team physician, what they’re really looking at is what does their memory look like? Are they able to track and follow? That’s how they’re determining whether or not this person had a concussion or just some other type of injury.

Now, symptoms are the things that people experience themselves. Sometimes, after a concussion, people don’t have any symptoms. And then other times, when people do have symptoms, they typically fit into four symptom clusters. One are the cognitive symptoms, and that’s where you kind of have fogginess, difficulty concentrating, memory difficulties, finding you get tired when you try to do different things that require brain function. The most common symptoms are more the somatic ones, so that’s the headache occurring. Up to 78% of people who have gotten dizziness, up to 50% nausea, light and sound sensitivity. A lot of people have sleep difficulties, falling asleep, staying asleep, too much sleep, too little sleep. You heard in the video — the kid slept for four days. And then mood disruption, which is another major area and fits into the majority of the psychiatric components, which is the irritability, sadness and anxiety.

When the concussion research first came out — and a lot of it was done in Pittsburgh, and development came out as a result of NFL and other sports — the focus was very much on, “When can I play again?” And the saying that came out was, “When in doubt, sit them out.” When they started to learn about the effects of multiple concussions and having concussions when people aren’t healed, they really focused on not having people return to play. So, you weren’t supposed to return to the practice of the game, and you really needed monitoring and medical evaluation and then a step-wise process to be able to get back to play. That included intact neurocognitive functioning. 

New Jersey came out with their own rules and they said, for at least children and adolescents, you needed to be removed from your game or practice. But then you also had to be symptom-free for an entire week before even initiating a return to play protocol. So, anybody who had a concussion in the state of New Jersey — once this law got passed, they weren’t going to return to play for at least two weeks because you had to wait that first week and then have the standard week-long return to play protocol. If symptoms were to return during that, you’d have to pause the protocol and then advance as tolerated. The real purpose of this was to really make sure that people weren’t returning too early.

The other thing that was put into law by Christie in December of 2010 was that you also had to have a licensed health care provider trained in the evaluation and management of concussion provide the clearance. You could no longer get clearance from your coach or your athletic trainer; I mean, you could get it from your trainer, but you couldn’t get it from your coach or your parent. You had to get a health care provider who’s trained in concussion management to get you back onto the field.

So, what did this mean? It meant that if you were on the sideline and you were parents or you were a kid in the game, you should stop playing. If you had any symptoms of concussion and go seek medical evaluation, then you needed to be symptom-free before you’d even think about returning. And then exercise and make sure that you could tolerate general light exercise, heavier exercise, and that your thinking and neurocognition were back. And then you can get back to play. You’re really looking at, as we talked about, not having any signs or symptoms of a concussion before you put yourself at risk for another concussion.

Ultimately, people were like thinking most of these kids are not professional athletes, but they are professional students. What developed was this concept of “return to learn” and the idea that we can’t have kids returning to sports before they’re able to return to school, but school can be really challenging as well. The idea of trying to focus in a classroom — or if you have vision difficulties, trying to look at a board, look down, take notes — all of these things can be really difficult. And oftentimes, I find in practice, kids who had no difficulty in school before a concussion — all of a sudden, their grades drop and they don’t even know why, but they’re not able to remember things or aren’t able to take notes or they’re getting headaches. What they’ve really worked on is kind of a return-to-learn program as well. Which is to say, we’re going to rest a little bit, but then what we’re going to do is really gradually get back into the cognitive activities, the homework activities. Get into school part-time, then full-time, increase the school workload and then get back into full-time school. And it’s very much modeled after the idea of the return to play.

I’ve mentioned a number of times “neurocognition.” For those of you who aren’t familiar, neurocognition refers to kind of the way in which you are able to pay attention to things, concentrate, remember things, process information, how you perform and how quickly you’re able to perform, your reaction time. This can be tested by neuropsychologists, and it has been — people do IQ and other types of educational testing, performance testing, which can be paper and pencil and computerized. And that is the way that it used to occur. But in concussion, they’ve developed kind of short-term, McDonald’s versions of neuropsychological testing. The one that I was trained in and the one that’s been used by the NFL and NHL and things like that is called the ImPACT testing. What it is is about a 20-minute computerized test, and it looks at those neurocognitive functions. Typically, for athletes starting in middle school, you’ll do the testing before you start sports, and then if you have a concussion, you’ll repeat the testing, and that’ll be the judge to see if you can get back to your baseline level. So, they’ll know kind of where you started at with your memory and attention and processing speed. And then if you have a concussion, they’ll test it again. If you’re not able to get back to your baseline neuro functioning, then what they’re going to do is have you test every week as you’re symptom-free to see when your brain gets back. It’s just another tool to assess for recovery of concussion.

So, how long does recovery take? When we’re looking at athletes, typically, recovery is going to occur in seven to 10 days. The younger the athlete, the longer it can take. When you’re looking at elementary and middle schoolers, it could take up to 28 days or four weeks. When you’re looking at professional athletes, sometimes it only takes three to five days, and that’s how you can have a concussion on a Sunday, go through the whole protocol and be back to play the next Sunday. Now, 80% or more of athletes are going to recover spontaneously within three weeks. Really, what I focus on in my practice are the people who do worse, and there are some predictors in terms of who might do worse. If you had a learning disability ahead of time, if you’ve got younger age, if you’ve had prior concussions, if you have amnesia at the time of the head injury, if you have migraines or have a family history of migraines, or if you’re an over-exerter — one of those people who can’t rest at all and just wants to go right back to doing everything full throttle.

The thing that we really worry about is the repeat concussions. Athletes are at increased risk, obviously, because they’re putting themselves into a situation where they have that risk of a concussion. It’s six times more likely if you had loss of consciousness when you had your initial concussion. The greatest risk is in the first week to 10 days, which is where things like the laws in New Jersey came out to say, “We’re not even going to let you get back on the field — at most — for the 14 days. Longer recovery often occurs after repeat concussions. Maybe the first one, you bounced back within a couple of days, but then the next one takes a couple of weeks, and then the next one takes a couple of months, and that’s when things can start to get a little scary.

The thing that was talked about in one of the videos, and Max Conradt and the law in Oregon was based on this kind of second impact syndrome, and that’s the idea that having a second head injury before recovery from the first head injury — even if the second injury is minor — can lead to significant concerns of permanent brain damage, death, brain swelling and things along those lines, and kids may be at increased risk. One of these huge things that we’re trying to avoid with all this concussion education and these laws of preventing people from returning to play is to prevent this idea of having people with second impact syndrome. You don’t hear about too much second impact syndrome like you did 10 or 20 years ago. Now, here’s a video of an athlete who had so many concussions he actually retired early. 

Video:
Lindros and Stevens have battled like this over the years, the power forward against the power defense for the NHL. Another look at it — he catches him right there. The head snaps back, and Lindros was escorted off the ice. Stevens’ shoulder is the one that always makes contact first, the shoulder. 

Dr. Strauss:
That brings up the question of retirement, and I deal with this a lot in my practice as well. There’s an emotional toll to retirement, and all athletes are going to retire at some point. But when you’re retiring due to concussion, it’s typically before you feel like you’re ready to retire. It’s often important to include mental health in the management of that and really think about the pros and cons of continuing to get back out onto the field. One proposed criteria is having three concussions in a year or three months or more of symptoms. But I definitely see plenty of people who do return to sports after that, and there really is no clear plan in terms of who has retirement and who doesn’t or when it occurs.

We’re going to talk a little bit about long-term effects that can happen post-concussion. These can lead to more permanent neurocognitive deficits, psychiatric problems and the scary chronic traumatic encephalopathy, the CTE, studies that have come out of the head injuries of NFL players, as well as the research and movie with Will Smith, “Concussion,” talking about chronic traumatic encephalopathy.

So, chronic traumatic encephalopathy. If you look it up and read about it, I think they studied over a hundred brains from the NFL, and all but one of them had signs of chronic traumatic encephalopathy. And this was originally termed dementia pugilistica, and where you saw it in earlier years was in boxers who had continued and repeated brain trauma. They’d have memory disturbances, behavioral difficulties, and Parkinsonism, where they have difficulties with movement, speech, gaits and other neurodegenerative conditions. Estimates of at least 17% of people who have repetitive, mild traumatic brain injury could develop this, but it’s extremely difficult to really understand how much repetitive brain trauma, severe or not so severe, will lead to chronic traumatic encephalopathy — and if there’s other factors, like substance use or other things that get involved in brain damage that you often see in professional athletes or fighters or things like that.

Let’s talk a little bit about post-concussive syndrome, ‘cause this is what I deal with the most in my practice. Also, it’s not completely clearly defined, but the Diagnostic Statistical Manual in 1994, the DSM-IV, did have kind of the concept of having three or more symptoms from those symptom clusters of the physical symptoms or the psychiatric symptoms or the attentional symptoms or the sleep symptoms lasting three or more months, and then causing impairment and decline of function. And these are — the majority of the people that end up in my office are people who have these types of prolonged symptoms following a head injury. Again, that’s in a percentage of people that’s maybe 10%, 20% of people who have concussions.

The development of the neuropsychiatric complications can occur in about 20% of people after they’ve had a traumatic brain injury. Even with no past psychiatric history, the increased rates can be up to 2.8 times the risk of somebody who did not have a head injury. If you had a past psychiatric history of illness, you have an even greater risk of psychiatric illness following head injury. So, what you’re seeing is people who never had psychiatric illness developing it and people who have had it with it worsening.

These are the most common. So, cognitive deficits or things that look like ADHD occur in 25% to 70% of folks; depression, 25 to 50% of people; and anxiety, 10% to 77%; and sleep problems, 30% to 70%. We see agitation and aggression in maybe three out of 10, but you definitely see that more in the more moderate and severe. There’s also a three-times incidence of suicide. You see increased substance use, and this can go both ways in terms of “people who have head injuries may go towards using substances,” but you also see that substance use increases your risk of having a traumatic brain injury. We also see, rarely, things like psychosis or OCD, personality changes, dementia, mania as part of a bipolar spectrum, stress disorders and apathy. But really, the things that I see in practice are the focus and attentional concerns, depression, anxiety, sleep difficulties and then the substance use. And suicide definitely pops its head, unfortunately.

I wish that we had a “treatment be gone,” a “concussion be gone” machine. That we could just kind of put it on their head and fix their concussion, but unfortunately, that does not exist. And the treatment of post-concussion is very multidisciplinary in nature with many different aspects, due to the wide range of symptomatology that people experience.

What I want to do is run through a little bit on each of these treatment modalities — the collaborative care, the education, the rest, the accommodations, sleep, relaxation, vestibular therapy, physical therapy, cognitive rehab, occupational and speech therapy, psychotherapy and medications. For folks who have post-concussive syndrome — and again, this is folks who have symptoms of concussion that are lasting for many weeks to many months — what they’ve really found is that if you work in a collaborative way with things like cognitive behavioral therapy, case management, medication as needed, there’s a significant improvement over just kind of getting the usual care of going to the emergency room and being sent home or going to your pediatrician and being told to rest. What we really try to do is get folks who’ve had concussions and have prolonged symptoms into care with providers who really know what they’re doing and multiple providers to address the needs that each individual has.

Education, support and guidance is also really important. It’s not uncommon for people to come in who’ve had a concussion — their first concussion — and be terrified that they’re going to get chronic traumatic encephalopathy or things along those lines. What we noticed is that increased anxiety and fear really increases the symptoms and prolongs the symptoms. The sooner that people can be told about the fact that 80% to 90% of them are going to get better within a couple of weeks, and that it’s okay to have these symptoms. That 70% plus are going to have headaches and 70% plus are going to have sleep issues — this is all normal, and the body typically recovers as well. If you can decrease that stress, that anxiety, people often have less symptoms and get better quicker.

This is a big thing that has changed over the course of the last decade of my work in the area. When I was initially practicing the focus — and some people called it cocoon therapy, where you put somebody into a dark room and lock them away after a concussion and wait for their symptoms to go away. So, you’d see all these teenagers who weren’t allowed to have phones and weren’t allowed to go to school and weren’t allowed to go to sports. They would just be in a dark room for days or weeks or months at a time. And the symptoms generally, over time, would go away, but what often developed was depression and anxiety and other things that you’d imagine from isolating these kids from their school and their friends and their sports and everything that they were used to. Over time, they actually realized that that was the case, as I was noticing in my practice, and the guidelines have changed. Now, rest is not recommended for any more than 48 hours. You’re really looking at no more than two days of rest. And really, the goal is to kind of get up and get moving as tolerated early on, as you would do with any other type of musculoskeletal injury. And you still, in the first couple of days, maybe you’re not going to be texting and doing TV and video games and things like that.

But then you’re going to really start to follow that return-to-learn protocol very, very quickly and really get people back into reading and into the school setting, even if they’re continuing to have symptoms. You may not get them back to exercise and sports right away — or intensive exercise, I should say — but you want to get them back walking and moving and things like that.

And as I said, typically, people — 80% to 90% — they’re going to get back in a week or two. So, you’re really only looking at a small percentage who, after a little rest and a little return on a lighter scale, aren’t going to be doing better. The ones who have the prolonged symptoms — you really need to make sure that they’re still able to engage in life as tolerated.

Sleep I find to be extremely important in pretty much all areas of life, but in concussion, it gets all messed up. And oftentimes, the picture that I see are people who never had sleep problems before. They have a concussion; all of a sudden, they sleep for multiple days in a row. Lots of sleep, which is totally fine, but then their sleep schedule gets messed up. And obviously, this occurs more if you put people on rest and they don’t have to go to work or school or things like that. They don’t have any reason to get up and they don’t have a schedule of things to do. One of the first things that I do when I meet with somebody is really follow and track their sleep patterns, and then really focus on normal sleep hygiene, as well as different techniques to help them sleep. Maybe even getting into cognitive behavioral therapy — insomnia, if need be — to really work on getting their sleep structured. Because if they can get a good, clean sleep during the night and be awake during the day and not be taking naps, oftentimes, that’s going to lead to improvement in all areas of post-concussive syndrome.

As I said previously, anxiety can often be a factor that leads to these prolonged symptoms. If anxiety is a factor, I’ve often used analyzing, relaxation strategies, deep breathing, progressive muscle relaxation, visualization, meditation — all of these things help to decrease the post-concussive syndrome and improve brain recovery. 

More and more, we’re seeing that there are visual and balance issues that frequently occur post-concussion. Sometimes, people are really good at picking those up, and sometimes, not so much. And as I said, it could be as simple as kids are getting headaches because they’re trying to look at a board and then write down their notes or things along those lines. Vestibular functioning can be abnormal in 90% of youth following a concussion. Getting to a vestibular physical therapist who understands post-concussion and is able to do a comprehensive evaluation and then work on appropriate treatment to get the vestibular system back into place can be extremely beneficial for a lot of the difficulties in a lot of the physical symptoms. So, you can be getting nauseous or dizzy, not because necessarily it has to do with your brain in respect to it being hit; it has to do with your eyes and the way in which they’re not tracking the world appropriately.

Now, physical therapy in a non-vestibular way is often beneficial because a lot of folks get deconditioned as they’re resting following a head injury. If you look at the New Jersey law, you’re not going to be able to get back to sports for at least two weeks. People who are high-intensity athletes often will get deconditioned over that period of time. And then, as you’re getting back into sports, you’re starting to get symptoms that you never had before because you were in good shape. And now, you’re starting to get your heart racing or you’re getting headaches, or you’re getting nauseous because you’re out of shape, and people contribute those to concussion when actually, it’s just getting back into shape. So, getting to a good physical therapist who can help to associate, “This is normal. This is healthy. We’re going to start off on the bike and move our way to the treadmill, and then we’re going to start doing some more sports-specific things. We’re going to track your heart rate.” That can help people confidently get back to the physical activity they were doing before their concussion.

As I was mentioning before, upwards of 70% of people can have an ADHD-like picture following concussion, where memory, focus and attention becomes an issue. Cognitive rehabilitation has ways in which they’re able to assess for and then help people learn different approaches to addressing these cognitive deficits that they have. In addition, oftentimes, occupational therapists can be used more times for the more moderate or severe head injuries, but also for the more mild ones, and they can help to evaluate gross and fine motor deficits. Are you having difficulty with writing? Are you having difficulty with being able to tie your shoes or zip your coat or things along those? And then figure out ways to address that and teach activities of daily living strategies to help with those things.

Speech therapy doesn’t only deal with speech, but also deals with strategies to help with attention, concentration, study skills and organization. Sometimes, you see folks who never had difficulties before and can benefit from learning. Sometimes, they had them before and then they got worse and it kind of pushed them over a threshold, and now they’re struggling more academically than they ever were before. Getting to a speech therapist or academic support can really help people get on track.

Psychotherapy, which is one of the big things that I do, has been shown to be effective post-concussion in post-concussive syndrome, and I would agree with this. Basically, there’s a lot of, as I said, depression, anxiety and also just kind of automatic negative thoughts and other things that people come up with that aren’t necessarily true — cognitive distortions that come into play. And sitting down and kind of working through what’s going on and what people believe about their injury and what they believe about their recovery can often lead to improvement.

The other thing that cognitive behavioral therapy is good for are headaches and migraines. And this is just showing a couple of studies. I know that, oftentimes, when people go to the doctor, they’re put on medications for headaches. But this demonstrates that in children, adolescents with recurrent headaches and migraines — again, a very common post-concussive symptom — you can get significant improvement just by doing cognitive behavioral therapy with these kids and helping them understand their headaches and what might trigger their headaches and what might make them better and what pain means to them can all be extremely beneficial. And not using any type of medication to treat the headaches.

When you’re working with kids, you can’t forget about their families. If you think about it, a lot of the folks that are having these head injuries, as we talked about, are in their 15- to 19-year-old years when they’re separating from their parents, and they’re starting to get their driver’s permits and driver’s license and go off and do their own things. And oftentimes, a head injury really changes that because now, all of a sudden, they might be home more. They might not be able to drive for a little bit. They can’t play sports. That can really mess up the dynamic and the independence that a lot of these kids have had. And oftentimes, working with the family on thinking about how the prolonged symptoms of post-concussion have affected them and ways to return to normalcy and independence can be extremely beneficial in the healing process of post-concussive syndrome.

Finally, being a physician and prescribing medications, I want to talk about medications and the use of a post-concussion. First, there’s no medications that are FDA-approved to treat anything — neuropsychiatric consequences of traumatic brain injury. Almost all of the literature is on adults, and if you look at it and look around the country, there’s a ton of different medications that have been used with variable success.

The approach that I’d recommend and what’s really been shown to, I think, make the most sense is understanding that the brain may be more fragile following a head injury. So, you really want to not use medication if you don’t have to. You want to really wait for those symptoms to go away. And then if you need to initiate any medication, you really want to start with very low doses of medication and only increase slowly, as tolerated, watching out for anything that could be a side effect or people getting worse. A big thing that I see in my practice is people not discontinuing medications that don’t work, so people add medications on top of medications, and that’s not good in any type of psychiatry — but definitely not in head injury. You want to watch out for seizure threshold, although I’ve never seen a seizure in a concussion, and you definitely want to watch out for side effects, especially the anticholinergic side effects. And that is actually common with over-the-counter medication. 

Typically, people would take things like a ZzzQuil or Benadryl to go to sleep at night, and those have significant anticholinergic side effects. What that does is, other than make you tired, it can make you groggy in the morning. It can also lead to cognitive difficulties, so you can have difficulties with memory and attention and concentration associated with these medications. You have been listening to the talk that that happens with concussion too. All of a sudden, you’re not sleeping well, and you’re feeling like you’re having memory problems and you start to take Benadryl every night or ZzzQuil every night and you start sleeping better and you get even more cloudy. And the reason that that’s happening is not because your concussion is getting worse, but it’s because you’re taking ZzzQuil every night. As I said, mixing drugs — not a good idea — so you really want to limit any type of drug interactions in anybody.

Just to summarize, and then we can open it up to questions for the last couple of minutes if there are any. Again, there’s over a million concussions each year in the United States, and many are going undiagnosed, although that’s fewer now with all the education that’s out there. Most youth are going to recover within two to four weeks, and it’s really only 10% to 20% that are going to go on to have any type of chronic problems or post-concussive syndrome. And really, only about 2% are going to have any symptoms beyond a year. Treatment is going to require a multidisciplinary approach, and I highly recommend if you’re a treatment provider or a family member or someone who’s had a concussion, get a good multidisciplinary team together and really address this, not just with one doctor or one therapist. Really work as a team, and we’re able to really get even some of the most challenging long-term cases better with that model. Again, thank you so much for coming out today. If you guys have any questions, please feel free to put them up in the chat box.

Thank you for watching this video. We hope you enjoyed the presentation.

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