Social and Emotional
Aspects of Concussion:
It’s Not Just About The
Game
Dr. Fred Klingbeil, MD
Hannah Jepson, ARNP, PNP
Ashley Jobe, OTR/L
Laura Van Dusseldorp, PT, DPT, CBIS
Allison Fayard, MA, CCC-SLP
Presentation Objectives
• Define concussion
• Discuss a timeline for emergence of symptoms and
commonly seen symptoms in the physical, social, and
emotional arenas
• Identify what symptoms to look for or monitor during
acute phase (<72 hours)
• Overview of step wise return to play/academics
addressing all areas of development
• Impact of concussion on academics and possible
accommodations
2
Concussion
Concussion is a
traumatic brain
injury!
The pathophysiological definition of a concussion is:
“A complex process that affects the brain, which is induced
by traumatic biomechanical forces, that includes major
features such as the sodium and potassium pump
imbalance.”
3
Pathophysiology
• Forces: May be caused by
direct or indirect forces
resulting in coup-contre-coup
injuries
• Consciousness: Loss of
consciousness may or may not
occur
• Pathophysiology: Symptoms
typically reflect a functional
disturbance (not structural
injury) of the brain
• Imaging: Forces causing a
concussion are not typically
seen with a CT scan
4
Complicating Factors
Factors that may complicate the recognition of
concussions
– Athlete may not recognize he/she has concussive
signs and symptoms
– Symptoms may not appear until several hours or
even days after concussive episode
– Athlete may not be forthcoming he/she is
experiencing concussive symptoms
– Loss of consciousness may not occur
5
Incidence
ESTIMATED
AVERAGE ANNUAL
NUMBER OF TBI IN
THE UNITED STATES
2002–20061
52,000
Deaths
275,000
Hospitalizations
1,365,000
Emergency Departments Visits
???
Receiving other medical care or no care*
6
Incidence
7
Iowa Law 280.13C
• Iowa Law regarding concussion management pertains to high
school sports only
• All schools must distribute concussion information to athletes and
parents prior to any participation
• All coaches, officials, athletes, parents, health care providers must
receive education about concussions
– IHSAA and IGHSAU websites include materials
• High school student athletes must be immediately removed from
play if exhibiting concussion symptoms
– Cannot return until “evaluated and cleared to play by a licensed health
care provider trained in the evaluation and management in concussions
and other brain injuries”
– If suspected concussion, child should not return
to competition/practice that day
8
Rates in High School Sports
SPORT
INJURY RATE/
1000 ATHLETE EXPOSURES
Football
0.47-1.03
Girls’ Soccer
0.36
Boys’ Lacrosse
0.28 – 0.34
Boys’ Soccer
0.22
Girls’ Basketball
0.21
Wrestling
0.18
Girls’ Lacrosse
0.10 – 0.21
Softball
0.07
Boys’ Basketball
0.07
Boys’ & Girls’ Volleyball
0.05
Baseball
0.05
9
Age Implications
Studies have shown that younger children:
– May have a more prolonged recovery
– More susceptible to a second concussion
– Less likely to be removed from activity
– Less likely to seek follow-up care
– More likely to continue to play
10
Clinical Features
Signs and Symptoms
PHYSICAL
COGNITIVE
EMOTIONAL
SLEEP
Headache
Feeling Mentally Foggy
Irritability
Drowsiness
Nausea
Feeling Slowed Down
Sadness
Vomiting
Difficulty Concentrating
More Emotional
Sleeping More
than Usual
Balance Problems
Difficulty Remembering
Nervousness
Visual Problems
Forgetful of Information
Fatigue
Confused About Events
Sensitivity to Light
Answering Questions Slowly
Sensitivity to Noise
Repeating Questions
Sleeping Less
than Usual
Difficulty
Falling Asleep
Dazed
Stunned
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Systematic Management
1. At time of injury
Remove from activity
Emergency Department
2. Post-injury management
Rest
Symptom management
Primary Care Provider
Referral to concussion specialist
3. Team approach
Communication
Graduated Return to Learn
Graduated Return to Activity/Play
12
Indications for Urgent Care/ED
•
•
•
•
•
•
•
•
Unusual behavior
Repeat vomiting
Severe or progressive worsening headache
Seizure activity
Unsteady gait or slurred speech
Weakness or numbness in extremities
Signs of basilar skull fracture
Altered mental status resulting in
GCS < 15
13
Team Collaboration
Health Care
Provider
Psychology
PT/OT/SLP
Special
Education
Specialty
Medical
Teacher
Individual
with
Concussion
School
Counselor
Coach
School
Nurse
Athletic
trainer
Athletic
Director
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ChildServe Clinic
Physician
Physician
Services
Services
Therapy Services
Multidisciplinary
Education
Team
Community
Community
Return-toacademics
Education
Education
Return-toplay/activity
Prevention
Prevention
Vestibular Ocular
Physical Exam
Ocular motor
Neuro Exam
Balance and
Coordination
SCAT 3
ImPACT
Physical
Conditioning
Cognitive
Accommodations
Education
Collaboration
Collaboration
Accommodations
Support
Support
15
Social Emotional Effects
Early identification and treatment of
negative emotional responses is critical
as it can dramatically improve outcomes,
decrease recovery time, and prevent
development of more severe
psychological responses.
16
Social Emotional Effects
Physical
Symptoms
Limitations in
Impaired
Physical
Cognitive
Activities
and Athletics
Difficulty
with Daily
Function
and
Routines
Functioning
Social/
Emotional
Poor
Academic
Performance
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Behavioral Effects
•
•
•
•
•
•
•
More irritable
Easily frustrated
Increased anxiety
New onset or worsening depression
Sleep changes
Increased defiant behaviors and outbursts
Overall feeling of ‘sadness’ that can’t be
described
• Difficulty completing daily routines
18
Academic Effects
• Decreased academic performance
• Having to ask for more help or have
special accommodations that single
individual out
• Forgetting to complete homework
• Difficulty with new tasks and instructions
• Avoidance of difficult classwork due to fear
of symptoms worsening
19
Academic Effects
• Needing to go to the nurse more frequently
due to increased symptoms or needing a
break from too much stimulation
• Difficulty remembering and concentrating
• Symptoms can easily be exacerbated by
increased sensory input in their environment
• Modifications at school are key to allow
individuals to return to academics but not
become overwhelmed
20
Social Effects
• Decreased interest in once enjoyed activities
• Not wanting to hang out with friends due to
inability to process sensory stimulus in their
environment
• Others may think you are acting “differently”
• Fear of losing friends
• Isolation due to being told “not” to do this,
that, and the other
21
Social Effects
• No longer feel that they are an active and
contributing member of their team
• Not able to participate in the “big game” or
other sports
• Fear of challenging self due to possibility of
symptoms worsening
• Modifications are key to allow the individual
to return to their sport or other activity without
exacerbation of symptoms
22
Now What?
Important to limit stimulation and
stress during return to academics
and activity while allowing for
regular, healthy interactions as
isolation can lead to worsening of
symptoms.
23
Return--toReturn
to-Academics
The objective of return-to-academics is
to provide the child, family, school, and
teachers with progressive academic
guidance and recommendations.
24
Return--toReturn
to-Academics
25
General School Accommodations
• Abbreviated class day schedule (every other
day, shortened day)
• No physical education class/modified
physical education class
• Modified recess
• Consider reducing make-up work to critical
work only
• No testing (e.g. midterms, finals,
standardized) during recovery period
26
Academic Accommodations
• Provide extended time to complete assignments
and/or shortened assignments
• Provide extended time to take tests
• Provide a quiet environment to take tests
• Provide written instructions for homework
• Provide class notes by teacher or peer
• Allow use of notes for test taking due to memory
challenges
• Consider using a tape recorder for note taking
27
Physical Accommodations
• Allow time to visit school nurse for treatment of
headaches or other symptoms
• Allow rest breaks during the day, if needed
• Allow hall passing time before or after the crowds have
cleared
• Allow student to wear sunglasses indoors to control for
light sensitivity
• Allow student to wear ear plugs, ear buds, or
headphones indoors to control for sound sensitivity
• Allow student to take lunch in quiet space to allow for
rest and control for noise sensitivity
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Emotional Accommodations
– Daily check-ins with the student are
recommended
– Share progress and difficulties with parents,
school nurse, counselor, medical provider, or
athletic trainer
– Develop an emotional support plan for the
student, which may include an adult with
whom the student can talk to if feeling
overwhelmed
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Behavioral Accommodations
• Address Sleep Changes
–
–
–
–
Avoid caffeine late in day
Limit long naps
Develop nightly routine
Limit screen time before bed
• New onset or worsening depression:
– Standardized depression screening PHQ-9 Modified
for Teens
– Initiation of low dose SSRI
– Referral for psychiatric evaluation.
30
Return--toReturn
to-Play/Activity
The objective of return-to-play is to
provide the child, family, school,
and coaches with progressive
activity guidance and
recommendations.
31
Return--toReturn
to-Play/Activity
32
Social Emotional Management
• Building trust and rapport with the individual
• Listening
– Do not discount social emotional symptoms
• Educating about the injury
– The symptoms they are experiencing are normal after a brain injury
• Identifying misinformation about the injury
– False information from community about what they should or should not
be experiencing
• Preparing the athlete and coach about the recovery process
– Knowing the characteristics of the injury
– Help to avoid isolation from the team
• Encourage use of coping skills
– Goal setting, stress management, deep breathing
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Indications for Mental Health Referral
•
•
•
•
Positive findings on depression screening
Substance abuse
Continuation of symptoms beyond what is expected
Disengagement with activities and people that were
previously enjoyed
• Excessive anger or rage
• Frequent crying or emotional outbursts
• Feeling of harming self or others
34
Post--Concussion Syndrome
Post
3-month duration or more of concussion related
symptoms:
•
•
•
•
Headaches
Dizziness
Fatigue
Personality changes
– Irritability/aggression
•
•
•
•
Anxiety
Difficulty sleeping
Loss of concentration and memory
Noise and light sensitivity
35
Post-Concussion Syndrome
Causes
– Symptoms are caused by damage to the brain or disruption of
neurotransmitter systems.
– Symptoms are related to psychological factors, especially since the
most common symptoms — headache, dizziness and sleep problems
— are similar to those often experienced by people diagnosed with
depression, anxiety or post-traumatic stress disorder.
Diagnosis
– No tests available
– Made by prolonged presence of symptoms and the affects on daily
functioning
Treatment
– Accommodation of functional deficits
– Long-term symptom management
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How many is too many?
• No evidenced-based guidelines
• Each situation needs to be evaluated on an
individual basis
• Factors to consider:
–
–
–
–
–
–
Second Impact Syndrome
Multiple lifetime concussions
Structural abnormality on imaging
Persistent decreased academic or workplace performance
History of prolonged recovery with past concussions
Post-concussive syndrome
37
Prevention
• Helmets do NOT prevent concussions
– Have been shown to prevent impact injuries
such as fractures
• Safe techniques
• Enforcement of rules
• Prevention of complications thru a stepwise return to academics/play guided by a
trained healthcare provider
• Education!
38
Review of Objectives
• Define concussion
• Discuss a timeline for emergence of symptoms and
commonly seen symptoms in the physical, social, and
emotional arenas
• Identify what symptoms to look for or monitor during
acute phase (<72 hours)
• Overview of step wise return to play/academics
addressing all areas of development
• Impact of concussion on academics and possible
accommodations
39
References
•
•
•
•
•
Burns, T., Ono, K.E. Impact Research Report: Sex Based Differences as a
Predictor of Recovery Trajectories Using ImPACT. Volume 3 (2015).
Centers for Disease Control and Prevention (CDC), National Center for
Injury Prevention and Control. Report to Congress on mild traumatic brain
injury in the United States: steps to prevent a serious public health problem.
Atlanta (GA): Centers for Disease Control and Prevention; 2003.
Centers for Disease Control and Prevention. Nonfatal Traumatic Brain
Injuries Related to Sports and Recreation Activities Among Persons Aged
≤19 Years — United States, 2001–2009. MMWR 2011; 60(39):1337–1342.
Comstock, D. R., Currie, D. H., Pierpoint, L., Grubenhoff, J., Fields, S. K.,
(AMAP ediatr. doi:10.1001/jamapediatrics.2015.1062.
Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United
States: emergency department visits, hospitalizations, and deaths. Atlanta
(GA): Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control; 2010.
40
References continued
•
•
•
•
•
•
•
•
Halstead, M., Walter, K., The Council on Sports Medicine and Fitness.
Sport-related concussion in children and adolescents. Pediatrics.126(3).
September 2010. p. 597-615.
Harmon, KG et al. (2012). American Medical Society for Sports Medicine
position statement: concussion in sport. Br J Sports Med 2013;47:1 15-26
doi:10.1136/bjsports-2012-091941.
Herring et al. (2008). Orthopaedic Society for Sports Medicine concensus
statement: Psychological Issues Related to Injury in Athletes and the Team
Physician. American Orthopaedic Society for Sports Medicine.
Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. Journal
of Athletic Training. 2001;36(3):228-235.
Meehan III, William P., Medical Therapies for Concussion. Clinical Sports
Medicine.30. (2011). 115-124.
http://www.cdc.gov/traumaticbraininjury/get_the_facts.html
http://www.brainandspinalcord.org/traumatic-brain-injury-types/secondimpact-syndrome/index.html
http://www.mayoclinic.org/diseases-conditions/post-concussion41
syndrome/basics/prevention/con-20032705
Research article references
• http://www.ncaa.org/health-and-safety/medicalconditions/psychological-aspects-sports-concussion
• http://bjsm.bmj.com/content/38/5/519.full
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