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PCS Post-concussion syndrome

A concussion usually occurs without complications lasting no more than a few days or a few weeks. In some cases however, the concussion symptoms persist for months or years. If symptoms persist longer than three months, it is usually no longer referred to as a concussion, but rather Post-Concussion Syndrome. (See footnote 1 and wikipedia)

 

Different definitions

Worldwide, scientific researchers work with different definitions of concussion and post-concussion syndrome. As a result there is no universal definition, creating ambiguity. (See footnote 2)

 

Psychic or Physical?

There is still plenty of discussion about the reason for the persistence of complaints after a concussion. Research is being done and continues to be pursued in various scientific studies.

 

Microhemorrhages

With mild traumatic brain injury (mTBI) or concussion, micro-hemorrhages can occur. As a result, interconnections between brain cells are severed. This can cause neurotransmitters to be disconnected causing brain cells to die off. The signals can no longer be transmitted.
The tearing of the brain cells at a microscopic level is also called 'axonal shearing injury', or 'diffused axonal injury'. Diffused meaning extended without sharp boundary. This is also called axonal damage. An axon is the spur of a brain cell that transmits signals and communicates with other brain cells.

 

Disorder in blood flow

In a study in the Unites States, a disturbance in blood circulation in the brain was observed in 53% of people with long-term post-concussion syndrome (PCS). A Canadian study linked the change in brainwave activity to problems with concentration years later.

 

Brain scans

An autopsy shows that people with PCS have damage to the white matter of their brains. (See footnote 3)

A DTI scan (Diffusion Tensor Imaging) is a recent development in which the white matter can also be scanned. In the Netherlands, the DTI scan is not yet used for clinical purposes, but for the moment only for research. In a study about a comparison between MRI and CT scan showed that the SPECT scan showed more deviations in this area.

 

Biomarkers

A biomarker (calpain-cleaved αII-spectrin N-terminal fragment (SNTF)) in blood predicts the risk of white matter abnormalities and cognitive complaints after mild traumatic brain injury. See study here.

 

Neuropsychological Examination

A neuropsychological investigation can also reveal 'hidden cognitive damage'.

If a person has a lot of complaints and is diagnosed with the term 'light' or 'mild' brain injury, it is advisable to inquire about the possibility of having a neuropsychological examination.

If the MRI or CT scan fails to reveal any damage, a person may be inclined to carry on without knowing something is definitely wrong.

 

Complaints and symptoms

According to some definitions, there is a post-concussion Syndrome if at least three of the following symptoms occur: headache, dizziness, fatigue, irritability, concentration and memory weakness, insomnia, hypersensitivity to sound and light. (See footnote 4)
The most common symptoms are divided into three categories: somatic (physical), cognitive and emotional symptoms.

 

Physical Cognitive Emotional
Headache (migraine) Concentration problems Irritability
Vertigo Attention problems Emotional, fast in tears
Nausea Learning problems Sad
Abnormal fatigue Slower response capability Fear
Sound hypersensitivity Memory problems Decreased sex drive
Hypersensitivity to light (photophobia) Tired faster Personality changes
Visual disturbances, for example double vision Not aware of time, place, date Reduced frustration tolerance
Sleeping problems Confusion, absence
Tone / ringing in the ears (tinnitus) Period of memory loss
Speech problems
Balance problems
See stars, see black, see flashes of light

Cognitive disorders

Cognitive disorders are related to cognition: thinking, language, memory, concentration, acquiring and processing knowledge, perception, awareness and attention. A cognitive disorder therefore has wide ranging implications. Difficulties with memory, concentration and thinking speed are the most common. Cognitive disorders can be measured with a Neuro Psychological Examination

 

Treatment

For patients with Post-Concussion Syndrome the usual approach is a multidisciplinary treatment performed at a rehabilitation center that specializes in mild traumatic brain injury. Usually the rehabilitation team consists of an occupational therapist, a psychologist and a rehabilitation doctor. Depending on the challenges the patient presents, the treatment plan is supplemented with the necessary therapy, such as physiotherapy, sensory integration therapy, etc.

 

Recover by rest

Doctors only speak of Post-Concussion Syndrome after three months. Rest is usually advised as being sufficient for recovery from a concussion. It is assumed that if the MRI scan shows no medically demonstrable damage then there is a problem with the 'software' of the brain and not the 'hardware'. That’s why it is treated as a temporary disruption that can be remediated with rest.

 

Difference male / female

A Dutch study, published in 2014, investigated the menstrual cycle of women and how it could impact the recovery after a mild traumatic brain injury (mTBI). Women who have a concussion in the two weeks prior to their menstruation recover more slowly and experience poorer health a month longer than women at a different stage of their menstrual cycle or women who use the pill. (See footnote 7)

 

Sport

In recent years, in the United States, there has been an increased focus on elite athletes who have suffered a concussion. Some scientists call it 'the silent epidemic'. There is a lot of discussion about the consequences of one or even multiple concussions over the long term. (See footnote 8)

 

Multiple concussion syndrome

A sport like boxing in which the athlete receives many repeated minor hits may be harmful. Investigations have shown that up to 10 days after a concussion there is a greater risk of a second concussion having a more serious outcome. In particular the National Football League (NFL) in the United States is often in the news because athletes in this sport, being a contact sport experience repeated concussion.

 

CTE = Chronic Traumatic Encephalopathy

Autopsy performed on former NFL players showed that in several former players the brain was severely damaged. This is called CTE (chronic traumatic encephalopathy), ie the gradual death of the brain cells / brain. Investigations are ongoing to determine whether there is a link between multiple concussions and diseases such as ALS. In 2015, a film called ‘Concussion’ was released with Will Smith in the main role.
Read more on our page about CTE.

 

Elite sport versus amateur sport

American Football is not the only sport in which athletes experience concussions. This also occurs in soccer, rugby, ice hockey, boxing, etc. This isn’t limited to professional sports. It also happens in amateur sports.
Unfortunately, information concerning the possible dangers of concussions in sports has received minimal coverage in other countries. For example, in the Netherlands there are about 76,000 accidents a year in which athletes suffer head injuries. The main cause is the falling off a bicycle, horse or pony (29%), a collision between two athletes (28%) and contact with a ball or hockey stick (20%).
(See footnote 9)

 

Headers in soccer

At the moment (in 2018), in soccer there is a discussion about how dangerous headers are for the brain. From scientific research there are no indications that headers lead to brain damage. Till now, it is assumed that a certain number of headers (1800 times per year) is unlikely to be a noticeable risk. (See footnote 9)

 

There is still a lot of debate about the long-term effects of concussions. The consequences are difficult to prove. The conclusion remains that after head injury rest is necessary and that there are individual differences in the after effects of a concussion.

 

Conferences on Concussion in Sport

The first Conference on concussions in sport took place in Vienna in 2000. A new definition for a sport-related concussion was developed.
On October 27-28, 2016, the fifth International Consensus Conference on Concussion in Sport was held in Berlin. The scientific committee is expected to publish the latest findings in May 2017.

 

Movie trailer about Concussion in sports

Check here to watch the trailer of the documentary 'Headgames: The Global Concussion Crisis'. The documentary illustrates the consequences of concussions in sports and why people are so concerned  about the consequences. Another trailer can be found here.

 

PCS in children

In accidents involving infants it can be difficult to establish whether brain damage has occurred. Loss of consciousness is a clear signal, but other symptoms can also occur, such as crying, being inconsolable, not being consoled, vomiting or excessive drowsiness. Refusing to eat, prolonged irritability, or uncommon or prolonged periods of rest or inactivity may also show signs of concussion or more severe brain injury. In addition, an important signal is the bulging of the fontanelle, the soft spot on the head.

 

Usually there is a temporary loss of skills, but afterwards the child will acquire other skills. The child can be pickier with food or get a different sleeping pattern.

Crying can suggest dizziness if the child cries more with certain movements or when their head is held in a certain position. This response can disappear after a few weeks of rest (physical and mental rest).

 

As long as a child remains symptom-free, the physical effort may be increased.

In children under the age of six it is difficult to estimate whether a short attention span or short-term memory is affected. Having a short attention span is not inappropriate for that age.

If symptoms worsen, it is advisable to consult a doctor. If problems surface later during their schooling it is advisable to consult a neuropsychologist. See our page on brain injury in children.

 

 

 

Footnotes

1_. McHugh T, Laforce R, Gallagher P, Quinn S, Diggle P, Buchanan L (2006). "Natural history of the long-term cognitive, affective, and physical sequelae of a minor traumatic brain injury". Brain and Cognition. 60 (2): 209–11. doi:10.1016/j.bandc.2004.09.018. PMID 16646125.

2_. https://www.ncbi.nlm.nih.gov/pubmed/26918481

3._ https://americannursetoday.com/post-concussive-syndrome-what-patients-and-providers-need-to-know/

4._ Legome E. 2006. Postconcussive syndrome. eMedicine.com. Accessed January 1, 2007.

5.http://www.tijdschriftvoorpsychiatrie.nl/assets/articles/articles_2745pdf.pdf

6 ._https://www.ncbi.nlm.nih.gov/pubmed/24220566

7._http://www.nu.nl/gezondheid/3628576/menstruatiecyclus-heeft-invloed-hersenschudding.html

8. Whitepaper Dr. Jacques H.A. van Rossum

9. Schiphof-Godart, L.(29-3-2016)Sport en hersenletsel, presentatie symposium Sportgericht

10. http://www.brainline.org/content/2010/08/what-does-post-concussive-syndrome-look-like-in-children.html