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PCS Post-concussion syndrome

A concussion usually occurs without complications and lasts no more than a few days or a few weeks. In some cases, however, the concussion symptoms are still there after months and years. If symptoms persist longer than three months, it is usually no longer referred to as a concussion, but post-concussion syndrome. (See footnote 1 and wikipedia)

 

Different definitions

Worldwide different definitions of concussions and the post-concussion syndrome are used in scientific research. There is therefore no universal definition and this creates ambiguity. (See footnote 2)

 

Psychic or Physical?

There is still a lot of discussion about the cause of the persistent persistence of complaints after a concussion. Research has been done and is still done in various scientific studies.

 

Microhemorrhages

In case of a mild traumatic brain injury, for example a concussion, micro-hemorrhages can occur and, as a result, interconnections between brain cells are broken. This can cause neurotransmitters to be released and brain cells to die down. The mutual signals can no longer be transmitted.

The tearing of the brain cells at a microscopic level is also called 'axonal shearing injury'. Or 'diffuse axonal injury'. Diffuse means: spread without sharp boundary. This is also called axonal damage. An axon is a spur of a brain cell spur 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). Also a Canadian study shows after years still a changed brain wave activity that explained the concentration problems.

 

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.

Certainly if there is nothing to see on MRI or CT scan, a person may be inclined to keep going and keep going while something is really 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 is therefore a comprehensive concept. 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, usually a multidisciplinary treatment approach is performed within rehabilitation centers that specialize in (light) traumatic brain injury. Usually the rehabilitation team consists of an occupational therapist, a psychologist and a rehabilitation doctor. This team is, depending on the complaints, supplemented with the necessary therapy, for example physiotherapy, sensory integration therapy, etc.

 

Recover by rest

Because the doctors from three months only speak of post-commotional syndrome, it will usually be advised that rest is sufficient for the recovery of a concussion. It is assumed that if there is no medically demonstrable damage on the MRI scan, that there is a problem with the 'software' of the brain and not with the 'hardware' and this temporary disturbance can be solved by rest.

 

Difference male / female

A special study (in Dutch) that was published in 2014 investigated  the menstrual cycle of women and how this could influence the recovery after mildly traumatic brain injury. Women who have a concussion in the two weeks before their menstruation recover more slowly and have a worse health for a month than women at a different stage of their cycle or women who use the pill. (See footnote 7)

 

Sport

In recent years, in the United States there has been a lot to do around top athletes who have suffered a concussion. Some scientists call it 'the silent epidemic', because there is a lot of discussion about the consequences of one (or even multiple) concussion (s) in the longer term. (See footnote 8)

 

Multiple concussion syndrome

A sport like boxing in which the athlete gets too many repeated (lighter) hits may be harmful. It has been investigated that up to 10 days after a concussion there is a greater chance of a second injury that can turn out to be serious. Especially the National Football League (NFL) in the United States is thus often in the news because the athletes in this contact sport very often suffer a 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 gradual death of the brain cells / brain. It is still being investigated whether there is a link between multiple concussions and diseases such as ALS. In 2015, a film was published about this, called 'Concussion' with Will Smith in the main role.
Read more on our page about CTE.

 

Topsport versus amateursport

American Football is not the only sport in which athletes incur concussions. This also occurs in football, rugby, ice hockey, hockey, boxing, etc. Moreover this is the case not only in top sport but also in amateur sport.

Unfortunately, this information about the possible dangers of concussions in sports has barely penetrated 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 fall of a bicycle, horse or pony (29%), then a collision between two athletes (28%) and a third 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 damage. Up to now, it is assumed that up to 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 consequences of a concussion.

 

Conferences on Concussion in Sport

In Vienna, the first Conference on concussions in sport took place in 2000. A new definition for a sport-related concussion has been developed here.

On 27-28 October 2016, the fifth International Consensus Conference on Concussion in Sport was held in Berlin. The scientific committee expected to publish the latest knowledge in May 2017.

 

Trailer of Concussion in sports movie

See here the trailer of the documentary 'Headgames: The Global Concussion Crisis' which illustrates the consequences of concussions in sport and why people are so worried about the consequences. Another trailer can be found here.

 

PCS in children

In case of an accident in infants, it can be difficult to establish whether brain damage has occurred. Unconsciousness 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.

Signs of acquired dizziness complaints may be that the child is more crying with certain movements or with a certain position of the head. This can disappear after a few weeks of rest (physical and mental).

 

As long as a child remains symptom-free, the physical effort can 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, because that is still appropriate for the age.

If symptoms worsen, it is advisable to consult a doctor. If problems occur during the further school period, it is also 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