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Post-Concussive Syndrome

Post-Concussive Syndrome
Erin O. Mattingly, MA, CCC-SLP, CBIS
August 2, 2022

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Editor’s Note: This text is a transcript of the course, Post-Concussive Syndrome, presented by Erin Mattingly, MA, CCC-SLP, CBIS.

Learning Outcomes

After this course, participants will be able to:

  • Identify common symptoms of post-concussion syndrome
  • Describe the challenges between differential diagnosis of post-concussion syndrome, mental health diagnoses, and other physical diagnoses
  • Identify predictors of post-concussion syndrome

Mild TBI/Concussion (ACRM Definition)

I want to start with a review of the definition of mild traumatic brain injury that comes from the American Congress of Rehabilitation Medicine (ACRM). A patient with a mild TBI has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following, any period of loss of consciousness, any loss of memory for events immediately before or after the accident or injury, any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, confused) and focal neurological deficits that may or may not be transient, but where the severity of the injury does not exceed the following:

  • Loss of consciousness of approximately 30 minutes or less
  • After 30 minutes, an initial Glasgow Coma Scale of 13 to 15
  • Post traumatic amnesia, not greater than 24 hours.

That's quite the definition, but those last three points are the most helpful. It's also worth noting, in general, that there are 2.5 million cases of traumatic brain injury reported annually in the US. However, this number may not be accurate given that many cases of acute concussion in particular often go unreported.  For example, they may happen on the sports field and maybe the child or the adult doesn't feel the symptoms or the symptoms aren’t severe enough so they don't go to the hospital. Those types of cases are then not tracked.

Etiology of Mild Traumatic Brain Injury and Concussion

  • Falls - particularly in the elderly will have an increased risk
  • Vehicle accidents - includes bikes, cars, motor scooters 
  • Violence - domestic violence, gunshot wounds, Shaken Baby Syndrome, intimate partner violence
  • Sports injuries -  Everyone thinks of football when it comes to concussions due to the hard hits. But, soccer, lacrosse, any sport along those lines
  • Blast injuries - Service members and veterans, when deployed or in training, can experience a blast injury that can also cause a mild traumatic brain injury or concussion.

Overview of Concussion Symptoms

Symptoms of concussion include headache, fatigue, balance issues, vestibular issues, vision issues, nausea, and vomiting. Symptoms are divided into three areas.  Semantic symptoms are headaches, nausea, dizziness, and fatigue. Cognitive symptoms are the “mental fog” or feeling slow.  Emotional symptoms include feeling sadder than usual, nervous, and more emotional.

There are also memory difficulties, dizziness (with the balance piece), and visual changes such as blurry vision. Other cognitive symptoms include difficulty concentrating, and sensitivity to light and sound. A person might have emotional lability which is difficulty controlling emotions,  as well as insomnia, lack of coordination, and slowed response time.

In regard to sleep, initially, after concussion patients can be really sleepy and the guidance is to not let them sleep unsupervised for a while. But, over time, that sleep can actually change and lead to difficulty falling asleep or staying asleep.  It almost switches from needing too much sleep to less sleep.

Think, again, about a football player who sustains a concussion. We might see that this football player, who had a really big hit, is stumbling around, having problems catching his balance, and may be vomiting on the sideline. If we do a quick sideline assessment, we want to look at memory orientation, visual impairment, following the finger attention, and processing speed.

Treatment of Uncomplicated Concussion

Treatment will include physical and cognitive rest and progressive return to activity. We don't want the person to return too quickly, especially to sports or an activity that is more aerobic in nature because that can actually exacerbate symptoms. However, we also don't want to wait too long.

Education is critical. The person must be educated about the recovery trajectory and symptom management. I will talk more about how education is such an important part of preventing post-concussion syndrome and validating symptoms later.  It prevents misattribution of symptoms and may prevent the persistence of the symptoms. For example, if I say, "Hey, you should be recovered within seven to 10 days,” the person understands that's the normal trajectory. Everything they’re feeling is right on target. I'm validating that they're having trouble with their memory or trouble sleeping. All of those things help to normalize the symptoms and not exaggerate them or make them seem worse than they are to the patient.

Most (85-90%) recover within seven to 10 days, post-injury, at least in the case of sports concussion. But symptoms can continue for months, years, or indefinitely. In non-sports-related concussions, they say that if any symptoms persist beyond three months, then that's considered post-concussion syndrome.

Post-Concussion Syndrome

Ten to twenty percent of individuals who sustain a mild traumatic brain injury will experience post-concussion syndrome which is persistent concussion symptoms that last weeks or months. This is tricky because there are a variety of definitions that I’ll discuss later, but you're basically using a differential diagnosis to determine what caused the symptoms. It's not a single pathophysiological entity. It's a constellation of a variety of symptoms - headache, sleep disturbance, fatigue, anxiety, depression, attention, and memory due to comorbidities. It’s not necessarily an organic brain injury. It’s the combination of symptoms that come from different causes.  Of course, the primary symptom is the initial hit to the head and the concussion. But there are other factors that can contribute to PCS.

As I mentioned, there's a lack of a consistent standardized definition of PCS. So, I gathered a few different definitions. One is from a combination of the DSM-5 and ICD10 which states that it is a history of head trauma that has caused concussion, evidence of poor performance on neuropsychological assessment of attention and memory, and three or more of the following symptoms occurring after head trauma and lasting at least three months:

  • mood changes
  • fatigue
  • difficulty sleeping
  • change in personality or apathy
  • significant decline in social or occupational functioning

Etiology

Both physiological and psychological factors have an influence on symptoms during the acute phase of recovery. The psychological factors contribute to more long-term symptoms of PCS. Again, it’s that constellation of symptoms and the psychological piece that play a big role.

It's worth noting that these persistent symptoms can lead to a feeling of loss for the patient; a loss of who they were previously and a loss of their function. It can also lead to depression, which can then lead to fatigue and a lack of motivation to engage.  It is definitely a cycle that we want to try to stop as early on as we can.

Overview of Symptoms

I have touched on these already, but as I review these symptoms keep in mind that none of them are unique to post-concussive syndrome. Somatosensory symptoms include headache, light sensitivity, visual disturbance, sleep disturbance, pain, fatigue, tinnitus, and dizziness. Emotional symptoms include anxiety, increased irritability, easily angered or frustrated, impulsiveness, low energy or motivation, and depression. On the cognitive side, there is poor concentration, easily distracted, memory deficits, slowed processing speed, problems with organization, difficulty with multitasking, and difficulty with decision making.

Again, it's important to focus on the depression piece and the emotional side of things. Because, as the previous function has changed, the person may mourn that loss and that can contribute to some of these other symptoms.

Differential Diagnosis

It’s not our job as SLPs to diagnose PCS,  but we do contribute as part of an interdisciplinary team to differentiate between depression, chronic fatigue, chronic pain, cervical injury, vestibular dysfunction, ocular or visual dysfunction, somatization, or a combination of these symptoms.

PCS mirrors all of these things, and these things can mirror the symptoms of post-concussive syndrome.  It's important to rule out premorbid conditions as well because a concussion can exaggerate premorbid conditions such as ADHD, depression, or other psychological health diagnoses. Concussion can also highlight some of these previous areas of deficit and make the symptoms worse. Therefore, it’s important to get a strong medical and behavioral health history, so that you're aware of any of these premorbid conditions.

Predictors of Post-Concussion Syndrome

Some predictors of post-concussion syndrome are pre-injury psychiatric and physical history, anxiety and trauma-related symptoms, PTSD, life stressors, financial relationship stress, and pain.  All of these are predictive of post-concussive symptoms.

Other predictors include mental health diagnoses or migraines. Additionally, premorbid and concurrent anxiety increases the risk for prolonged concussion recovery. Preexisting neurologic vulnerability (e.g., early birth complications, seizures, developmental delays, learning disabilities, and history of sleep pathology) are all predictors of post-concussion syndrome. Other factors that can be predictors include an early post-traumatic headache, fatigue or fogginess, amnesia or disorientation, the severity of the hit to the head, or multiple concussions.

Here are some interesting facts. Studies have found that female athletes remain symptomatic for longer periods of time when compared with male athletes, regardless of the sport played. Also, female concussed athletes may report a higher number of symptoms.  That being said, some studies showed that post-injuries symptom reporting may be impacted by the gender of the interviewer. If the interviewer is a female interviewer, they may elicit more symptom responses than a male interviewer. So, the symptom reporting by gender may be a bit skewed.

Other factors that can contribute to PCS include reduced support from teammates or family members. If the teammates or family members don't validate the symptoms, don't believe them, or say that they're faking, then that can actually contribute to PCS.

Financial implications can have an impact.  If the person is not able to return to work or has difficulty paying for treatment or care, then those can actually cause stress which could predict PCS.

Finally, litigation in the context of gain. For example, if a car accident resulted in a concussion, there may be financial gain from the lawsuit and that may result in PCS.

Treatment of PCS

There used to be a significant focus on rest. Rest, avoid screens, provide accommodations or adjustments to work, adjustments to school, and avoid further head trauma are all used to treat PCS, and are very important.

Rest. After that initial period of rest, the recommendations are focused on therapy.  It’s not just taking time off from work or school for a week and hoping to recover and rest that way, but actually having more of an active approach to treatment of PCS.

Screen Use. In regards to screen use, we have all had increased strain due to exposure to so much screen time, especially during the COVID pandemic.  If we think about the strain screen time has had on us and compare that to those who have had concussions, think about how much more difficult it might be to recover.

Education. I have talked a little bit about education for concussion and the course of recovery, but it is worth noting that education used in isolation does not have much efficacy. However, education in partnership with other modalities is extremely important and helpful.

Resilience. I will address resilience in greater detail later, but an interesting point about resilience is that it has been found that elite athletes tend to have more resilience probably because of their intense training. For that reason, they may actually be less susceptible to post-concussion syndrome because they have stronger resilience. When we think about teaching resilience, it could actually be preventative.

Mindfulness. Mindfulness and meditation can help the patient not focus on the symptoms as much and help them to focus on wellness instead. Those are very helpful practices.

Cognitive Treatment. We all know cognitive treatment well. I will go into more specifics about how we do this for this particular population. 

Biofeedback. This includes temperature biofeedback, sweating, and EMGs which provide sensitive, objective, physiologic data. For example, heart rate variability would be a type of biofeedback.  If you teach a patient to focus on reducing the rate of their breathing and having decreased heart rate variability, that’s a type of biofeedback that can help the patient relax. It can also help patients, again, to not be as symptom focused which ties back to that mindfulness piece.

Cognitive Behavioral Therapy (CBT).  This approach educates patients about maladaptive reactions to concussion symptoms. By talking about the normal symptoms after concussion, CBT can help prevent some of these distortions, overgeneralizations, and catastrophizing.  For example, after a concussion, a patient has normal difficulty paying attention or is very distracted. They may think that they can't pay attention ever and will never be able to return to work, return to school, or engage in a conversation. But we can provide education about what the reality of their situation is and that they can do these things. They may have to have some accommodations or think about things differently, but CBT helps to redirect some of those things.

Other Types of Treatment

I mentioned that previous treatment for concussion was really focused on rest, taking a break from things, avoiding screens, etc. However, in the past five to 10 years, we are moving more towards active therapies to address some of these issues. In particular, vision therapy (i.e., double vision/diplopia or blurry vision) trains the visual system to return to normal. There are vision exercises that can be performed by an ophthalmologist or a neuro-ophthalmologist. An OT can also sometimes do vision therapies. Vestibular therapy for balance is usually done by a physical therapist.  PTs can also help with headaches or neck pain. Often times when a person sustains a significant hit resulting in concussion, they may also sustain cervicogenic pain or neck pain. Being able to treat that is important.

A patient may also receive exertional therapy. This is getting a patient to exert themselves aerobically but in a safe and monitored environment. We don't want it to be in an aerobic situation where they might sustain an additional head injury. It could be something like swimming or walking on the treadmill.  An activity that is observed/ monitored in a safe environment can help because when a person exerts him or herself after a concussion, that can exacerbate symptoms mentioned earlier, and they will know to what level they can push themselves. Additionally, exercise has been shown to be a neuroprotective factor and can actually assist with fatigue and lethargic symptoms. Patients with PCS need to monitor if their symptoms are provoked, then they need to back down from that exercise. This also helps with getting people back to their routines, back into movement, and engaged again. 

Neuropsychology can help manage the psychological and cognitive symptoms while continuing to assess at various stages.  Assessing, for example, ear, nose, and throat for tinnitus, vertigo, or balance and occupational therapy for vision and occasional cognitive assistance.

To reiterate, prolonged rest and delayed return to activity may result in an increase in symptoms or heightened symptoms, particularly in athletes. They're used to working out all the time and playing sports activities. Removal from that activity may lead to depression and actual physical deconditioning. This goes back to that exertional therapy and how to get folks re-engaged? This is not just about sports; it actually applies to any activity. We want them to return to work, return to school, or return to hobbies. We want to get them engaged so that they don't feel socially isolated. We're not removing them from their teams or their friends, and they're not physically deconditioning as well.

Treatment and care for patients with continued long-term reports of symptoms following mild traumatic brain injury or concussion is complex. We are going to want a team of medical professionals, mental health professionals, social workers, and rehab specialists involved. The team is important for making sure we are addressing any premorbid issues, as well as the symptoms that we're seeing.

“Cognitive symptoms… are typically not primary symptoms, but rather secondary symptoms are rising from medical or psychological conditions” (Mashima et al., 2021).  If you're seeing somebody with attention issues that they are attributing to a concussion, perhaps they had ADHD prior to the injury, so it’s important to look at those things.

It's important not to highlight or exaggerate symptoms and continue to educate about the typical trajectory of recovery.  If neuropsychological or psychological testing suggests a patient demonstrates exaggerated symptoms, it's important to note that with your interdisciplinary team members. It's also important that all of the team members have the tools to respond or report exaggerated symptoms in a supportive and validating way.

We want to try to remove enabling the patient and validating symptoms in a way that exaggerates symptoms. We don’t want to say, “Oh yeah, you're right, you really are bad off. Most people recover already. You're in that 10-20%. You aren't going to recover.” You don't want to do any of that because that can potentially create a cycle of secondary gain.

Focusing on patient goals and function is important for any diagnosis and any patient. It empowers the patient and encourages resilience and self-awareness, and we're going to get the most patient buy-in to treatment when we're focusing on tasks and goals that they're interested in.

Patients may perform within normal limits on standardized assessments but may perceive significant functional challenges. Anyone who has worked in mild traumatic brain injury has seen this. A patient will perform within normal limits on an assessment, but if they were a straight A student before the injury and are now getting Bs, they perceive that as still having significant challenges.  

In my career, I treat a lot of Navy SEALs.  They will test in the normal range after their injuries. But before their injury, they were extremely intelligent and used to functioning at a very complex, high level. So, they say to me, “I don't understand, this testing shouldn't be normal. I'm experiencing problems with my memory. I can no longer multitask, etc.”

When labeled “brain injured” or “post-concussive”, patients can experience a self-fulfilling prophecy around those impairments. It can lead to that exaggeration and amplification of symptoms. Additionally, they may have heightened awareness because of the concussion. Things that are normal cognitive lapses become evidence of continued brain injury, which can then cause hyper-vigilance, increased attention difficulties, et cetera.  It can be a really vicious cycle.

We need to provide education to families, teachers, coworkers when appropriate, as well as interdisciplinary team members. If the standardized assessments are showing results in the normal range, that can create patient and healthcare professional confusion leading to concerns about malingering or faking. Being able to educate team members and say, “Sure, Rob was within normal limits on all standardized assessments, but he's the CEO of X company, so he clearly was functioning at a much higher level prior to this concussion." So, we need to make sure we're providing treatment and validation because the patient does deserve to have treatment. As SLPs, we can validate patient symptoms as real and we can validate the patient's distress. We can clarify the likelihood of comorbid conditions impacting brain function, such as previous ADHD, previous anxiety, or psychological health disorders, rather than just focusing on the brain injury.

Focusing on resilience and self-efficacy have been identified as significant factors in positive recovery outcomes.  What is self-efficacy? It's your belief that you have the ability to achieve goals. You're efficient at doing those things, and you believe in yourself. Resilience is, “the ability to persist in the face of challenges and bounce back from adversity."

As I mentioned before, elite athletes have increased resilience because they've been training, have persisted through mental and physical pain, and they continue to succeed. They have increased resilience, so they may not have the same frequency of PCS. Research is showing that high levels of resilience lead to less fatigue, fewer PCS symptoms, and a higher quality of life.

What factors focus on resilience and brain injury? How do we create resilience? We can do this by identifying personal strengths. Ask your patient, “What are your strengths? What are you good at? What are you succeeding in?” We develop supportive relationships through the interdisciplinary team, family members, and caregivers; and identify examples of how a patient has overcome adversity in the past.

Here is an example. Let’s say you broke your leg.  You weren't able to walk initially, but now you've recovered from that, and you just finished a marathon. That's a broad example, but it gets at, “Where have you had difficulties in the past and how have you overcome those things?”

We want to incorporate patient choice and give them options during treatment. This goes back to the patient goals and function piece. Additionally, we want to provide positive feedback and highlight successes. We can say, “Hey, we started out this session and you were telling me that you were struggling with remembering your grocery list. Well, we just knocked out an activity where you remembered five items while we were doing attention tasks, while we were multitasking.  That's awesome, and that's going to show you that you can now remember your grocery list." We are validating those things.

Role of the SLP

The role of the SLP includes empowering patients, increasing resilience through activities, educating about the positive expectation of recovery, as well as the impact of comorbid conditions on cognition and function. These are all those comorbidities like ADHD, depression, other psych diagnoses, and sleep issues that may have been present before the concussion.

We're naturally good at building rapport, so we want to build rapport and create a therapeutic relationship which, in turn, motivates the patient to become engaged. Of course, our ultimate goal is to restore the premorbid cognitive communication function when possible.

Validating the symptoms, discussing routines and rest - but not too much rest - symptom mitigation (e.g., getting exercise), taking care of your nutrition, taking medications, and providing accommodations for school and work and typical cognitive treatment.

Apply a typical course of cognitive treatment focused on symptoms. Attention is the gateway to all things cognition. If you have decreased attention, you can't remember things. That leads to increased cognitive fatigue, which leads to pushing through, which leads to physical symptoms such as headache and stress, which then leads to decreased attention. Therefore, we really need to focus on the attention piece first and then build on that.

Similar to any course of treatment, you're going to assess the symptoms as you would a mild to moderate brain injury by focusing on attention, executive dysfunction, memory, word finding, stuttering/dysfluency, processing speed, and problem-solving.

To assess attention, you might use the Test of Everyday Attention or Attention Process Training tests. For executive function, you could use the Behavioral Assessment of the Dysexecutive Syndrome (the BADS), or the Functional Assessment of Verbal Reasoning and Executive Strategies.  For memory, you might use the Rivermead Behavioral Memory Test. These are really good assessments for the milder symptoms. They will also pick up on the severe symptoms, but in this setting, you can build your goals with your patient, involve them in that process, and treat those areas.

Treatment

We want to include motivational interviewing, collaborative goal setting, and dynamic coaching in our treatment plan. These three approaches create a positive patient environment that builds rapport, focuses on strengths and patient choice, and fosters self-efficacy and resilience.

Motivational Interviewing

Motivational interviewing is when you, as the SLP, talk less and listen more. It's a collaborative communication style where you guide your patient rather than direct them. It ties into collaborative goal setting and you're asking the patient to develop their goals with your guidance. You can say, "Hey, you've mentioned that you really want to work on memory. Is there one thing, in particular, that is bothering you about your memory? Are there specific functional areas that we can focus on in treatment?”

Dynamic Coaching

This is where we, as clinicians, serve as a coach to support and guide. It's consistent with motivational interviewing. We ask questions of the patient that prompt reflection and critical thinking and then translate that into how they might problem solve in real-world scenarios. It’s teaching the patients to solve their own problems.

In addition, we want treatment to be very functional. For example, if they're returning to school, what kind of school prep activities can you do that will focus on attention, memory, or problem-solving?

Benefits of Interprofessional Collaboration

As you know, interprofessional collaboration is very important. There is currently a significant focus to collaborate more with our colleagues across a variety of disciplines because it reduces the risk of missing predisposing factors contributing to PCS. For example, if you're working with a psychologist on your team, they may be able to pick up on symptoms or issues that you may not have thought of. 

Interprofessional collaboration allows for consistent messaging and education around recovery trajectory and expectations. This is our chance to say as a team, “We're all going to reinforce that this person should be recovering at a typical trajectory.” This is when, as I said before, even if the person tested within normal limits, they’re still having functional issues. 

It's important to know to refer when something is outside of our scope of practice. The person may need a medical reevaluation or they're reporting significant chronic pain, or in need of a sleep evaluation, etc.  We always want to refer out for issues outside of our scope of practice.

Some of the professionals who could potentially be involved in an inter-disciplinary team include: social work, rehab, nursing, occupational therapy, ophthalmology, audiology, and vocational rehab. An interprofessional team ensures timely and effective management and referrals for all domains - emotional, psychological, and physical. It continues to enforce resiliency and self-efficacy because our patients are getting treated by a large team.

Research Needs

At the beginning of the course, I talked about the lengthy, convoluted definition. There needs to be one consistent, standardized definition of post-concussion syndrome. Research needs include developing biomarkers to immediately diagnose a TBI, mild traumatic brain injury, or concussion. Finally, there is a need for evidence-based treatment outcomes, which is always the case when working in cognitive rehabilitation.

Case Study

Let’s look at a case study. This is a 26-year-old female who is college educated. She worked as a director of a childcare facility and recently lost her mother to cancer. She is status post motor vehicle accident. She had no loss of consciousness. Initially, there were no symptoms other than a headache and she returned to work after a few days. After two weeks, she developed severe migraines, dysfluency, memory difficulties, and could no longer return to work.

With all of these factors, what are your thoughts on a diagnosis and treatment? What referrals would you make? What type of interprofessional treatment would you recommend? What do you think could have contributed to her symptoms that happened prior to her accident?

Some contributing factors may include stress from the loss of her mother, anxiety, stress of returning to work, loss of sleep becoming worse, depression due to the loss of her mother.   We could address this person's needs by making an outpatient speech therapy recommendation and referring her to cognitive behavioral therapy. 

 

This is a good case for an interdisciplinary team because there are a lot of factors coming into play.  There are the possible premorbid psychological issues from the loss of her mother as well as a possible stressful position as a director of a child development center.  Additionally, we need to determine why the symptoms took two weeks to develop. 

Summary

In summary, post-concussion syndrome is challenging to diagnose and treat.  Eighty-five to ninety percent of those who are diagnosed with concussion, however, recover within seven to 10 days. That is that trajectory piece we keep talking about. There are multiple factors to consider when treating diagnosed PCS, and interprofessional management is the best course of action for these patients due to the complex nature of the injury.

Questions and Answers

Would any form of cerebral palsy ever constitute a mild traumatic brain injury?

No, it wouldn’t because a traumatic brain injury comes from a hit or blow to the head. I am not an expert in CP, but it is usually due to anoxia or lack of oxygen at birth.

Is there any treatment that can be done to prevent post-concussive syndrome?

This goes back to that resilience piece.  It’s also educating upfront. The research isn't there on prevention, but if you think about educating about the predicted course or trajectory of symptoms, then you're validating those.  You're also saying, “You should get better, most do,” If you use that statistic of 80 to 90% of those who have a concussion or mild traumatic brain injury recover fully, then only 10-20% have PCS. So those things can help to prevent and not exaggerate symptoms.

With the case study, would you be concerned with late onset of symptoms or a bleed? Yes, that's a great point. Absolutely, if you were seeing that patient, that would be a perfect time for a referral for a medical reevaluation.

Do you think multiple falls/concussions can contribute to the development of dementia in older persons?

That is a great question and could probably be a talk in and of itself. Yes, there is some evidence demonstrating that repeated concussions or brain injuries can potentially contribute to dementia as patients age.

Can you discuss blast concussions? Are there any differences in symptoms that present or stand out more than with a blunt force type head injury, specifically in military patients?

Yes, there are differences because it's not as much of a focal injury, it's a diffuse axonal injury. So, you're going to potentially see more of symptom overlap. When I treated that population, they almost always have attention issues, memory, and executive dysfunction. With a blast injury, there are multiple waves of a blast that actually create different reactions physically. So that also contributes.

For those of us interested in becoming a certified brain injury specialist or another credential in TBI, but haven't been in an environment that provides enough hours for cognitive rehabilitation, what would you recommend?

I have had my CBIS for so long now. I don't remember if you can get that cog rehab experience from volunteering or if you have to actually give it.  If you can go shadow or volunteer at a brain injury clubhouse, that be an idea.

I know a girl who had a sports-related concussion. She was then diagnosed with bipolar disorder shortly thereafter. Can the concussion be the reason for some mental health disorders in adolescents depending on the situation? Should adolescents be monitored by a therapist post-concussion?

I think what you're asking is if a concussion can trigger mental health diagnoses. I haven’t read any research about bipolar, but as I mentioned earlier, the depression, anxiety, etc can absolutely cause some of those mental health disorders. It's just a contributing factor.

How often do you refer to a therapist?

If you're seeing symptoms of mental health diagnoses, it's better to refer than not. I would absolutely refer every time if somebody is showing those symptoms. We want to get them evaluated by the appropriate mental health professional, since that is out of our scope and make sure that giving the patient the support that they need.

Do physicians typically refer patients to SLPs only if they develop post-concussion syndrome or would treatment sometimes begin for those with mild traumatic brain injury as well? Are there different codes for each?

Physicians definitely refer for mTBI treatment, especially if they're having long-term symptoms.  I would say that you're not going to see many referrals for symptom treatment within a week after a mild traumatic brain injury, but long-term absolutely. In my experience, I would usually see the diagnosis of mild traumatic brain injury over a diagnosis of post-concussion syndrome. I think a lot of physicians are more comfortable saying they have prolonged symptoms of mTBI.

Would yoga be considered appropriate?

In my mind, yes, but I'm not a physician, so don't take this as the absolute right answer.  But in my mind, it would tie into that mindfulness and meditation piece. But I don't know about certain positions because of blood flow, etc.  But, if it was maybe some lighter flow yoga, that might be appropriate.

References

 

Biagianti, B., Stocchetti, N., Brambilla, P. & Van Vleet, T. (2020). Brain dysfunction underlying prolonged post-concussive syndrome: a systematic review. Journal of Affective Disorders, 262, 71-76.

Broshek, D. K., De Marco, A. P. & Freeman, J. R. (2015). A review of post-concussion syndrome and psychological factors associated with concussion. Brain Injury, 29(2), 228-237.

Conder, A., Conder, R. & Friesen, C. (2020). Neurorehabilitation of persistent sport-related post-concussion syndrome. NeuroRehabilitation, 46(2), 167-180.

Legarreta, A. D., Brett, B. L., Solomon, G. S. & Zuckerman, S. L. (2018). The role of family and personal psychiatric history in postconcussion syndrome following sport-related concussion: a story of compounding risk. Journal of Neurosurgery: Pediatrics, 22(3), 238-243.

Leddy, J. J., Baker, J. G. & Willer, B. (2016). Active rehabilitation of concussion and post-concussion syndrome. Physical Medicine and Rehabilitation Clinics, 27(2), 437-454.

McCrea, M., Guskiewicz, K., Randolph, C., Barr, W. B., Hammeke, T. A., Marshall, S. W. & Kelly, J. P. (2013). Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. Journal of the International Neuropsychological Society, 19(1), 22-33.

Mashima, P. A., Waldron-Perrine, B., MacLennan, D., Sohlberg, M. M., Perla, L. Y. & Eapen, B. C. (2021). Interprofessional collaborative management of postconcussion cognitive symptoms. American Journal of Speech-Language Pathology, 30(4), 1598-1610.

Permenter, C. M. & Fernández-de Thomas, R. J. (2021). Postconcussive syndrome. StatPearls [Internet].

Tapia, R. N., & Eapen, B. C. (2017). Rehabilitation of persistent symptoms after concussion. Physical Medicine and Rehabilitation Clinics, 28(2), 287-299.

Varriano, B., Tomlinson, G., Tarazi, A., Wennberg, R., Tator, C., & Tartaglia, M. C. (2018). Age, gender and mechanism of injury interactions in post-concussion syndrome. Canadian Journal of Neurological Sciences, 45(6), 636-642.

Voormolen, D. C., Cnossen, M. C., Polinder, S., Von Steinbuechel, N., Vos, P. E. & Haagsma, J. A. (2018). Divergent classification methods of post-concussion syndrome after mild traumatic brain injury: prevalence rates, risk factors, and functional outcome. Journal of Neurotrauma, 35(11), 1233-1241.

Citation

Mattingly, E. (2022). Post-concussive syndrome. SpeechPathology.com. Article 20527. Available at www.speechpathology.com

 

 

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erin o mattingly

Erin O. Mattingly, MA, CCC-SLP, CBIS

Erin Mattingly is a Washington, DC-based strategic consultant, speech-language pathologist (SLP), traumatic brain injury (TBI) subject matter expert, and the Director of Strategic Development at Loyal Source Government Services. Ms. Mattingly has over 15 years of leadership experience ranging from large humanitarian medical operations, field-based patient direct care, and support of White House and senior-level federal agency high-visibility public health policy and program implementation. In her role as a consultant, most recently, she launched the medical operations for one of the Operations Allies Welcome sites and has worked on a variety of Congressional and Cabinet-level initiatives focused on suicide prevention and mental health across the Nation. In addition, Ms. Mattingly has treated patients across the continuum of brain injury severity, from mild to severe injury, in both civilian and military populations. She has served in a variety of leadership positions across brain injury, mental health, and SLP organizations, including the Academy of Certified Brain Injury Specialists (ACBIS), the Academy of Neurologic Communication Disorders and Sciences (ANCDS), and the Neurogenic Communication Disorders Special Interest Group of the American Speech-Language-Hearing Association (ASHA). She currently provides leadership serving as the Chair for Brain Injury Services, a non-profit organization serving brain injury survivors and their families in the DC and Virginia area. She has multiple publications and presentations at national conferences on the treatment and evaluation of survivors of brain injury and suicide prevention in the Veteran and civilian populations. Ms. Mattingly holds her ASHA certification in speech-language pathology, her license to practice speech-language pathology in Washington, DC, and is a Certified Brain Injury Specialist.



Related Courses

Post-concussive Syndrome
Presented by Erin O. Mattingly, MA, CCC-SLP, CBIS
Video
Course: #10057Level: Introductory1 Hour
This course describes post-concussive syndrome, including etiology, predictors, and common symptoms. Differential diagnosis and treatment considerations are also addressed.

Dysphagia after Traumatic Brain Injury: Etiology and Evaluation
Presented by Erin O. Mattingly, MA, CCC-SLP, CBIS
Video
Course: #8815Level: Introductory1 Hour
This is Part 1 of a two-part series. This course will discuss dysphagia following traumatic brain injury (TBI). Specifically, etiology, characteristics, and assessment of dysphagia following TBI will be addressed.

Evaluation of Mild Traumatic Brain Injury
Presented by Erin O. Mattingly, MA, CCC-SLP, CBIS
Video
Course: #9717Level: Introductory1 Hour
This is Part 1 of a two-part series. This back-to-basics course focuses on functional evaluation of mild traumatic brain injury (mTBI) across the treatment continuum, from acute care to outpatient care to sideline assessment. Symptom identification is discussed, as well as benefits and limitations of both formal and informal assessment tools.

Dysphagia after Traumatic Brain Injury: Treatment
Presented by Erin O. Mattingly, MA, CCC-SLP, CBIS
Video
Course: #8834Level: Introductory1 Hour
This is Part 2 of a two-part series. This course will review dysphagia treatment following traumatic brain injury (TBI). Specifically, it will cover the treatment of survivors of TBI in various levels of consciousness, techniques, oral care, and family education.

Back to Basics: Stroke
Presented by Erin O. Mattingly, MA, CCC-SLP, CBIS
Video
Course: #8958Level: Introductory1 Hour
This course will provide a "back to basics" review of the role of the speech pathologist in stroke care. This will include diagnosis, evaluation, and functional treatment recommendations.

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