Athletic Training and Sports Health Care

Evidence-Based Report 

Managing Mental Health Aspects of Post-concussion Syndrome in Collegiate Student-Athletes

Jennifer Jordan Hamson-Utley, PhD, LAT, ATC; Monna Arvinen-Barrow, PhD, C. Psychol; Damien Clement, PhD, ATC, CMPC

Abstract

The latest consensus statement on sport-related concussion states that psychological factors play a role in concussion symptom recovery and contribute to a prolonged recovery if left unmanaged. As such, care of an athlete following concussion has evolved from on-field immediate care offered by the athletic trainer and team physician to include an interprofessional team of health care experts trained in the management of concussion and post-concussion syndrome. This evidence-based report evaluates a representative patient's case in relation to the Conceptual Model of Psychological Response to Sport Concussion, discusses factors that influence diagnosis, presents appropriate psychosocial intervention for the patient, discusses relevant factors to consider as they relate to the patient's needs for mental health referral, and identifies the role of different professionals in ensuring a successful and safe return back to basketball. [Athletic Training & Sports Health Care. 2017;9(6):263–270.]

Abstract

The latest consensus statement on sport-related concussion states that psychological factors play a role in concussion symptom recovery and contribute to a prolonged recovery if left unmanaged. As such, care of an athlete following concussion has evolved from on-field immediate care offered by the athletic trainer and team physician to include an interprofessional team of health care experts trained in the management of concussion and post-concussion syndrome. This evidence-based report evaluates a representative patient's case in relation to the Conceptual Model of Psychological Response to Sport Concussion, discusses factors that influence diagnosis, presents appropriate psychosocial intervention for the patient, discusses relevant factors to consider as they relate to the patient's needs for mental health referral, and identifies the role of different professionals in ensuring a successful and safe return back to basketball. [Athletic Training & Sports Health Care. 2017;9(6):263–270.]

With an increased number of reported sport-related concussions, concerns regarding the prevalence of post-concussion syndrome have also gained interest among researchers in the field. Post-concussion syndrome is typically defined as a “complex and controversial constellation of physical, cognitive, and emotional symptoms associated with mild brain injury”1 that will last weeks, months, and even years following the initial injury.2 More recently, the Berlin Consensus Statement on Concussion in Sport referred to post-concussion syndrome more accurately as “persistent symptoms” characterized by a failure to achieve “normal clinical recovery,” which is framed by more than 10 to 14 days in adults and more than 4 weeks in children.3 Additionally, clinical recovery was further defined as a resolution of symptoms affording a functional return to normal daily living activities, including work, school, and sport.3 It is estimated that post-concussion syndrome affects 10% to 15% of individuals with sport-related concussion2 and that the severity of initial symptoms in the first 24 to 72 hours is predictive of recovery.3

Methods

The purpose of this evidence-based report was to evaluate a representative patient's case in relation to the Conceptual Model of Psychological Response to Sport Concussion,4 discuss factors that influence diagnosis, present an appropriate psychosocial intervention for the patient, discuss relevant factors to consider as they relate to his needs for mental health referral, and identify the role of different professionals in ensuring a successful and safe return to basketball.

Case Report

Seth (name changed to ensure anonymity) is a 21-year-old collegiate basketball player who collided with a teammate while going for a loose ball during practice. His forehead made contact with his teammate's knee and, although he did not lose consciousness, he presented with a terrible headache, ringing in his ears, and confusion characterized by slow cognition within a few minutes. He was removed from practice following an evaluation by the team's athletic trainer, who suspected a concussion. After several hours of evaluation following the injury, Seth showed signs of improvement, although he did remain symptomatic. The athletic trainer educated Seth on the importance of physical and mental rest and sent him home. When Seth saw the team's physician the next day, he presented with a moderate consistent headache, confusion, loss of appetite, dizziness, and sensitivity to light, and was consequently diagnosed as having a concussion. Seth expressed frustration that his injury occurred during practice, when stakes were low.

As per the plan, Seth engaged in 7 days of active rest (including activities of daily living) and began a return-to-play protocol with the athletic trainer once asymptomatic. As per academic policy defining athletic eligibility, Seth attended his face-to-face courses on campus between days 4 and 14 following the injury, which made him exhausted after only 2 to 3 hours. He avoided extended interactions with friends and teammates due to not feeling like himself. Fourteen days after the injury, Seth reported to be asymptomatic despite still experiencing headaches and concentration issues and he began the return-to-play protocol with the athletic trainer. Seth struggled to progress through the protocol due to experiencing exercise-induced cognitive and physical symptoms. Despite wanting to be honest with the athletic trainer, he understood that by communicating his symptoms, he would not progress to the next stage of the protocol. At day 21, Seth was still not cleared to return to practice because any increase beyond normal activity caused symptoms. Seth's mother, an athletic trainer, informed him of the importance of being open and honest during this process because honesty is the only way to return safely to practice. Seth's father voiced to the athletic trainer that he was worried about Seth because his son had “not been himself” lately.

Seth's symptoms remained steady 28 days after the injury, with headaches coming and going, trouble sleeping, forgetfulness, and fatigue. He communicated with his parents that he was having trouble reading and concentrating in classes and could not use the notes he was taking. He reported fighting fatigue after 2 to 3 hours of normal daily activity and not getting out of bed, even to eat, some days. Seth's mother contacted the team's athletic trainer via telephone and shared her concerns about Seth's academics and his increased anxiety about not being able to be back with his team. She also reported that Seth felt “left behind” as he watched his team travel and play games without him, and she was concerned that he was showing signs of pulling back from usual team and social events.

Considering the symptoms Seth was experiencing, it is probable to assume that the initial diagnosis of concussion needs to be reevaluated and potentially reclassified as post-concussion syndrome. In Seth's case, experiencing concussion in a practice setting had a significant effect on his life, both physically and psychologically.

Findings

Integrated Model of Psychological Response to Sport-Related Concussion Injury and Rehabilitation

According to the Conceptual Model of Psychological Response to Sport Concussion,4 psychological risk factors before concussion (ie, attention-deficit/hyperactivity disorder or other brain-related disabilities, history of life event stressors or post-traumatic stress disorder, coping style, social support, and existing concussion education) are considered important in influencing how an athlete may cognitively appraise and/or physically respond to a sport-related concussion. Experiencing shifts in attentional focus when placed in a potentially stressful athletic situation can predispose an individual to sustaining a concussion. Along with personal (ie, injury characteristics, anxiety, and depression) and situational (ie, sport, social, and environmental) factors, the aforementioned concussion risk factors are also proposed to influence a range of neurobiological, psychogenic, and pathophysiological causes of concussion. In turn, these will influence a bidirectional cyclical cycle of cognitive, affective, and behavioral symptoms and responses to concussion. Along with psychological care following concussion, these cognitive, affective, and behavioral responses will in turn influence the overall psychological outcomes of concussion.4

When placing Seth's case into the conceptual model, it is clear that Seth's family provided him with a sound social support network. It is also clear that Seth's education before the concussion undoubtedly helped him to be open and honest about his symptoms and progress and adhere to his rehabilitation and return-to-play protocol following the concussion. However, his initial cognitive and affective appraisals of the injury (ie, feeling frustrated because it occurred in a practice setting) along with clear neurobiological, psychogenic, and pathophysiological symptoms (ie, headache, confusion, loss of appetite, and sensitivity to light) likely contributed to his inability to cope with the prolonged symptoms following the concussion. More specifically, it appears that Seth found it difficult to cope with his situation. It is also apparent that all of the cognitive, affective, and behavioral symptoms that Seth exhibited point toward Seth's parents suspecting that their son was suffering from depression.

Clinical Impression

The suspicion by Seth's parents that Seth was suffering from depression is warranted because several studies have reported a prevalence of depression5–8 and other mood disturbances in athletes with post-concussion syndrome.9–11 Although this might appear to support the notion that individuals diagnosed as having concussion have an increased likelihood of developing depression, this may not always be the case. Evidence also suggests that athletes such as Seth who report and display more severe initial physical, cognitive, and affective symptoms and responses to concussion suffer from a prolonged recovery,3 which may or may not be linked with depression, but rather are symptoms of post-concussion syndrome. Indeed, many of the symptoms of post-concussion syndrome (eg, fatigue, irritability, sadness, and sleep disturbances) are parallel to common symptoms of depression. The many overlapping symptoms between post-concussion syndrome and depression also makes the differentiation between the two diagnoses difficult for both the athlete and the health care/sport medicine professional.3,12 Given the seriousness of both conditions and the difficulty in diagnosis, clinicians working with athletes who have a concussion need to be careful in making a clinical judgment without considering and evaluating the role of all possible physical and psychosocial risk factors, symptoms, and responses following concussion thoroughly.

According to the existing literature, some of the pre-disposing risk factors for post-concussion syndrome include having sustained one or more previous concussions, increasing age, concurrent anxiety, range of trauma-related symptoms, life stressors, and pain.13,14 Limited evidence also exists in support of the role of genetics in predicting a prolonged recovery and post-concussion syndrome following sport-related concussion.3 It is advised that athletes such as Seth should be periodically screened for any potential post-concussion syndrome or mental health risk factors because such baseline data can help clinicians to ensure accurate diagnosis and rule out any clinical mental health conditions following concussion.

Including an appropriately constructed demographic survey and psychosocial assessments on an athlete's physical examination before participation in sport can accomplish the aforementioned suggested prescreening.15 Questions related to concussion history and assessments related to trait and state anxiety,16 depression,17 and history and prevalence of major and minor stressors18,19 would be beneficial. Equally, including assessments such as the Profile of Mood States20 or Brunel Mood States21 would be beneficial because it is known that the existence of mood disturbances before an injury is a risk factor of prolonged recovery.22 Because mood disturbances may also cloud the usefulness of baseline testing,23 regular testing throughout the season would be advisable to ensure a valid baseline for the athlete. Additionally, conducting neuropsychological tests prior to any head-related trauma (eg, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]; ImPact Applications, Inc., San Diego, CA) would be beneficial in the establishment of a baseline for the athlete.24,25

Through clinical and mental health screenings, clinicians can identify any predisposing risk factors prior to the occurrence of a concussion, thus decreasing chances of making an erroneous post-concussion syndrome or depression diagnosis.12 However, there are a couple of things to note regarding the use of neurological and psychological baseline testing. First, it is imperative to note that many of the psychological assessments should be administered and interpreted by a mental health professional who is qualified to do so.26 Therefore, it is encouraged that sport medicine professionals work together with the appropriate mental health professionals to ensure that appropriate psychosocial13 and neuropsychological3 assessment occurs because they are the cornerstones of concussion diagnosis and management. Second, the feasibility of the aforementioned testing can be unattainable for many schools, especially for those that are not affiliated with a large community hospital or concussion clinic.

In addition to screening for potential risk factors and evaluating the presence of symptoms following concussion, it is also important for clinicians to be mindful of how psychosocial factors can exacerbate the reported symptoms3 and complicate the recovery process.27 For example, according to Broshek et al.,27 experiencing a concussion can “create vulnerability to multiple sources of fear” (p. 233). Fear related to isolation, loss of income/scholarship, loss of starting role, and reinjury are somewhat common among athletes who have a concussion, each of which can influence the ways in which an athlete will respond to his or her situation. In Seth's case, due to his ongoing symptoms with memory, attention, and concentration, he clearly experienced increased worry over his position on the team, which led to increased anxiety over his situation. It is also likely that such worries and anxieties contributed to his sleeping patterns and fatigue (and vice versa), all of which exacerbated his issues with memory, attention, and concentration. It can also be assumed that Seth's lack of interaction and communication with teammates and coaches influenced his prolonged symptoms and lack of recovery; external sources can place undue pressure on the athlete, potentially leading to additional stress on an individual who is operating with “reduced cognitive resiliency”27 (p. 233).

Taking the above into account, it is our professional opinion that Seth should be rediagnosed as having post-concussion syndrome. His main cognitive, emotional, and behavioral symptoms point to increased anxiety and worry, with some early signs of depression (evident as avoidant coping, social isolation, and fatigue). It is important to address the symptoms above; if symptoms are left unmanaged, they can lead to clinical depression.

Appropriate Psychosocial Interventions

Given Seth's diagnosis and his most prominent cognitive, affective, and behavioral symptoms and responses (Figure 1), it is clear that Seth's recovery would benefit from comprehensive psychological care. Such care is aimed to influence the cognitive–affective–behavioral cycle4 and should consist of careful selection of appropriate assessments, providers, and interventions.4 Thus far, research has highlighted psychological interventions as an integral part of rehabilitation following concussion.3 However, given the importance of cognitive rest while recovering from a concussion,28 such care should be designed while also being mindful not to “overload” the athlete. It is with these considerations that we recommend Seth's psychological care to consist of the following: cognitive behavioral therapy provided by an appropriately trained counseling/clinical/school/sport psychologist, appropriate patient education on post-concussion syndrome provided by Seth's athletic trainer, and a systematic practice of mental relaxation strategies such as deep breathing independently at home and during his cognitive behavioral therapy and athletic training sessions. Additionally, because sleep–wake disturbances seem to be a prominent behavioral symptom for Seth, monitoring and addressing sleep should be a priority for the athletic trainer and Seth himself. Such a multi-modal, interprofessional team approach to Seth's care can help facilitate his recovery several ways,29–31 which are outlined below.

Evidence-based approach to post-concussion symptom management. ADHD = attention-deficit/hyperactivity disorder; PCS = post-concussion syndrome

Figure 1.

Evidence-based approach to post-concussion symptom management. ADHD = attention-deficit/hyperactivity disorder; PCS = post-concussion syndrome

Cognitive Behavioral Therapy

Cognitive behavioral therapy has been found to be effective for individuals who present with post-concussion syndrome, particularly when started as soon as possible.1,3,32 The importance of cognitive behavioral therapy in recovery following concussion is that it aims to harness maladaptive thinking and catastrophizing that accompanies the new, foreign disability and enables the athlete to function within the injury-imposed cognitive and physical limitations.14 A recent systematic review of 71 clinical trials examining evidence-based treatment of concussion found that cognitive behavioral therapy was the most used and studied intervention (28% of the studies reviewed) and was found to be successful in treating anxiety, depression, and related sleep disruptions often present in post-concussion syndrome.33 Additional research has made the connection between the lack of behavioral and emotional coping strategies and higher levels of negative cognitive and affective states (eg, depression, fear, sleep, and cognitive disturbances),34 all of which have been proposed as leading to a prolonged recovery.4 In Seth's case, his care team following concussion should include a mental health professional and such inclusion should be organized by his care team lead, which could be his athletic trainer or team physician. It is known that having established networks with a range of professionals will likely promote early intervention.

Because Seth experienced both affective and behavioral disturbances, he may have benefited from the inclusion of cognitive behavioral therapy within his rehabilitation following concussion. In particular, the cognitive behavioral therapy could be used to address Seth's anxiety and worry and to help him become more aware of any potential mal-adaptive cognitive appraisals he may have (but is not aware of) that contribute to his affective and behavioral symptoms. It is also important to note that hypervigilance to somatic symptoms with constant monitoring may result in prolonged recovery.35 In Seth's case, he was injured in practice, which he cognitively appraised to be a situation of lesser importance (ie, not a game), which then led to increased frustration. Cognitive behavioral therapy could also be used to help Seth reframe his appraisals of the injury event itself to facilitate better recovery outcomes. It must be noted that the proposed cognitive behavioral therapy intervention should be implemented by the members of the broader sports medicine team31 who are appropriately trained in using cognitive behavioral therapy with competitive athletes.

Patient Education

Seth reported difficulty with his scholastic routine and being able to execute common tasks such as note-taking and reading. Given that the apparent memory, attention, and concentration impairments appeared to cause Seth increased anxiety and worry, it is important to educate Seth about post-concussion syndrome to help him understand how it affects his cognitive function and how to best facilitate recovery. Seth should be fully aware of how much cognitive activity he should be engaging in and that too much too soon can extend the recovery process.36 Alongside that, educating Seth on how long the cognitive symptoms of concussion usually persist can help him more accurately appraise his situation, minimize his misattribution of symptoms and recovery expectations, reduce his anxiety and worry, and improve his sleep,37 ultimately improving his recovery.4 Through patient education, clinicians who are adequately trained in post-concussion syndrome can best place Seth in a position of control over his own recovery.38

Relaxation Strategies

Seth's care team should also consider implementing the systematic practice of relaxation strategies to help minimize the effects of anxiety and worry.39 In a recent review of counseling strategies to treat post-concussion syndrome and improve recovery, relaxation strategies and mental skills were highlighted as ways to reduce incidence and duration of symptoms following concussion.40 These strategies, albeit usually implemented and initiated by counseling/clinical/school/sport psychologist, could also be reinforced and implemented during his regular rehabilitation sessions with the athletic trainer.41 It must be noted that support for the use of relaxation strategies as a stand-alone intervention is limited42; however, given its effectiveness as part of a multimodal intervention,39,43 its usefulness for Seth during rehabilitation for post-concussion syndrome could be highly beneficial.

Sleep Monitoring

Seth also reported increased levels of fatigue and disrupted sleep patterns. Difficulty managing sleep affects 30% to 70% of the population following concussion.44 This is not surprising because sleep disturbances, including insomnia, sleep apnea, and fatigue,45 are some of the most commonly reported behavioral symptoms for patients with post-concussion syndrome, typically resulting in a range of negative cognitive and affective states.46 Related to general sleep difficulty, sleep–wake disturbance has been shown to have a negative effect on recovery outcomes following concussion.45 Sleep–wake disturbance is commonly referred to when examining recovery in a population following concussion and includes insomnia, hypersomnia, and excessive daytime sleepiness.47 Research by Chiu et al.48 compared participants with acute post-concussion and normative values for sleep-related factors and found significantly different sleep quality, total sleep time, and times awake after sleep onset. Recent research has used Fitbit activity trackers (Fitbit, Inc., San Francisco, CA) within athletic populations to gather healthy baseline activity levels and sleep quantity and quality49; theoretically, this same technique could be applied following concussion to monitor activity and sleep patterns to inform Seth's care team of potential areas for intervention. Sport psychologists, psychologists, and counselors can deliver interventions aimed at improving sleep quality and the athletic trainer (or physician) that documents the athlete's complaints of trouble sleeping should initiate this referral.

Although there is insufficient evidence to confirm its effectiveness, prescribed rest remains the most common intervention used following concussion.3 Additionally, although it has been theorized to promote recovery by minimizing cognitive demand, rest takes on a different shape in post-concussion syndrome. In post-concussion terms, rest includes taking a break from normal daily physical activities, including usual technology, television, and texting time.36 In addition, how athletes interpret rest is inconsistent.50 In post-concussion syndrome, rest includes understanding current thresholds for asymptomatic function and learning coping strategies to facilitate functioning within that range. Defining active rest and research that attempts to quantify rest are needed to better shape rest interventions for both post-concussion and post-concussion syndrome care.49

Consideration for Alternative Interventions

Given the environment in which Seth sustained his injury, in all likelihood, he would have been referred to his team physician. Due to the complexity of symptoms associated with post-concussion syndrome, a holistic approach is often needed for effective rehabilitation outcomes.51 In addition to the above-mentioned psychosocial interventions, other nonpharmacological interventions such as aerobic exercise should be considered as potential treatment options. More specifically, submaximal aerobic exercise has been shown to reduce the symptoms of post-concussion syndrome by reversing the mechanism of physiologic dysfunction.52–55 Similarly, vestibular rehabilitation helps individuals modify their responses to movement and other stimuli in addition to their fear of activities that may cause dizziness.56 Should Seth's symptoms persist or worsen, his care team should consider the need for pharmaceutical intervention and/or the need for additional mental health referral. Because concussions cause an excessive release of neurotransmitters,57 pharmacological options such as catecholamine augmentation, dopamine agonists, and antidepressants51 can be used to address this occurrence. In such cases, reevaluation of the care team composition is warranted31 to ensure that those involved in Seth's care are appropriately trained for different aspects of the treatment plan.

Conclusions

The latest consensus statement on sport-related concussion states that psychological factors play a role in concussion symptom recovery and contribute to a prolonged recovery if left unmanaged.3 Due to this, care of the athlete following concussion has evolved from on-field immediate care offered by the athletic trainer and team physician to include an interprofessional team of health care experts trained in the management of concussion and post-concussion syndrome. Considering the potential effect of underlying preexisting mental health issues, gathering baseline cognitive and mental health information during pre-season collegiate student-athlete testing is recommended. As such, members of the broader health care team, specifically the mental health practitioners (ie, counselor, psychologist, and/or psychiatrist) should be involved in the athlete care even prior to the injury occurrence to ensure early detection of possible disturbances following concussion. In addition, the sports medicine team members with regular contact with the athlete should be on the look-out for early warning signs of distress in an attempt to avoid the development of post-concussion syndrome. It is known that early referral to an appropriate licensed mental health practitioner may facilitate early intervention and the avoidance of the development of post-concussion syndrome.

Had Seth initially completed the baseline measures, it would be considered best practice for the clinicians working with Seth to complete the same measures for comparison and to help facilitate any potential needs for referral. In the absence of such data, the onus of appropriate post-concussion syndrome and mental health disturbance screening and diagnosis falls on the appropriately qualified sport medicine and mental health professionals.

Implications for Clinical Practice

As discussed in this evidence-based report, theoretical conceptualizations and existing empirical evidence suggest that an athlete who is struggling with persistent physical symptoms is typically also experiencing psychological symptoms. Consistent with their educational competencies, athletic trainers, who are typically the closest professionals working with an injured athlete, should systematically keep track of any potential signs of abnormal thoughts, emotions, and behaviors, and refer the athlete to a mental health professional if they suspect more serious mental health concerns than typical responses to a concussion injury. In Seth's case, his athletic trainer should work closely with the team physician and the university's mental health providers. It is imperative that these collaborative links and referral practices are established at the beginning of the season and that the members of the team have developed a mutual trust, rapport, and understanding of each other's roles, responsibilities, and existing procedures for the referral and care process. Finally, recovery from sport-related concussion is individualistic and requires a personalized approach to achieve symptom resolution. Evidence suggests that there is often a lag between cognitive and physical symptom recovery,3 which can be the source of frustration and anxiety regarding achieving symptom resolution and often necessitates a referral.

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Authors

From the College of Health Sciences & Administration, University of St. Augustine for Health Sciences, Austin, Texas (JJH-U); the College of Health Sciences, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin (MA-B); and the College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, West Virginia (DC).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Jennifer Jordan Hamson-Utley, PhD, LAT, ATC, 313 Bachman Creek Drive, McKinney, TX 75070. E-mail: Jutley@usa.edu

Received: May 17, 2017
Accepted: October 09, 2017

10.3928/19425864-20171010-05

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