Post-Concussion Syndrome DSM-IV requires 3 or more symptoms to be present at least 3 months after injury: – Anxiety, apathy, depression, dizziness, fatigue, HA, irritability, personality changes, sleep problems ICD-10 dx involves symptoms in 3 or more categories Role of anxiety and/or beliefs about injury – Educating the patient about possible symptoms and recovery may decrease risk of PCS

Second Impact Syndrome Brain swelling resulting from >1 mTBI. – Increased ICP, diffuse swelling, brain herniation. Second injury may result from a less severe impact. Often fatal – if not fatal, prognosis may be similar to that of severe TBI. – Other sxs: dilated pupils, LOC, loss of eye mvmt, respiratory failure. Pediatric and adolescent athletes at greater risk for SIS.

Pediatric Athletes Age-dependent effects since brain is still developing – Status of sutures, skull development, water content and blood volume of brain, and myelination level Young brain may not recover as well as older brain – but, may require larger force to become injured Neck/shoulder musculature – less able to transfer forces Force of impacts – may be lower Neurobiological Development Environmental Considerations – school/learning, social network Consider more conservative approach

Gender Differences Differences in LOC with concussion Broshek et al (2005) found gender differences at follow-up after concussion: – Cognitive changes from baseline performance – Self-reported number of symptoms – Differences still existed after adjusting for helmet use Hormonal differences may contribute – Neuroprotective or negative effects of estrogen controversial – conflicting evidence in rat models Other differences: – Blood flow rates, rate of glucose metabolism, neuronal density

Conclusions LOC should not be used to determine severity of injury Consider impact of injury on various levels: – Somatic, emotional/behavior, & cognitive – Subjective & objective Tracking/reassessing sxs over time important Education important – Sxs of concussion – Recovery/return to sport after concussion – Prevention

References Broshek, DK, Kaushik, T, Freeman, JR, Erlanger, D, Webbe, F, & Barth, JT. “Sex differences in outcome following sports- related concussion.” Journal of Neurosurgery; : DeLaney, J. “The impact of sports: concussion may affect genders differently.” Today in PT; November 2008: Garvey, D. “Brief clinical update: when can teens return to sports after a head injury?” UCLA Department of Medicine: Accessed online February 6, 2009 at Kirkwood, MW, Yeates, KO, & Wilson, PE. “Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population.” Pediatrics; : “Postconcussion syndrome: why this diagnosis is controversial and what treatments may help.” Harvard Mental Health Letter; (6): 6. Mittenberg, W, Canyock, EM, Condit, D, & Patton, C. “Treatment of post-concussion syndrome following mild head injury.” Journal of Clinical and Experimental Neuropsychology; (6): Wood, RL. “Post concussial syndrom: all in the minds eye!” Journal of Neurology, Neurosurgery, and Psychiatry; (6):552.