It’s not “Just a Concussion”: Addressing the Whole Student-Athlete
Objectively, attention surrounding concussions has focused on side-line evaluation tools, symptom identification and management, and long term post-concussive follow up regarding chronic traumatic encephalopathy (CTE) potential. As an athletic trainer, concussion symptom identification is fundamental. It is incredibly difficult to tell an athlete they are not allowed to return to play until they are fully recovered; however, it is essential to make sure we have their number one interest of safety in mind especially when they may be blinded as to the severity of their symptoms. Where we seem to be lacking is the understanding of what the athlete is feeling during their post-concussive recovery and what we can do to help them through this difficult journey from a mental health standpoint.
Physical and cognitive rest are important for athletes who have sustained a concussion. Medical professionals need to do a better job addressing the cognitive component for these post-concussive athletes. Cognitive rest represents a wide spectrum of limitations including and not limited to the avoidance of reading, television, music, stressful life events like testing, SAT’s, game-day film reviews, team practice playbook reviews, etc.
Orthopedic injuries remove athletes away from their sport because of pain or deformity; concussion symptoms are multifaceted and remove them from everything social, physical and cognitive while they may be acutely emotionally labile as well. This is an incredibly difficult time for them. They are under a tremendous amount of stress coming from all different aspects of their life. Their worries begin with not being able to play their sport, not practicing, losing their spot, letting their coach and team down, the social exclusion of not being around their team and taking away the athletes’ biggest stress reliever- exercise .
Additionally, student-athletes have the educational component of their life. With a concussion, attending class, doing schoolwork, and studying for exams can be very difficult to do when still symptomatic. Educational stress variables for a student athlete include missing class, falling behind, not being able to finish assignments, studying for exams, and having teachers or professors who do not understand what they are going through symptomatically because every concussed patient presents differently. Increased cognitive activity is associated with longer recovery from concussion. We may need to step in and gently educate the faculty, staff and coaches that the athlete needs to be supported both physically and cognitively with regard to schoolwork demands and deadlines.
Athletes who have sustained a concussion also deal with other stressors; unknown timeline for returning to their sport, becoming symptom free, and the underlying pressure from teammates, coaches, friends, and parents who may not fully comprehend the athletes symptoms or recovery process. ImPACT and other neurocognitive tests are often administered during this stressful time of often feeling secluded and alone through the recovery of the “invisible injury” of concussion. The student-athlete is truly unique as they have the demands of both academic life and sport. How is the athlete supposed to truly cognitively rest with the above noted feelings of doubt, worry, social exclusion and academic demands?
We can improve patient care by aiding the athlete in identifying stressors early on and providing support for them. As Athletic Trainers, we share a bond with our student athletes unlike most medical professionals. We see, treat, and interact with them every day. Symptomatically each athlete presents differently. Patients who experience symptoms beyond seven to ten days need to be monitored for post-concussion syndrome (PCS). This subgroup of athletes consists of 5%-10% of concussions . For these athletes we need to recognize all the different barriers that can hinder the athletes’ return to life and play by providing them with the support and resources to overcome the physical, social, emotional, and cognitive barriers of recovery.
Generally, the athletes’ physical symptoms can often be identified without a problem, but the mental-health symptoms may be more difficult to pick up on, especially when these symptoms often mimic early concussion symptoms. To best help the athlete with their recovery is to be actively present and guide them as needed in the direction towards optimal health and well-being.
Medical professionals, like Athletic Trainers (AT’s) and Physical Therapists (PT’s), play a crucial role in the management of concussions since these are the people the athlete generally has the closest rapport. Daily communication between the AT, PT and the athlete is important. When possible the time spent with the athlete each day should be face to face to pick up on the non-verbals. Asking questions other than ones about the physical symptoms of the concussion are important. Questions such as “How was your day today?” or “Did you get everything straightened out with your professors?” really help show the athlete that you care for and are there to support them. These questions may also allow the athlete to open up and share something deeper about themselves aiding in their recovery with regard to signs of anxiety and depression. Identifying issues early on will allow the AT and PT to set up the appropriate referral source expediting the athletes’ overall recovery. Having clear, concise, multidisciplinary communication between the athlete, medical and educational team is paramount for not only the athlete feeling well cared for during a stressful time, but also to assist in the athletes overall well-being and recovery.
As first responders on the medical team, we are the first group of medical professionals who initially and continuously monitors the post-concussive athlete. We need to be aware of this subgroup of PCS athletes and know how to identify, treat, and refer out to the appropriate medical provider of choice-physician, physical therapist, occupational therapist, vision or vestibular therapist, or neuropsychologist. Knowing our scope of practice, making these connections, and having an action plan in place while maintaining a trustworthy and comfortable environment will be the key to success to treating the concussed athlete.
1.Tator, C.H., Chronic traumatic encephalopathy: how serious a sports problem is it? Br J Sports Med, 2014. 48(2): p. 81-3.
2.Chen, J.K., et al., Neural Substrates of Symptoms of Depression Following Concussion in Male Athletes With Persisting Postconcussion Symptoms. Arch Gen Psychiatry, 2008. 65(1): p. 81-89.
3.Brown, N.J., et al., Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics, 2014. 133(2): p. e299-304.
4.Leddy, J.J., et al., A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome. Clin J Sport Med, 2010. 20: p. 20-27.
5.McCrory, P., et al., What is the evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and clinical outcomes? Br J Sports Med, 2013. 47: p. 327-330.
6.Kontos, A.P., et al., Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Arch Phys Med Rehabil, 2012. 93(10): p. 1751-6.
7.McGrath, N., Supporting the Student-Athlete’s Return to the Classroom After a Sport-Related Concussion. J Athl Train, 2010. 45(5): p. 492-498.