COVERT CONCUSSIVE SYNDROMETM
Overview of Concussion Identification, Diagnosis, and Treatment:
Awareness of the prevalence and seriousness of concussions has grown dramatically in the past 10 years. There is an enormous volume of research being conducted on concussions, as indicated by an academic database search (EBSCOhost) that reveals 138,555 research articles specifically focused on concussions, with over 300 being published since 2016. To provide further evidence of the exploding academic and clinical interest in concussions, 77.4% of all research articles on concussion have been published since 2009 (107,341/138,555).
Despite all the interest and investigation into concussions, the identification, diagnosis, and treatment of concussions continues to be imprecise, inaccurate, and ineffective in many cases. To add to the confusion and challenges presented by concussions, particularly in children, many states have laws governing removal and return to play and learning that are inconsistently defined, implemented, and monitored.
The combined effect of under-detection, inadequate identification, and missed diagnosis of concussions, and the resulting lack of effective treatment, is producing a variety of life problems in children and adults who have experienced one. These issues cover a significant continuum that range from functional adaptations that are undetectable apart from professional assessment (such as poor body alignment that puts strain on joints and muscles), to being mis-identified or attributed to a variety of causes other than concussion (such as a decline in school performance being due to laziness), to ones that are contributing to further concussions and other injuries, substance abuse, depression and anxiety, even incarceration or death (often by suicide).
There are a number of myths and misconceptions in the general population and medical practice about concussions that must be changed. Some of these myths are based on inaccurate or incomplete information about concussions, and some are based on popular expectations that are not questioned, reconsidered or examined. These include the belief that most head injuries do not result in concussions (due to inaccurate and overly broad definitions of a concussion and inaccurate application of current diagnostic standards), concussions are resolved or heal in 10 days or less, there are no lingering effects of concussions, and that if the symptoms that accompany a subdural hematoma are not experienced then a concussion has either not occurred or the danger from the concussion has passed.
To be clear, there are inaccurate expectations that a concussion has only occurred if severe and life-threatening symptoms are present, and the related belief that if there are no symptoms during the night of the concussive event then there has not been a concussion at all. When the symptoms of a subdural hematoma are present, then and only then do people believe a concussion has occurred.
The two most detrimental myths and misconceptions are related. The first is, that if the symptoms clinically associated with a subdural hematoma, and mistakenly believed to be the symptoms of a concussion, are not present then a concussion has either not occurred or the danger has passed, and the second is that there are no lingering effects of concussions.
Briefly, the symptoms of a subdural hematoma are the following:
· slurred speech
· loss of consciousness or coma
· severe headaches
· visual problems (www.healthline.com)
· difficulty in gait, balance
· motor deficit
· memory loss
· cognitive dysfunction (www.medscape.com ~ chronic subdural hematoma)
People have been led to believe that these symptoms (particularly loss of consciousness, slurred speech, severe headaches, and vomiting, which was not included in this list) are the only ones that indicate the presence of a concussion. When they are not present at the time of the concussion or during the night following the injury, the assumption is that a concussion did not occur. Even when a headache continues to be present the following day, it is often not attributed to the concussion, or is considered to be residual and not a significant concern. This particular myth is so ingrained in our popular culture that it is seldom recognized and even less frequently challenged, and yet it results in most concussions being overlooked and not receiving the assessment, diagnosis, and treatment that are required for complete recovery. Ironically, a vastly greater number of people are negatively affected by concussions being overlooked than are negatively affected by subdural hematomas. It is critical to understand that concussions are much more common than popularly (or even scientifically) thought, and have damaging effects that continue indefinitely if not properly treated.
The second myth is there are typically no lingering effects from concussions, and in the rare cases where effects do linger it is not for more than 10 days. We at Performance Pediatrics are discovering that a significant percentage of high school athletes (and students) have suffered previous concussions of which they are not aware, and that due to the concussion not being identified or diagnosed no treatment has occurred. It is common to find concussions that occurred 10 or more years earlier and yet are still exerting negative effects. The effect of concussions is perpetual, resulting in neuro-physical, neuro-cognitive, neuro-interpretive, and neuro-emotional (what we call the concussive quartet) functional problems that do not resolve without appropriate diagnosis and intervention.
Undetected, underdiagnosed, and misdiagnosed concussions occur due to the presence of the myths described above, and the use of inaccurate or ineffective screening tools. Among the most commonly used concussion screening tools are the Immediate Post Concussion and Cognitive Test (ImPACT), the Standardized Assessment of Concussion (SAC), the King-Devick Test, and the Standardized Concussion Assessment Tool, recently upgraded to a Fifth Edition (SCAT-5). Despite clear statements embedded in each of these instruments that they are not sufficient or appropriate stand-alone tools by which to diagnose concussions, they are frequently used for exactly that purpose. Additionally, they are often used inappropriately to make Return-to-Play decisions. Typically, the “baseline” results are compared to the results of the test given on the sideline at the time of the injury, or in the hours or days following the injury. If there is a significant decline in performance from the baseline assessment it is determined that a concussion has occurred. Similarly, when the test is given again following a brief period of recovery, if there is significant improvement from the score obtained shortly after the injury, it is determined that the person has recovered and can return to play.
This practice unintentionally serves to reinforce the myth that concussions resolve or “disappear” after 7 - 10 days, since most athletes can demonstrate improvement on the relatively easy cognitive tasks that these instruments utilize. Once an athlete has demonstrated improvement on repeated administration of these tests, it is assumed that the concussive symptoms have disappeared and the concussion is resolved or healed.
These assessment and diagnostic practices are problematic for several reasons. First, “baseline” tests do not provide a true baseline in our opinion and experience, because we are finding that up to 50% or more of high school athletes (and adults) have prior undetected, undiagnosed, and untreated concussions from which they have not recovered. There is a growing body of literature that identifies the negative effects of repetitive blows to the head, or whiplash and other concussive force injuries (Svaldi, 2018; Xu, L., Nguyen, J.V., Lehar, M., Rha, E., et al, 2016; Gagnon, I., Grilli, L., Friedman, D., & Iverson, G.L., 2016; Dachtyl & Morris, 2017; Alosco, M.L., Kasimis, A.B., Chua, A.S., Baugh, C.M., et al, 2017; Giza, C.C., 2006; Daneshvar, M.A., Riley, D.O., Nowinski, C.J., McKee, A.C., et al, 2011).
Additionally, these tests are constructed or administered in a way that allows for grossly inaccurate “baseline” results. The tests require such basic ability and low-level cognitive functioning that anything but the most severe injury will go undetected if the test scores are used as the sole basis for determining if a concussion has occurred. There is such variability in the way the tests are administered (in group settings that are not properly monitored, via computer with much uncertainty about how or even who is completing the test, in the presence of noise and distractions, etc.) that it is difficult to have much confidence in the results. Adolescents (and perhaps even younger children) are savvy enough to understand that if they obtain low scores on the “baseline” test they can often continue to play when they’re injured because there will not be a large enough difference from the baseline to the post-injury result to detect the concussion and pull them from play. Functional neuro-physical, neuro-cognitive, neuro-interpretive, neuro-emotional (or concussive quartet) deficits cannot be identified simply through using these tests or questioning whether an athlete is continuing to experience symptoms.
The ImPACT is the most commonly used of the instruments described above, and yet its use (and the use of other similar instruments) is problematic for several reasons. To summarize the problems with the instrument, it has inadequate sensitivity and even worse specificity (the ability of the instrument to accurately detect when somebody has had a concussion and when they have not), it is often not administered under standardized conditions, and it is easy to “fake” the results.
None of the instruments identified should be substituted for a more thorough neuropsychological screening or evaluation. As noted above in a variety of ways, they are designed for an on-the-field detection of the most severe injuries, and are not psychometrically or clinically appropriate for the purposes for which they are used.
Finally, although there is recognition and acknowledgement of “postconcussion syndrome” by ICD-10 and most clinicians, it is often overlooked and the symptoms are in most cases misattributed to other causes.
The International Classification of Diseases-10th Revision (ICD-10) includes a diagnosis of Postconcussion Syndrome (F07.81), and lists the criteria as follows:
The organic and psychogenic disturbances observed after closed head injuries (head injuries, closed). Post-concussion syndrome includes subjective physical complaints (i.e. Headache, dizziness), cognitive, emotional, and behavioral changes. These disturbances can be chronic, permanent, or late emerging.
While it is encouraging that ICD notes, “these disturbances can be chronic, permanent, or late emerging,” concussion myths have resulted in clinicians seldom looking for the symptoms for more than a week post-injury. When parents, teachers, and coaches notice the presence of symptoms that were caused by concussion or concussive events, they in most cases mistakenly believe that the cause of the symptoms are not concussive related.
Tragically, treatment is seldom a consideration for concussion, and many believe that treating a concussion is not possible. The myth surrounding the recovery time, and the problems with the use and structure of diagnostic tests (particularly as it relates to Return-to-Play and Return-to-Learn) contribute to a lack of appropriate treatment or rehabilitation. The obvious symptoms of headaches, dizziness, nausea, light sensitivity, etc., typically do resolve in a matter of hours or days, leading to the belief that treatment is not possible or necessary. Alternatively, we have discovered, and the professional literature supports, that functional deficits occur and can remain indefinitely, requiring post-concussive follow-up and rehabilitation (Daneshvar, D.H., Riley, D.O., Nowinski, C.J., McKee, A.C., et al, 2011; Guerriero, R.M., Giza, C.C., & Rotenberg, A., 2015).
The combination of myths, failing to identify or misidentifying concussions, problematic Return-to-Play and Return-to-Learn processes, and most importantly the functional physical, cognitive, and emotional enduring problems that result from concussive events that are often blamed on anything but the concussion, have all led to our identifying Covert Concussion Syndrome. We believe that recognition of this syndrome will lead to more accurate diagnosis, necessary rehabilitative activities, and the end of the permanent covert and undetected continuum of concussive-related symptoms and maladaptive functioning. The continuum of problems linked to undetected, undiagnosed, and untreated concussions ranges from mild dysfunction to devastating outcomes such as repeated physical injuries, substance abuse, academic problems and dropping out of school prematurely, incarceration, dementia and other illnesses such as Multiple Sclerosis, Parkinson’s Disease, and even death.
Covert Concussive Syndrome
Covert Concussive Syndrome (CCS) is defined as a set of neuro-physical, neuro-cognitive symptoms, neuro-interpretive, and/or neuro-emotional symptoms (identified as the concussive quartet) that are generated by undetected, undiagnosed, and untreated concussive forces (impact or motion) to the brain, and result in a variety of physical, cognitive, emotional, and academic deficits or maladaptations.
The clinicians at Performance Pediatrics have been diagnosing and treating concussions and other cognitive difficulties and impairments for many years. In recent years we began providing baseline assessments primarily to athletes from high schools across the Colorado Springs, CO metropolitan area. The baseline assessments are provided primarily for the purpose of providing information from which to determine the presence and/or extent of a concussion suffered by a high school athlete, as well as to assist in monitoring and managing the graduated return to play process as mandated by Colorado state law (Jake Snakenberg Youth Concussion Act) and the Colorado High School Activities Association (CHSAA).
A ”Beyond the Bump” program was created to assist the local high schools with managing the increasing number of suspected concussions, and doing so in a way that complied with the legal and regulatory requirements of the concussion statute and CHSAA. “Beyond the Bump” provides baseline screening, concussion assessment and diagnosis, and full graduated Return to Play (RTP) and Return to Learn (RTL) processes. When an athlete is suspected of suffering a concussion, he or she can call or come to our clinic, receive an evaluation and diagnosis within 24 hours, and immediately begin the treatment, recovery and graduated return processes. This provides comfort to the parents, since they know the head injury is being taken seriously, and comfort to the school since they have confidence that the athlete is being returned to play in the context of full compliance with state law and regulatory requirements.
The baseline screening process has been refined over the years, and now includes the concussive quartet of neuro-physical, neuro-cognitive, neuro-interpretive, and neuro-emotional elements. The neuro-physical screening includes an evaluation of balance, posture, visual system functioning, vestibular system functioning and gait mechanics. This is accomplished through use of a computer-based software program. Neuro-cognitive screening consists of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which is a neuropsychological screening instrument commonly used in clinical practice. Neuro-interpretive screening is accomplished primarily through a comprehensive clinical interview. Neuro-emotional screening includes self-report statements, and the use of screening instruments such as the Beck Depression and Beck Anxiety inventories. In our opinion and experience, this provides a comprehensive picture of the current concussive triad experienced by the athlete.
In recent years, and as a result of our baseline screening process and “Beyond the Bump” program, we were surprised to discover that a majority of these “baseline” screenings were not baselines at all. High school athletes who came to our clinic for their pre-sport baseline screening were presenting with neuro-physical, neuro-cognitive, neuro-interpretive, and neuro-emotional symptoms resulting from (in many cases years) prior concussive injuries. A review of over 400 “baseline,” pre-sport screenings revealed that a significant percentage had evidence of prior concussive injuries and current functional maladaptations in the areas of physical functioning, emotional functioning, cognitive functioning, interpretive functioning, and/or academic functioning. Perhaps even more surprising than the discovery that we were seldom conducting true baseline assessments was the response of the parents. Many parents and coaches, in preseason trainings provided as part of the Beyond the Bump program, reported experiencing current functional impairments similar to those being described and discovered with their children. When they were questioned further they began to recall a personal history of concussions or concussive events, even when they initially denied experiencing any concussive events.
As a result of these "baseline" screenings not actually measuring pre-injury status due to the presence of prior, undetected concussions, we no longer provide "baseline" screenings. This is consistent with the Berlin Consensus Statement on Concussion in Sport (2017), which states that baseline screening may be useful (italics added), but is not necessary, and the decision by the Parachute organization in Canada (self-defined as a national charitable organization in Canada dedicated to preventing injuries and saving lives) to no longer recommend or financially support the practice of baseline testing for potential concussive injuries.
The "baseline" screenings have been replaced by Brain Health Screenings, which is a more accurate and appropriate title, and results in much better long-term brain health and functioning. The Brain Health Screenings should occur on an approximately annual basis, with more frequent screening occurring following a concussive force (impact or motion) injury.
Description of CCS:
CCS, as defined above, occurs in a high percentage of the population, as our current data indicates. CCS can result in strictly neuro-physical functional deficits or dysfunctions, strictly neuro-cognitive deficits, strictly neuro-interpretive deficits or dysfunctions, strictly neuro-emotional deficits, or more commonly in a combination of all four.
CCS begins when an individual suffers an injury to the brain resulting from the excessive force caused by either an impact to the head or a sudden, forceful movement. It does not require a formal diagnosis of a concussion, but rather identification of the force injury that resulted in the concussive quartet and accompanying functional adaptive problems.
The following is a (non-exhaustive) list of potential problems resulting in part from, or caused by, CCS:
· Vision Adaptations
· Vestibular System Dysfunction
· Balance Difficulties
· Chronic Headache
· Chronic Pain
· Potential Vulnerability to Fibromyalgia/Immunological Problems/Endocrinological Problems
· Joint Injuries
· Muscular Dysfunction
· Postural Adaptations
· Physical Mechanics (movement literacy & gait)
· Proprioceptive Difficulties
· Potential Vulnerability to Multiple Sclerosis, Parkinson’s Disease, Dementia
· Memory Issues
· Attention/Concentration Problems
· Language Difficulties
· Visuospatial/Constructional Problems
· Learning Difficulty
· Academic Dysfunction
· Executive Function problems (e.g., problems with judgment, decision-making, impulse control, etc.)
· Motivation Deficits
· “Thinking Errors”
· Dysfunctional Belief and Thought Systems
· Interpretive Errors
· Automatic Inaccurate Perceptive Systems
· Elevated anxiety levels
· Panic attacks
· Irritability or Anger
· Low Self-Esteem
· Inaccurate Self-Concept
Diagnosis and Treatment of CCS:
At present, Performance Pediatrics is the only clinic that understands, identifies, diagnoses and treats CCS. Our assessment includes all elements of the concussive quartet and focuses on functional deficits in these areas. When a minimum of two functional deficits are identified in any or all domains, and the symptoms or functional deficits are occurring a minimum of three months following the most recent concussive force injury, the diagnosis of CCS is justified. The diagnosis includes a determination of severity, with the possibilities being Mild, Moderate, or Severe.
We have developed a series of treatments to address the symptoms of CCS. A key concept is homeostasis or balance, in that we want the individual (child, adolescent, athlete, non-athlete, adult, or senior) to achieve homeostatic (or balanced at pre-injury levels) brain and body function.
Because many of the symptoms can be mild, or more commonly, misattributed to other causes, people may be reluctant to participate in treatment themselves, or to authorize treatment of their children. While this is understandable, we believe it is a mistake.
The primary problem with ignoring the symptoms of CCS is that it will continue to cause greater functional physical and cognitive problems over time if unaddressed. New research is demonstrating a progressively stronger link between a history of traumatic brain injury (TBI) or mild traumatic brain injury (mTBI) and those who develop dementia and other brain disorders (Parkinson’s Disease, Multiple Sclerosis, seizure disorders, etc.) (Collins-Praino, L.E., Corrigan, F., 2017; Ramalho, J. & Castillo, M., 2015; Henry, L.C., Tremblay, S., DeBeaumont, L., 2017).
Additionally, we are collecting data that implicates CCS in a variety of behavioral disorders, including substance abuse, violence, and suicide.
Of less urgency, but perhaps no less important, are the many functional and adaptive problems caused by not addressing CCS. Our data indicates that athletes who address and resolve CCS are suffering fewer joint and musculo-skeletal injuries. Patients report (and treatment outcome measures validate) better posture, fewer balance problems, reduced or eliminated pain, and many other positive benefits. We have a comprehensive list (the following list are elements of the outcome measures, but there are a number of additional ones we use) of both objective (Kinetisense score; time to maximum cognitive triad load in rehabilitation; academic performance; behavioral incidents or infractions, RBANS follow-up scores, etc.) and subjective (reported sleep levels, self-report depression and anxiety inventories, observed gait, posture, and emotional changes, etc.) outcome measures that guide treatment interventions and demonstrate treatment progress and positive outcomes.
Finally, resolving CCS removes an important obstacle to individuals of all ages functioning and achieving at their highest possible level. CCS may result in talented athletes not functioning at their highest potential, limiting athletic scholarships and possible professional competition. It may also result in lower student achievement, lower college-aptitude scores, eliminating entrance into a university of their choice; it can result in chronic pain and chronically poor performance in a variety of areas that may be misattributed to laziness, “hypochondria,” lack of ability, stupidity, clumsiness, and a number of other inaccurate, pejorative perceptions. We believe that individuals of all ages should achieve homeostasis, be capable of performing at their best in whatever endeavor they choose, and give themselves every opportunity to achieve a pain-free life with reduced risk of dementia or other later-in-life brain disorders.