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Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Psychosocial and Mental Health Influences in Sports-Related Concussion Stephen A. Russo, Ph.D. Clinical Psychologist / Concussion Management

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 1

Psychosocial and Mental Health Influences in Sports-Related Concussion

Stephen A. Russo, Ph.D.

Clinical Psychologist / Concussion Management Specialist Clinical Director and Founder, Philadelphia Concussion Specialists Rothman Orthopedics Concussion Network Provider Phone: (484) 818-2225 E-mail: srusso@philaconcussion.com

 Dr. Russo has no relevant

financial relationships to disclose.

 Dr. Russo was Director of Sport Psychology

at the University of Pittsburgh Medical Center (UPMC) from 1999-2003 and is married to a former ImPACT Applications employee and a current employee of Sway Balance Systems. Disclosure Statement

Stephen A. Russo, Ph.D. 1 2

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 2

Presentations Goals



Highlight Potential Emotional and Mental Health Outcomes that Can Influence Compliance Practices as well as Recovery from SRC



Conceptualize Concussion as a Heterogeneous Injury with Various Clinical Trajectories and Outline Differences Between an Unresolved Concussion and Post-Concussion Syndrome



Explain How a Health Psychology Paradigm; an Inter-Disciplinary Approach to Clinical Management; and Consultation with a Concussion “Specialist” Can Promote Improved Clinical Outcomes

 Provide Attendees

with an Understanding

f the Evolution of

Sports-Related Concussion (SRC) Management

 Demonstrate How

Social, Biological, and Psychological Factors Influence Concussion Recovery and Suicide.

The Current Definition of Cerebral Concussion

McCrory et. al. (2005). Clinical Journal of Sports Medicine, 15 (2), 48-55.

A Complex Pathophysiological Process Affecting the Brain, Induced by Traumatic Biomechanical Forces to the Head, Face, Neck or Elsewhere

n the Body …

 Rapid Onset of Short-Lived Neurological Impairment that Resolves Spontaneously  Clinical Symptoms Reflect a Functional Disturbance Rather than Structural Injury  Typically Associated with Grossly Normal Structural Neuro-imaging.

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 3

Cognitive Behavioral Conceptualizations of Injury

Biopsychosocial Model Views Injury, Pain, and Chronic Health Conditions as a Multidimensional Integration of Physical, Psychological, and Social Factors Where Relationships Among Factors Influences Ones Clinical Presentation and Rehabilitation Outcomes

Adapted from Brewer (2012), New York: John Wiley & Sons, Inc; Engel, GL (1980), Am J Psychiatry; Murphy et al. (2014), Washington DC: U.S. Department of Veterans Affairs; Santi & Pietrantni (2013) Journal of Human Sport & Exercise.

Patient 1 Patient 3

Psych

Social Bio

Social

Bio Psych Patient 2

Bio

Psych Social

Cognitive Behavioral Conceptualizations of Injury

Patient 1 Patient 3

Psych

Social Bio

Social

Bio Psych Patient 2

Bio

Psych Social

5 6

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 4

Neurometabolic Cascade Following Cerebral Concussion

Giza & Hovda (2001). Journal of Athletic Training, 36 (3), 228-235.

2 6 12 20 30 6 24 3 6 10 minutes hours days 500 400 300 200 100 % of normal

K+

Glutamate

Glucose Cerebral Blood Flow Calcium

UCLA Brain Injury Research Center

Characteristics of Post-Traumatic Cerebral Metabolism & Blood Flow

Giza & Hovda (2001). Journal of Athletic Training, 36 (3), 228-235.

Cerebral Glucose Metabolism Cerebral Blood Flow 100% Above Normal 50% of Normal, No Ischemia

UCLA Brain Injury Research Center

THE MISMATCH BETWEEN THE ENERGY DEMANDS OF THE BRAIN AND THE METABOLIC FUNCTIONS THAT SUPPLY CEREBRAL GLUCOSE PRODUCE AN “ENERGY CRISIS” 7 8

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 5

Most Commonly Reported Concussion Symptoms: High School and College Athletes

Lovell et al. (2004); N = 215

71 % Headache 58 % Feeling Slowed Down 57% Difficulty Concentrating 55 % Dizziness 53% Fogginess 50 % Fatigue 49% Blurry or Double Vision 47% Light Sensitivity 43% Memory Dysfunction 43% Balance Problems

BASELINE TESTING

CONCUSSION

FIRST FOLLOW- UP FOLLOW- UP TESTING, AS NEEDED RETURN TO PLAY AT SCHOOL OR CLINIC REMOVE FROM PLAY EVALUATION PRE-SEASON 1-3 DAYS

Because Concussed Athletes Were Notorious for Hiding Symptoms and Vary Tremendously in How They Perform on Formal Testing, The Concepts of Baseline and Post-injury Testing Were Developed

Concussion Management: Return to Play Protocol

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VESTIBULAR ANXIETY / MOOD OCULAR COGNITIVE / FATIGUE MIGRAINE CERVICAL SPINE

Using Trajectories to Inform Treatment

Clinical Interview

 Constitutional Risk Factors  Functional or Acquired Risk Factors

Computerized Neurocognitive Testing

 Match / Exceed Baseline Performance?  Examine Composite and Subtest Cognitive Profiles for Trajectories

Postural Stability/Balance Assessment

 Fatigue / Examination Findings  Findings Help Determine Level / Type of Activity

Vestibular-Ocular Screening (VOMS)

 Provocation Events?  Vestibular Tasks  Ocular Tasks

Clinical Management

 Behavioral Management (Rest, Exert, Refer)  Therapy and/or Medication Considerations  Academic and Vocational Considerations

Collins et al. (2014). Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 22(2), 235-246.

The Cranial Nerves

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Visual System Structures and Function

Visual System one of the Most Complex Structures of the Human Brain! Eyes and Cerebral Pathways of the Visual System are Responsible for Much More than Just Eyesight. Color and Movement Recognition as Well as Visual Acuity Begins in the Eye Eye has Some Camera-Like Features:



The Cornea and Lens Focus Light



Light Refracts (BENDS) as it Passes Through the Cornea on its Way to Retina



Ciliary Muscles within the Eye Adjust Focus by Changing Shape of Lens (ACCOMMODATION).

Visual System Structures and Function

The Ability to Coordinate Sensory Input as well as Derive Meaning and Direct Action from what We See is Related to the Basic Functioning of the Eyes. However, Brain does NOT Function like a Camera!

Sensory Information Must be Decoded and Processed by Brain, Which Requires Energy and Accurate Information!

Vision Requires Sensory and Cognitive Integration and Assessing Vision Allows Us to Detect Dysfunction Not Picked Up Using Cognitive Testing Alone Vision is Also Dependent on Eye Movement Which is Controlled By Extraocular Muscles that Function Along Cranial Nerves

Type of Visual Impairment: % mTBI n = 20 % Controls n = 20 p Convergence Insufficiency 55% 5%

0.0012*

Saccadic Impairment 30% 0%

0.0202*

Pursuit impairment 60% 0%

<0.0001 *

Ocular Misalignments (Vertical Phoria) 55% 5%

0.0012*

Ocular Misalignment (Horizontal Phoria) 45% 5%

0.0084*

Accommodative Dysfunction 65% 15%

0.0031*

Capo´-Aponte et. al. Military Medicine, 2012

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Persistent Sxs May Be Due to Vestibular Dysfunction

An Understanding of the Visual and Vestibular Systems and the Assessment of these Systems is Necessary to Treat Concussive Injuries Effectively “Active” Intervention May Be Needed to Ensure Resolution of Vestibular and Visual Problems

Nerve Fibers from Vestibular Receptors Synapse in the Vestibular Nuclei in the Brainstem



Hair Cells Embedded in Columns (Cupulae) Emerge from Receptors and Transduce Movement into Electrical Signals



Some Fibers Go Directly to the Cerebellum.



Head Tilt and Acceleration / Deceleration is Signaled by Slippage of Otolith-Laden Gel across the Hair Cells of the Saccule / Utricle

The Vestibulo-Ocular Reflex (VOR): Allows You To Gaze at a Fixed Point while Your Head Moves. Motion Sickness: The Feeling of Nausea Caused by Passive Movements Sensory Conflict Theory: Motion Sickness Can Be Due to Conflict in Visual and Vestibular Information

Vestibular System Structures and Function

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 9

Generic Accommodations and Interventions For Vestibular / Ocular Dysfunction:

Pre-printed Notes /

Presentations in 18pt Font

Limit Screen Time / Schedule

Breaks

Turn Brightness Down on Devices /

Allow Sunglasses / Hats where Possible

Note to Excuse from Class Early to

Avoid Busy Environments

Keep Active – Need to “Recalibrate”

Ocular and Vestibular Systems through Activity and Targeted Treatments

Vestibular and Ocular Interventions

If VOMS Provokes / Worsens Symptoms or Measurements are NOT within Normal Limits, Consider Referral to:

Optometrist, with Specific Training

In Concussion Rehabilitation

Neuro-Optometrist
Behavioral Optometrist
Vision Therapist
Vestibular Therapist
Occupational Therapist

Are There Long-Term Effects of mTBI?

In 2007, Guskiewicz et al. Reported a Dose-Response Relationship Between Self-Reported SRCs and Clinical Depression Later in Life in Ex-NFL Athletes. Separately, Costanza (2011) Reported as much as a 5-Fold Increase in the Prevalence of Mild Cognitive Impairment (MCI) and Earlier Onset

f Dementia w/ Multiple Concussions …

But Public Concerns about Long-Term Effects Were often Discounted

Costanza, A. (2011). Neuropathology and Applied Neurobiology, 37, 570-584.

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Chronic Traumatic Encephalopathy: Defined

A Neuro-Degenerative Disorder Resulting from Repetitive Brain Trauma



Called “Punch-drunk” by Martland in 1928



“Dementia Pugilistica” by Millspaugh in 1937



Psychopathic Deterioration of Pugilists by Courville in 1962



Termed CTE by Miller in 1966

Clinical Features Include Slurred and Dysarthric Speech, Gait Problems, Parkinsonism, Cognitive Impairment, and Dementia Recent Emphasis Has Been in Athletic Populations

Historically Reported in Boxers Now Documented in Football, Professional Wrestling, Ice Hockey, Rugby, Martial Arts, Lacrosse, Soccer Is Associated with Concussions, but Does not Require Concussive Hits

Iverson. (2017). Sports Neuropsychology Society Symposium

Corsellis et al. (1973). Psychological Medicine, 3, 270-303. McKee et al. (2013). Brain, 136, 43-64

Iverson. (2017). Sports Neuropsychology Society Symposium

Corsellis et al. (1973). Psychological Medicine, 3, 270-303. McKee et al. (2013). Brain, 136, 43-64

CORCELLIS ET AL. (1973) OUTLINED THREE (3) STAGES OF CTE

Early Symptoms: Irritability / Anger, Dizziness, Apathy, Poor Episodic Memory, Executive Dysfunction, Disorientation /Confusion, Persistent Headaches Late Symptoms: Suicidality, Risky Behaviors / Accidents, Movement Abnormalities Language Difficulties, Amnesia / Dementia, Ocular Abnormalities, Accidental Overdoses

Prior to 2015, There Were No Empirically Evaluated Diagnostic Criteria for Either the Neuropathology or the Clinical Features of CTE!

The First Consensus Meeting (2016) to Define Neuropathological Criteria for CTE Could Only Agree On Two (2) “Characteristic” Features: Hyperphosphorylated Tau + Neuropathological Tau Buildup in Depts of Brain Sulci

Today, No Study Has Been Able To Connect Neurodegeneration To Clinical Presentation or Provide Determinations Regarding Static Versus Progressive Versions of CTE

Chronic Traumatic Encephalopathy: Epidemiology & Course

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Chronic Traumatic Encephalopathy: Epidemiology & Course

Only Epidemiology Study was Conducted in Boxing and Found that 17% of 224 Retired Boxers Had CTE (Roberts, et al., 1990) Roberts described what appeared to be Two (2) Distinct Syndromes, Where One Appeared to be a Static Condition and Another Appeared to be Progressive. McKee et al.’s 2009 study confirmed 51 cases of CTE 90% (46) occurred in athletes 39 boxers (mean 14.4 years playing) 5 football players (mean 18.4 years playing) 1 wrestler and 1 soccer player Of 321 Retired NFL Players who Died between 2008-2010, 12 were Examined Neuropathologically and All Showed Signs of CTE. If only Those That were Examined Had CTE (i.e., 12/321) then Lifetime Prevalence would be 3.7%

Iverson. (2017). Sports Neuropsychology Society Symposium

Corsellis et al. (1973). Psychological Medicine, 3, 270-303. McKee et al. (2013). Brain, 136, 43-64

ORIGINAL CTE CASES ALMOST EXCLUSIVELY MALE, BUT FEMALES AND NON-ATHLETIC POPULATIONS HAVE ALSO BEEN FOUND WITH CTE As of 2019, Populations / Health Conditions with CTE-Related Neuropathology:

Depression Sleep Apnea Insomnia Alcohol Use Chronic Pain Narcotic Opiate Use Hypertension Diabetes Migraine MCI / Alzheimer’s Parkinson’s Disease Autism + Self-Injury Substance Abuse + No Known Neurotrauma No Substance Abuse + No Known Neurotrauma

Proposed Risk Factors for CTE:

Length of Career Exposure to Head Impacts Magnitude vs. Amount of Trauma Amount of Sparring / Hitting in Practice Stand and Slugging Fighting Styles Hitting Technique / Aggressive Play Position Played Age of Retirement Caucasian?? Possible ApoE ε4 Genotype??

Chronic Traumatic Encephalopathy: Epidemiology & Course

Iverson. (2017). Sports Neuropsychology Society Symposium

Corsellis et al. (1973). Psychological Medicine, 3, 270-303. McKee et al. (2013). Brain, 136, 43-64

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Cognitive Behavioral Conceptualizations of Injury

Patient 1 Patient 3

Psych

Social Bio

Social

Bio Psych Patient 2

Bio

Psych Social

VESTIBULAR ANXIETY / MOOD OCULAR COGNITIVE / FATIGUE MIGRAINE CERVICAL SPINE

Using Trajectories to Inform Concussion Treatment

Previous Concussions
Migraine History (Family / Personal)
Age
LD / ADHD History
Sex
Ocular History
Motion Sensitivity
Litigation
Prior Functioning: Physical
Prior Functioning: Psychological

FACTORS THAT INFLUENCE RECOVERY

Collins et al. (2014). Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 22(2), 235-246.

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Bucks County Intermediate Unit's 4th Annual School Concussion Conference January 29th, 2020 Psychosocial and Mental Health Influences in Sport-Related Concussion 13

High School Statistics

The Overall Rate of Injury for High School was 4.36 Per 1000 Athlete-

Exposures. Of Those Injuries, Concussions Represented 9.2% in Practice

and 12.0% in Competition. Injury Rates Are 11x Higher for Games than Practice! The Largest Percentage of mTBI Occurred among Linebackers (14.3%), Running Backs (14%) and Offensive Lineman (13.4%) The Most Common Mechanism of Injury was Contact with an Opponent (63.3%), Contact with a Teammate (16.9%) and Contact with Equipment

r Playing Field (3.8%).

26% OF ATHLETES REPORTED SUSTAINING A CONCUSSION AND KEPT COMPETING WITHOUT NOTIFYING ANYONE ABOUT THE CONCUSSION.

Concussions in A Football Environment

Shankar et al., 2007, AJSM; Powell, 1999, JAMA; Guskiewicz, 2000. AJSM http://www.pressrepublican.com/saturday/local_story_201000133.html/resources_printstory

Why Don’t HS Athletes Report?

(McCrea et al., 2004. CJSM)

McCrea et al., 2004. CJSM

Who Do They Report To?

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Douglas Brunt – Time Magazine; May, 2017 “Money is Ruining Youth Sports” Jacob Bogage – Washington Post; Jan, 2017 “Sport Specialization Increases Injury Risk For HS Athletes, Study Finds”

The Culture of Youth Athletics

Sports No Longer A Prize Unto Itself!

Educational Component Diminished
Greater Focus on “Destinations” Such as College and Professional Sports,

Particularly for Parents w/o H.S. Degrees.

Prevailing Mindset for Success has Become Sport Specialization.
Other Pursuits (e.g., Music, Art) Have Also Adopted Specialization Approach.
Dedication, Time, & Money for Year-round Play is Far Beyond Previous Generations

Kids Aren’t Just Picking One Sport at the Expense of Other Sports. They’re Picking One Sport at Expense of Other Extracurricular Interests.

Early Specialization Actually Narrows Development and Increases Risk of Injury!! Specialized Athletes More Susceptible To Injury Because They Are “Exposed” To Their Sport More Often and Put More Stress on The Concentrated Group of Muscles, Ligaments and Bones Related To Their Individual Sport (i.e., “Overtrained”).

Predictor of Overuse Injuries: Training Volume

Injury Rates in High School Athletes Have A Direct Relationship to Exposures by Hours Per Week and Higher Training Intensity / Volumes Have Consistently Been Shown To Increase The Risk of Overuse Injuries.

Injury

Scheduling

Multiple Events on Same Day or Several Events over Consecutive Days is Considered A Risk Factor for an Overuse Injury

Yearly Volume

Kids (9-14) Who Pitched More Than 100 Innings A Year Were 3.5 Times More Likely To Suffer An Overuse Injury

Yearly Volume

There Is an Increased Risk for Shoulder and Elbow Injuries in Youth Pitchers Who Pitch More than 8 Months A Year.

Yearly Volume

There Was 42% Increase in Overuse Injuries in High School Athletes Who Participated All Year Versus 3 Seasons or Less Per Year

Weekly Volume

Training More than 16 Hours A Week Was Associated with A Significantly Increased Risk of Overuse Injury

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Pre-College Specialization in Athletics

Familial Expectations for NCAA Athletes

60 66 66 51 39 30 32 14 10 20 30 40 50 60 70 FB: DI - FBS FB: DI - FCS FB: DII FB: DIII College Athlete Pro / Olympic

Since I was young, my family expected I would be a …

(% of NCAA Football Players Responding “Agree” or “Strongly Agree”)

ACCORDING TO NCAA 2015 GOALS STUDY

Endorsement of Top Two (2) Categories on a 6-Point Scale (Note: 4,724 Football Student-Athletes Surveyed)

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Familial Expectations for NCAA Athletes

71 67 53 28 14 4 10 20 30 40 50 60 70 80 WBB - DI WBB - DII WBB - DIII College Athlete Pro / Olympic

ACCORDING TO NCAA 2015 GOALS STUDY

Endorsement of Top Two (2) Categories on a 6-Point Scale (Note: 1,089 Women’s Basketball Student-Athletes Surveyed)

Since I was young, my family expected I would be a …

(% of NCAA Women’s Basketball Players Responding “Agree” or “Strongly Agree”)

The Current Culture of Adolescence

Today’s Adolescents: Post-9/11 Generation, Raised in Era of Insecurity

 Never Known a Time when Terrorism and School Shootings Weren't the Norm.  Grew Up Watching Their Parents Weather a Severe Recession  Hit Puberty when Technology and Social Media Were Transforming Society.  In addition to Schoolwork, Significantly More Standardized Testing Protocols Implemented in the Past Decade

For Today’s Adolescents, "No Firm Line” between Real and Online Worlds

 Technology and Online Bullying Are Affecting Kids as Early as Fifth Grade.  Every Fight / Slight is Documented Online for Hours or Days after the Incident.  Managing a Social-Media Identity Plus Fretting about Unique Cultural and Societal Pressures

Anxiety and Depression in High School Has Been on the Rise Since 2012

 Statistic Cuts Across All Demographics - Suburban, Urban, and Rural  Mental Illness Impacts Those Who Are College Bound And Those Who Aren‘t  Family Financial Stress Can Exacerbate These Issues  Studies Show That Girls Are More At Risk Than Boys.

Susanna Schrobsdorff – Time Magazine; Oct., 2016 “Teen Depression and Anxiety: Why the Kids Are Not Alright”

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The Current Culture of Adolescence

In 2015, HHS Reported that about 3 Million Teens (Ages 12-17) Experienced at Least One Major Depressive Episode in the Preceding Year

 More Than 2 Million Report Experiencing Depression that Impairs Daily Function.

According to the NIMH, about 30% of Girls and 20% of Boys (Almost 6.3 Million Teens) Have Had an Anxiety Disorder

 Child Mind Institute (2015) found only about 20% of youth with a Diagnosable Anxiety Disorder Get Treatment.

Susanna Schrobsdorff – Time Magazine; Oct., 2016 “Teen Depression and Anxiety: Why the Kids Are Not Alright”

Student Athletes and Stress

College Student-Athletes Experience More Psychological Pressure and Stress than their Non-Athletic peers, But are Significantly Less Likely to Seek Mental Health Services. When Student-Athletes Seek Counseling, They Have More Stress-Related Physical Illnesses and Higher Rates of Depression and Anxiety. Examination of Student-Athlete Sleep Patterns Show they Experience, on Average, Four Nights of Insufficient Sleep per Week. Sleep Deprivation Has Been Demonstrated to be A Factor in Diminished Performance on Neuropsychological Assessments w/o HX of Concussion (McClure et al., 2014; Haran et al., 2019)

Issues Such as Pressure to Perform, Time-constraints, High Training Volumes, and Limited Sleep Exemplify Their Heightened Stress Levels.

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Cognitive Behavioral Conceptualizations of Injury

Patient 1 Patient 3

Psych

Social Bio

Social

Bio Psych Patient 2

Bio

Psych Social

Injury-Related Emotions Associated with Rehab Outcomes

Persistent Emotional Disturbance after Injury is Associated with:

 Poor Adherence To Rehabilitation Regimen  Decreased Confidence in a Full Recovery  Diminished Belief in Future Success In Sport  Poor Rehabilitation Outcome

A Reluctance to Discuss Emotions Related to Being Injured with Peers or Coaches Was Associated with:

 Persistent Feelings of Isolation and Alienation  Reduced Long-term Psychological Rehabilitation

Factors Associated with Faster Recovery from Injury Include:

1. Maintaining a Positive

Attitude and Outlook

2. Being Self-Motivated /

Having Desire to Heal

3. Having Social Support in

Primary Social Network and Rehabilitation Facility. 35 36

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Kontos, A.P. (2017). Sport, exercise, and performance psychology, 6 (3), 215–219.

Physical / Psychological Readiness to Return to Sport Don’t Always Coincide! Mental Factors Can Influence Response to Injury as Well as Physical Outcome!! The Impact of Psychological Factors Post-Concussion is Not Well Understood!!!

Mood and Emotions Motivation Trust in Treatment Self-Efficacy Athletic Identity Social Support Cognitions

Recovery

Physical / Mental Recovery From Sports Injuries

Injury-Related Emotions Associated with Rehab Outcomes

Injury: A Significant Stressor That Athletes Are Sometimes Ill-prepared (or Unwilling) To Face!!

 Frustration, Confusion, Anger, & Fear Are Common Reactions, but Generally Decrease as Rehabilitation Progresses  Injured Athletes More Likely to Have Depression, Anxiety, and Low Self-esteem Than Non-Injured Peers  EMOTIONAL REACTIONS NOT AS FIXED OR ORDERLY AS SUGGESTED BY “GRIEF” MODELS.

Athletes Also Have Fear During the Transition Back to Sport. Common Fears Include:

 Fear of Re-injury  Fear of Falling Behind Others  Fear of Underperforming  Fear of Missing Out

Athletes with Lower Self-esteem and Greater Emotional Reactions After Injury Were:

 Generally More Invested in Playing Professional Sports  Had A Greater Identification with Being an Athlete  Rarely Had Other Interests, Activities, or Motivations Outside of Sports.

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Anxiety Symptoms Associated with Concussion

Children w/ Post-Concussion SXS for Longer Than One Month Reported More Anxiety Than Children Whose Symptoms Resolved Within One Week

(Grubenhaff et al., 2016)

In A Pediatric Population, Concussed Patients w/ No Premorbid HX of Anxiety Took  76 Days To Recover. Patients Diagnosed w/ Premorbid Anxiety Took  6 Months To Recover.

(Corwin et al., 2014)

Youth and Collegiate Athletes Who Exhibited Early Signs of Anxiety Should Be Targeted For Interventions To Decrease Their Chances of Prolonged Recovery From SRC

(Collins, Kontos, Reynolds, Murawski & Fu, 2014)

Yang et al. (2015) Reported Over One-Third of Concussed College Athletes Experienced State Anxiety Following Their SRCs. Turner et al.’s (2017) Comparison

f CONC and MSK Groups:

 73.3% of Participants Exceeded Threshold for State Anxiety during Acute Phase of Post-Injury … REGARDLESS OF TYPE OF INJURY  Both Groups Demonstrated Gradual Improvement in Mood State Throughout The Recovery Process  Over Half of Participants in Each Group Scored Above Cutoff During ACUTE and RETURN TO PLAY Phase!!

Anxiety and Mood Clinical Profile Following SRC

Anxiety / Mood Clinical Profile is Characterized By Emotional Disturbance (e.g., Anxiety, Dysphoria), Hypervigilance of Somatic Complaints, and Sleep Dysregulation.

General Indicators of Emotional Disturbance after Injury Include:

 Inconsistencies in Subjective Sx Reporting vs. Objective Deficits  Worsening of Symptoms and Deficits Over Time BRAIN ALTERATIONS: The Overlap of SRC-Symptoms and Mental Health Disorders are Partially Due To Physiological Changes That Occur in The Emotional Centers of The Brain after Concussion. ANXIETY AND EMOTIONAL DYSREGULATION HAVE ALSO BEEN IDENTIFIED AS RISK FACTORS FOR BOTH SUICIDAL IDEATION AND SUICIDAL ATTEMPTS

Sandel et al. (2017). Sport, exercise, and performance psychology, Vol. 6 (3), 304–323. Sareen et al. (2005). Arch Gen Psychiatry, Vol. 62, 1249–1257.

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Anxiety and Mood Clinical Profile Following SRC

Sandel et al. (2017). Sport, exercise, and performance psychology, Vol. 6 (3), 304–323.

Primary Objectives After Injury = Restoration of Athletic Ability / Return To Play

Turner et al. (2017) Document Similar Psychological Responses in Concussion and MSK Injuries … Both Groups Show Elevated Emotionality within First 7-10 Days and Gradual Improvement in Mood State Throughout Recovery Process Authors Conclude Psychological Factors Play A Larger Role Than Physiological Response To Concussion:

 Time Loss From Practice / Games  Social Isolation  Withdrawal From ADLs

Mental Health History:

Diagnosed Mental Health History or Previous Mental Health Treatment Predicts Greater Symptom Endorsement and Protracted Recovery

Social Support:

Severity of Original Injury Does Not Directly Correlate with Risk of PCS, but Perceived Stress Post-Concussion Has Been Positively Associated with Levels of Anxiety and Depression High Levels of Parental Pre-injury Anxiety and Child Reported Stress after Concussion Were Predictive of Greater Symptoms at 18 Months Post-Injury. Covassin et al. (2014) Reported That Concussed Athletes Who Endorsed High Levels of Social Support Reported Low Levels Post-Injury Anxiety

Amotivation Athletic Identity

Quality of Social Support

Performance Anxiety

Motivational Climate of Coach / Parent

O’Rourke et al. (2017). Sport, exercise, and performance psychology, 6 (3), 262–276.

O’Rourke et al. (2017) Examined 70 Athletes Who Presented to a Concussion Clinic Affiliated with a University-Based Children’s Hospital.  Participants Presented to Clinic on Average 7.67 Days (+ 3.12 Days) Post-concussion and Were Assessed at Three, Separate Time Periods (<14 Days; 14-21 Days; 21-28 Days) Athletes w/ Continued SXS Up To 28 Days Post-Concussion had:  Higher Athletic Identity  Higher Levels of Amotivation  Higher Levels of Performance Anxiety Larger Social Network Size Predicted Greater Sx Improvement High Mastery / Low Ego Coach Environment and Low Mastery / High Ego Parent Environments Predicted Symptoms Reductions

PSYCHOSOCIAL VARIABLES ACCOUNTED FOR 23 - 31% OF SYMPTOM CHANGE OVER TIME

Concussion in A Health Psychology Context

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Cognitive Influences on Injury and Chronic Pain

Covassin et al. (2014) Suggested Prevalence of Anxiety In SRCs Due To:

 Heightened Perception of Severity  Lack of Prognostic Timeline for RTP  Loss of Athletic Identity

CATASTROPHIZING, is Associated with Higher Levels of Subjective Pain Intensity, Disability, and Emotional Distress. CATASTROPHIZING is a Way of Thinking about an Injury Where People:

Ruminate about Painful Sensations: Magnify Values of Pain Sensations: Feel Helpless To Cope Effectively:

“I Can’t Stop Thinking About the Pain” “Pain Means Something is Seriously Wrong” “There is Nothing I Can Do About It”

Other Cognitive Factors Associated with Chronic Pain:

 Hurt vs. Harm Mentality: Pain is Interpreted as Evidence of Further Damage To Tissue Rather than an Ongoing

Stable Problem That May Improve. Individuals with this Mindset Report Higher Pain Intensity, Regardless of Whether Damage is Actually Occurring

 Answer Seeking: Failure to Accept the Offered Cause of Pain or Being Unwilling to Accept That a Source of Pain

Cannot Be Determined Can Interfere with Affective Management. The Belief That One’s Pain is a “Mystery” Can Lead to Intense Distress as well as Increased Pain Intensity.

 Pain Self-Efficacy: A More Adaptive Belief about Pain Whereby Person Achieves a Level of Confidence that

Some Degree of Control can be Exerted over Pain. Improvements in Pain Self-Efficacy Often Correlate with Important Pain Outcomes Associated with Functionality Covassin et al. (2017). Sport, exercise, and performance psychology, 6 (3), 220–229. Murphy et al. (2014). Washington DC: U.S. Department of Veterans Affairs.

Depressive Symptoms Associated with Concussion

Several Have Documented Increased Depression in Athletes w/ SRC

(Hutchinson et al., 2009, Manwaring et al., 2004, Kontos et al., 2012).

Depression is a Common Feature of PCS AND Chronic Pain, But Difficult To Determine a Causal Direction Between an Emotional Disturbance and Pain Fixation. Armstrong & Oomen-Early (2009) Reported 33.5% of Collegiate Athletes Exhibit Depression Symptoms ... Found No Difference Between Student Athletes and Non-Athletic Students. Depression in HS and College Athletes w/ SRC Appears to Follow a Similar Trajectory as Cognitive Sequela of SRC, Typically Resolving w/in One Month of Injury

(McCrory et al., 2013, Roiger et al., 2015)

Yang et al. (2015) Found:

 20% of Concussed College Athletes Had Increased Depression Symptoms after SRC  21.4% of College Athletes Reported Depression Symptoms at Baseline!  College Athletes w/ Baseline Depression 4.59 Times More Likely To Suffer Dysphoria After SRC.

Haran et al (2019) Reported that Negative Mood States (i.e., Restlessness, Anxiety, Depression, Anger, Fatigue) have Negative Correlations with Neurocognitive Performance!!

Covassin et al. (2017). Sport, exercise, and performance psychology, 6 (3), 220–229.

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Suicide in A Health Psychology Context

Suicide: 10th Leading Cause of Death in U.S.

Over 43,000 Completed Suicide in 2015 Male-Female Suicide Ratio = 4:1 Suicide Rate Highest in Middle Aged, White Males, But Women are 3x More Likely to “Attempt” Suicide

From 2014-2015, Overall Age-Adjusted Suicide Death Rate Increased 2%, from 13.0-13.3 Deaths per 100,000

Suicide is Either the 2nd or 3rd Leading Cause of Death for Individuals Between the Ages of 10 and 35 years of age.

In 15-24 year-olds, Suicide Death Rate Rose 8% From 2014-2015, w/ 12.5 Deaths per 100,000 in 2015. Ratio of Suicide Attempts to Suicide Deaths in Youths is Estimated to be 25:1, Compared to 4:1 in the Elderly

Risk Factors for Suicide and Suicide Attempts Include Depression, Anxiety, and Substance Abuse Disorders

(Olfson et al., 2017)

American Foundation for Suicide Prevention, Suicide: 2016 Facts and Figures National Center for Health Statistics. Health, U.S., 2016: With Chartbook on Long-term Trends in Health.

Suicide, Traumatic Brain Injury, & Sport-Related Concussion

Connections Between Suicide & Health Conditions Associated with Concussions (i.e., Chronic Traumatic Encephalopathy) have been Greatly Exaggerated Due to Media Interest. Omalu et al. (2010) Concluded That Suicide MAY

BE Associated with CTE Because Their Seminal

Work, which Began in 2004, Examined Two Cases (Out of Three) That Completed Suicide. Suicide Was NOT Considered A Diagnostic Feature of CTE Throughout the First 80 Years of Examination:

 No Confirmed Suicides in Roberts’ (1969) Retired Boxer Study  In McKee et al.’s (2013) Autopsy Case Series, People w/ CTE Pathology Were Significantly

LESS LIKELY To Have Completed Suicide Than

Those w/o CTE  Currently No Published Studies Have Shown a Relation Between Contact Sports, CTE, and Risk of Suicide

Dreer et al. (2017). Current Opinion in Psychology, 22, 73-78.

Iverson. (2017). Sports Neuropsychology Society Symposium

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Suicide, Traumatic Brain Injury, & Sport-Related Concussion

Several Studies HAVE Documented an Increased Risk of Suicide Following Traumatic Brain Injury

(Bahraini et al., 2013, Berman & Pompili, 2011, Dreer et al., 2017).

Elevated Risk for Suicide Following TBI Has Been Reported in Several Studies, and Does not Appear to Decease for Many Years Post-Injury Concussion in Military and Civilian Populations Has Been Reported To Result in 3x-4x Greater Risk for Death by Suicide. Fralick et al. (2016) Reported a Suicide Rate 3x the Population Norm that Occurred over a Median Follow-up of 9.3 Years.

In Military, TBI Alone NOT Associated w/ Increased Risk of Suicide

 Likelihood Increases w/ TBI AND Posttraumatic Stress, Substance Abuse, or Depression In One of The Few Studies To Examine Suicide Following Sports-Related Concussion, Only 10% of Athletes with a Post-Injury Psychiatric Outcome Had Suicidal Ideation

(Ellis et al., 2015).

Suicidal Ideation in General Population Following TBI:

 13-28% of Individuals w/ Brain Injury Had Suicidal Ideation within the 12-Months That Followed  20 Years Post-Injury, Suicidal Ideation Estimated at

7-10%

Dreer et al. (2017) Observe:  Among those with mTBI, a propensity toward risky behavior may be associated with BOTH sustaining a concussion and engaging in suicidal behavior.

Dreer et al. (2017). Current Opinion in Psychology, 22, 73-78.

Iverson. (2017). Sports Neuropsychology Society Symposium

VESTIBULAR CERVICAL SPINE MIGRAINE COGNITIVE/ FATIGUE OCULAR ANXIETY/MOOD

Using Trajectories to Inform Treatment

Collins et al. (2014). Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 22(2), 235-246. Simpson & Tate (2005). Journal of Nervous and Mental Disease, Vol. 13(10), 680-685.

SIMPSON & TATE (2005) POSITED THAT SUICIDAL IDEATION / ATTEMPTS WERE DIRECTLY ASSOCIATED WITH THE EFFECTS OF mTBI AND IDENTIFIED CHANGES IN EYESIGHT; DIFFICULTY WITH BALANCE AND COORDINATION; AND PROBLEMS WITH MOOD / ANXIETY / EMOTIONAL REGULATION AS RISK FACTORS

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Cognitive Behavioral Conceptualizations of Injury / Chronic Pain

Biopsychosocial Model Is Largely Accepted as Best Way to Conceptualize Injury and Chronic Pain Because it Acknowledges Ways Individuals Experience Pain Uniquely! Severity of Injury and Injury HX Affect Biological, Psychological, and Social Dimensions, but so Do Demographic Factors like Age, Gender, and Socio-Economic Status.

Adapted from Brewer (2012), New York: John Wiley & Sons, Inc; Engel, GL (1980), Am J Psychiatry; Murphy et al. (2014), Washington DC: U.S. Department of Veterans Affairs; Kanzler et al. (2012). https://doi.org/10.1111/j.1533-2500.2012.00542.x Lowry (2013). JAMA Psychiatry Santi & Pietrantni (2013) Journal of Human Sport & Exercise

Readiness to Return to Sport
Readiness to Return to School
Satisfaction of Treatment
Functional Performance
Ability to Move Past Injury

Social Factors Biological Factors

Injury Characteristics Socio Demographic Factors Psychological Factors

Intermediate Biopsychological Outcomes Sport Injury Rehabilitation Outcomes Pain Intensity is One of the Most Powerful Predictors of Activity Tolerance, Particularly in Rehabilitation Settings, which Has Direct Bearing

n Treatment Outcome!

Chronic Pain, Subjective Pain Severity, and the Perceived “Burden” that Pain Sufferers Have on Others Have all Been Identified as Factors Associated with Suicide

Prescription of Prolonged, Strict Rest Has Been Associated w/ Development

f Emotional Difficulties That, For Some,

Include Suicidal Ideation and Intent.

PHYSICAL ACTIVITY AND DESENSITIZATION:

An Increase in Concussion Symptoms is a Common Occurrence As People Increase Their Activity Levels, Post-Injury Positive Influence of Physical Activity on Mood / Anxiety is Multifactorial while Avoidance Behaviors Can Become “Conditioned” Quickly Avoidance Results in Loss of Outlets for Coping w/ Stress as well as Limited Engagement In Meaningful, Social Interactions, Loss of Daily Routine, and Hopelessness

Psychological / Counseling Interventions for Concussion

Sandel et al. (2017). Sport, exercise, and performance psychology, Vol. 6 (3), 304–323.

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CBT Interventions for Chronic Pain Conditions

Intervention Focuses on Helping Individuals Change Thoughts and Behaviors Associated with Pain By Learning Adaptive Pain Coping Skills and Developing a Strong Sense of Pain Self-Efficacy.

Murphy et al. (2014). Washington DC: U.S. Department of Veterans Affairs.

Recent Studies Have Documented the Positive Impact that Physical Exercise has on Concussion Recovery

(Lal et al., 2017; Leddy et al., 2018)

Leddy et al. (2018) Compared:

 Exercise Group (EG, n=24): 20 minutes of daily subthreshold aerobic exercise  Rest Group (RG, n=30): Prescribed relative rest.

Both groups were tracked until recovery (i.e., days), defined as return to baseline symptoms, exercise tolerant, and “cleared” by physician

 Recovery time for EG = 8.29 + 3.9 Days  Recovery time for RG = 23.93 + 41.7 Days  No EG participants had delayed recovery (>30 days), but 13% (4/30) of RG participants did

Hugentobler, et al. (2019) identified exertional intolerance, vestibular deficiency, visual problems, and cervical dysfunction as “targets” for active concussion rehabilitation strategies following a thorough evaluation.

Empirical Support for Active Recovery

Managing Sport Concussions: Exercise

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Behavioral Regulation = Practice of Maintaining Healthy Lifestyle Factors To Prevent PCS Symptoms From Becoming Chronic Impairment:

 Sleep / School Schedule  Adequate Nutrition and Hydration  Daily Movements / Physical Activity  Management of Stress

COPING STYLE:

Active, Problem-Focused Coping Style Shown To Be Beneficial In Reducing PCS Symptom Burden Individuals w/ Higher Levels of Resiliency Demonstrated Less Emotionality as well as a Better Quality-of-Life after Concussion

PSYCHOEDUCATION:

Reassurance; Provision of Support; and Appropriate Education Shown To Reduce PCS Symptoms in Several, Replicated RCT Studies

Discussion of SXS In Positive Context; Cognitive Reattribution of Symptoms; and Gradual Activation Associated w/ Better Psychological Outcomes.

Education Has Included Informing Patients about Concussion SXS To Medication Management Issues and Expected Recovery Times

Psychological / Counseling Interventions for Concussion

Sandel et al. (2017). Sport, exercise, and performance psychology, Vol. 6 (3), 304–323.

Vestibular / Ocular Issues: What Have We Learned?

 Vestibular / Ocular

Dysfunction is Quite Common Following Concussion

 Early Detection is

Critical for Appropriate Intervention Efforts.

 Symptoms, and Deficits on Objective

Assessments (i.e., ImPACT, SCAT, BESS, SWAY, VOMS, etc.) are Consistent, but Stand-Alone Assessments Do Not Adequately Assess Vestibular / Ocular Dysfunction.

 Vestibular / Ocular Problems Must be

“Actively” Treated and Exposure to Stimuli is Critical to Recovery. Rest and “Cocoon” Therapy Do Not Improve Symptoms … it Makes Them Worse!

 For Patients With Vestibular / Ocular

Dysfunction, it is Critical to Have a Physical Therapist Trained in Neuro- Vestibular Therapy in your Area. Concussion: A Heterogeneous Injury with Divergent Trajectories

VESTIBULAR OCULAR 53 54

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Sport Concussions: Where are We Now?

 Targeted Assessments

Should Include Detailed Clinical Interview and the Use of Multiple Tools as well as an Advanced Interpretive Understanding

f These Tools

 Type, Duration, and

Intensity of Exertion and Academic / Occupational Accommodations May Vary Depending Upon Clinical Trajectory and Severity of Impairment

 Psychosocial Components of Athletics

and the Culture of Today’s Sports Environments Have a Direct Influence on Emotional and Psychological Reactions to Concussive Injuries

 The Influence of Psychological Factors

n Concussion Recovery is Not

Currently Understood, but Evidence Suggests a Similarity with Chronic Pain Literature

 Clinicians Must Balance Tenants of

Concussion Management w/ the Risk of Fostering Emotional Difficulties That Include Risk for Suicide Concussion: A Heterogeneous Injury with Divergent Trajectories

THANK YOU

Stephen A. Russo, Ph.D.

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REFERENCES / FURTHER EXPLORATION

Anderson, M.B. & Fawkner, H.J. (2005). Returning to Self: The Anxieties of Coming Back After Injury. In Anderson,

M. B. (Ed.). Sport Psychology in Practice. Champaign, IL:

Human Kinetics. Brewer, B. W (2012). Psychology of Sport Injury

Rehabilitation. In Tennanbaum, G. & Ecklund, R.C. (Eds.)

Handbook of Sport Psychology (3rd Edition, pp.404-424). New York: John Wiley & Sons, Inc. https://doi.org/10.1002/9781118270011.ch18 Brewer, B. W & Petrie, T. A. (2014). Psychopathology in Sport and Exercise. In Van Raalte, J. L. & Brewer, B. W. (Eds.) Exploring sport and exercise psychology (3rd Edition, pp. 311-336). Washington, DC: American Psychological Association. DiFiori, J.P., Benjamin, H.J., Brenner, J., Gregory, A., Jayanthi, N., Landry, G.L., & Luke, A. (2014). Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports

Medicine. Clinical Journal of Sport Medicine, 24(1), 3-20.

Evans, L. & Hardy, L. (1995). Sport Injury and Grief Responses: A Review. Journal of Sport & Exercise Psychology, 17, 227-245. Ferguson, R. W. Green, A., & Hansen, L. M. (2013). Game Changers: Stats, Stories, and What Communities Are Doing to Protect Young Athletes. Washington DC: Safe Kids Worldwide Forsdyke, D., Smith, A., Jones, M. & Geldhill, A. (2016). Psychosocial Factors Associated with Outcomes of Sports Injury Rehabilitation in Competitive Athletes: A Mixed Studies Systematic Review. British Journal of Sport Medicine, 50, 1-10. Green, S. L. & Weinberg, R. S. (2001). Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational

participants. Journal of Applied Sport Psych, 13, 40-59

Take a deeper dive into the world of sport psychology and injury by reviewing the following:

Grandner, M. (2014). Sleeping Disorders. In Brown, G. T. (Ed.) Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. (p. 58-61). Indianapolis, IN: NCAA. Gutkind, S. M. (2004). Using Solution-focused Brief Counseling to Provide Injury Support. The Sport Psychologist, 18, 75-88. Hinkle, J. S. (1996). Depression, Adjustment Disorder, Generalized Anxiety, and Substance Abuse: An

verview for Sport Psychologists working with college

student-athletes. In Etzel, E. F., Ferrante, A.P., and Pinkney, J.W. (Eds.) Counseling College Student Athletes: Issues and Interventions (2nd Ed, pp. 110-136). Morgantown, WV: Fitness Information Technology, Inc. Kanzler, et al. (2012). Suicidal Ideation and Perceived Burdensomness in Patients with Chronic Pain. Pain

Practice. https://doi.org/10.1111/j.1533-2500.2012.00542.x

Knowles et al., (2006). A Prospective Study of Injury Incidence Among North Carolina High School Athletes. American Journal of Epidemiology, 164, 1209-1221. Kontos, A. P. (2004). Perceived Risk, Risk Taking, Estimation of Ability and Injury Among Adolsecent Sport Participants. J of Pediatric Psychology, 29, 447-445. Lowry, F. (2013). Chronic, Non-Cancer Pain Boosts Suicide Risk. JAMA Psychiatry. Published online, May 22,

2013. http://www.Medscape.com/viewarticle/804832

Madrigal, L. & Gill, D. L. (2014). Psycholoigical Responses of Division I Female Athletes Throughout Injury Recovery: A Case Study Approach. Journal of Clinical Sport Psychology, 8, 276-298. Nelson, M.B. (2009). The Damage I have Done to Myself: Physical Intelligence Among College Athletes. Journal of Intercollegiate Sports, 2, 127-144. Petrie, T. A., Deiters, J. & Harmison, R. J. (2014). Mental Toughness, Social Support, and Athletic Identity: Moderators of the Life Stress-Injury Relationship in Collegiate Football Players. Sport, Exercise, and Performance Psychology, 3, 13-27. Putukian, M. (2014). How Being Injured Affects Mental Health. In Brown, G. T. (Ed.) Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. (p. 72-75). Indianapolis, IN: NCAA. Putukian, M. (2016). The Psychological Response to Injury in Student Athletes: A Narrative Review with a Focus on Mental

Health. British Journal of Sports Medicine, 50, 145-148.

Santi, G. & Pietrantoni, L., (2013). Psychology of Sport Injury Rehabilitation: A Review of Model and Interventions. J. Hum. Sport Exerc; 8(4), 1029-1044. doi:10.4100/jhse2013.84.13 Simon, J. E. & Docherty, C. L. (2013). Current Health-Related Quality of Life is Lower in Former Division I Collegiate Athletes than in Non-Collegiate Athletes. The American Journal of Sports Medicine, 42(2), 423-429. Sullivan, M. J., Tripp, D. A., Rodgers, W. M., & Stanish, W. (2000). Catastrophizing and pain perception in sport participants. Journal

f Applied Sport Psychology, 12, 151-167.

Weinberg, R. S. & Gould, D. (2015). Athletic Injuries and

Psychology. In Weinberg, R. S. & Gould, D. (Eds.) Foundations of

Sport and Exercise Psychology (6th Edition, pp. 457-472). Champaign, IL: Human Kinestics. Wolanin, A., Hong, E., Marks, D., Panchoo, K. & Gross, M. (2016). Prevalence of Clinically Elevated Depressive Symptoms in College Athletes and Differences by Gender and Sport. British Journal of Sports Medicine, 50, 167-171. 58

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Allum JH. Recovery of vestibular ocular reflex function and balance control after a unilateral peripheral vestibular deficit. Front Neurol. 2012;3:83. Baillargeon A, Lassonde M, Leclerc S, Ellemberg D. Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults. Brain Inj. 2012;26(3):211- 220. Breedlove, S.M. & Watson, N.V. (2013). Hearing, vestibular perception, taste, and smell. In Breedlove, S.M. & Watson, N.V. (Eds.) Biological psychology: An introduction to behavioral, cognitive, and clinical neuroscience (7th edition). Sunderland, MA: Sinauer Associates, Inc. Breedlove, S.M. & Watson, N.V. (2013). Vision: From eye to brain. In Breedlove, S.M. & Watson, N.V. (Eds.) Biological psychology: An introduction to behavioral, cognitive, and clinical neuroscience (7th edition). Sunderland, MA: Sinauer Assoc., Inc. Camiolo Reddy C, Collins MW, Lovell M, Kontos AP (2013) Efficacy of Amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related

concussion. J Head Trauma Rehab 28(4):260–265

Capo-Aponte JE, Urosevich TG, Temme LA, Tarbett AK, Sanghera NK. Visual dysfunctions and symptoms during the subacute stage of blast- induced mild traumatic brain injury. Mil Med. 2012;177(7):804-813.

Take a deeper dive into the world of sport concussion by reviewing the following:

Centers for Disease Control and Prevention (CDC). Heads up: Facts for physicians about mild traumatic brain

injury. Atlanta (GA): Centers for Disease Control and
Prevention. Retrieved from: http://www.cdc.gov/ncipc/pub-

res/tbi_toolkit/physicians/mtbi/mtbi.pdf Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care

f athletes following sport-related concussion. Knee

Surg Sports Traumatol Arthrosc. 2014;22(2):235-246. Covassin T, Elbin RJ, Harris W, Parker T, Kontos A. The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after

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Cullen KE. The vestibular system: multimodal integration and encoding of self-motion for motor

control. Trends Neurosci. 2012;35(3):185-196.

Elbin RJ, Kontos AP, Kegel N, Johnson E, Burkhart S, Schatz P. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin

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REFERENCES / FURTHER EXPLORATION

Take a deeper dive into the world of sport concussion by reviewing the following: