The Concussion Blog

Information about concussions seems to have been suddenly placed upon all of us; the information and management has changed multiple times since the mid 2000’s – maybe not.  As early as the 1800’s other professions were relaying information to doctors that appear to symptoms of concussions (Caplan, 1995 – Erichson, 1997 – Keller, 1995), the authors focused on the railroad industry.  Information about concussion and it’s debatable cousin, Post Concussion Syndrome.

Information about concussions and PCS has been documented very well by R.W. Evans as early as 1987, here is the list of his symptoms;

• Headaches
• Muscle contraction type
• Migraine
• Occipital neuralgia
• Secondary to neck injury
• Secondary to temporomandibular joint syndrome
•  Due to scalp lacerations or local trauma
•  Mixed
• Dizziness
• Vertigo
• Tinnitus
• Blurry vision
• Diplopia
• Memory dysfunction
•  Impaired concentration
• Personality change
• Anxiety
• Depression
• Sleep disturbance
• Decreased libido
• Irritability
• Noise and light sensitivity
• Fatigue
• Slowed information processing

As you can see the knowledge was out there for all to see, however the concussion issue has not been a “hot topic” since circa 2008, but was gaining strength in the early 2000’s.  Now there is a trend to discern between the concussion and “post concussion syndrome” which was a phrase coined in 1934 by authors Straus and Savitsky.  The new model (rather the logical thinking) is that after you break a pinky and you have pain/symptoms is it called “post fracture syndrome”?  Currently that is not the model, so why should a brain injury be treated the same?

It is believed that once the symptoms resolved the injury may be healed, but if you have paid any attention to this blog you will know that is not exactly the case.  Symptoms can resolve due to many reasons, the biggest being rest, however when the injured is placed into “new” situations like activity or school the symptoms reappear.  This gives the clinician a second diagnosis, one of PCS, when in fact the possibility exists that these are pathologies from the existing injury.

This post arose from the comment section as Don Brady, PhD, PsyD, NCSP, LMFT had this to say;

I agree with you that the term post concussion symptom is very misleading. Please see below excerpts for additional comments.

Perhaps some excerpts from my 2004 Dissertation (…NFL Players’ Knowledge of Concussions) will assist you along with also reading a 1994 (yup 1994 !) article written by neurologist R. W. Evans, MD who was a trailblazer in the field of concussions. A brief list of some of his concussion related writings follow:

• Evans, R.W. (1987). Postconcussive syndrome: An overview. Texas Medicine, 83, 49-53.
• Evans, R.W. (1994). The postconcussive syndrome: 130 years of controversy. Seminars in Neurology, 14, 32-39.
• Evans, R.W. (1996). Neurology and Trauma. Philadelphia: W.B. Saunders Company.
• Evans, R.W. (2000). Postconcussion syndrome. In R.W. Evans, D.S.Baskin, & F.M. Yatsu (Eds.), Prognosis of neurological disorders (pp. 366-380). New York: Oxford Press.
• Evans, R.W., Evans, R. I., & Sharp, M. J. (1994). The physician survey on the post-concussion and whiplash syndrome. Headache, 34, 268-274.

I had the privilege of conversing with Dr. Evans during the completion of my PhD studies. Dr. Evan’s article that appeared in Seminars in Neurology is entitled The Postconcussion Syndrome: 130 years of Controversy. Upon reading the journal article you will find that many of today’s issues were being discussed during the 1800’s: substitute trains for sports.

Several Dissertation excerpts now follow and I trust this info will assist in making more sense of your insights while also providing new/expanded info to readers of this blog.
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Strauss and Savitsky (1934) are credited with coining the phrase postconcussion syndrome (Evans, 1994), and they posited that not only may a concussion occur without a loss of consciousness, but that it has an organic basis. In their extensive 63-page review of the topic, they emphasized the importance of documenting clinical observations and of not quickly attributing vague or unusual findings to functional/psychological origins. The value of the clinical judgment was also highlighted in the following statement: “Results of tests and exact quotients cannot take the place of the opinion of an experienced clinician” (p. 912).
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The term postconcussion evolved from early conceptions of a concussion as an entirely reversible syndrome without detectable neural pathology. As such, the prefix post literally meant after [the event] (Gasquoine, 1997). Agreement does not exist on how to conceptualize the concept of post concussion syndrome or even if the syndrome exists. According to Evans (1987), symptoms attributed to the effects of a concussion may also be called postconcussion syndrome. Rutherford (1989) advocated for the dropping of the prefix post, and thus called the collection of presenting symptoms the concussion syndrome. The author also argued and pointed out that since fractured ribs-related pain is not labeled “post rib fracture” pain, concussion-related symptoms should not be perceived as postconcussion symptoms. Furthermore, since some symptoms of a concussion and post concussion are similar, it is not easy to recognize when a concussion ends and the postconcussion syndrome begins (Wills & Leathem, 2001).
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Evans (1989, 1994) and Roberts (1988) elaborated on the notion of the PCS construct being entrenched in controversy for several hundred years. Evans also stated that current controversies pertaining to concussions are comparable to injuries and their respective symptoms that persons reportedly sustained in railroad-related accidents during the mid to late 1800s in the United States and Europe (Caplan, 1995; Erichsen, 1997; Keller, 1995). Reflected in the numerous terms utilized since the mid-1800s to describe the present day postconcussion construct, these controversies range from acknowledging to disputing the existence of the syndrome, and they include a debate as to whether its etiology is organic or psychological/functional. Evans also pointed out that the physiological basis of the postconcussive syndrome is becoming increasingly well-documented by abnormalities found in pathologic, neurophysiological, neuroimaging, and neuropsychological studies. (1994, p. 5).

The overall theme of this educational post is; education about the myth that there is agreement amongst clinical professionals on concussions and the related after effects and two CLINICAL JUDGMENT is key to this injury.  I would like to thank Dr. Brady for his time on this matter and applaud him for his expertise, providing you the reader more important information.