Post Concussion Syndrome in sport

Options if symptoms persist

In the case of both severe and mild concussions, athletes often still suffer from sometimes severe secondary symptoms despite extensive rehabilitation. According to medical test standards, these athletes should actually be fine again, as there are usually no pathological abnormalities. It is therefore important to recognize the reasons for persistent symptoms and to apply the right measures and therapy to ensure the athlete’s full recovery.

For those in a hurry:

People who have occasional or regular symptoms after a concussion should have a comprehensive visual and vestibular function assessment. Together

By asking specific questions about the functionality of the individual lobes of the brain and the subjectively experienced state of health, it is possible to determine which stimuli the respective organism needs in order to return to a balanced state of health in the long term through neuroplastic changes.

Mild concussions. Mild concussions are a gradual neurodegenerative process. The term concussion or traumatic brain injury (TBI) has become more common in recent years, not only because there are more and more cases in publicly visible professional sport in which a concussion has been diagnosed, but also because scientific efforts to better understand this type of brain injury are becoming more diverse.

This mainly concerns those concussions that do not require acute action,

i.e. where an athlete is not unconscious or briefly incapacitated, but can initially continue to play their sport as normal. However, it is precisely these cases that pose a high risk: so-called mild TBIs are often trivialized, as no pathological conditions are usually detected using imaging procedures such as MRI or CT. This is due to the fact that functional disorders usually occur, which only lead to truly recognizable structural damage after decades.

Due to the supposedly non-existent effects, either no diagnostic process is initiated, or after rehabilitation according to different (sometimes not congruent) guidelines, the athlete continues to perform their tasks and may receive the bill later in their career. The scientific situation clearly indicates that persistent or even recurrent symptoms such as headaches, sensitivity to light and sound, dizziness, instability problems, balance disorders, but also cognitive and emotional problems can result from mild TBIs (3, 4, 6).

A meta-analysis even showed that people who have already suffered a traumatic brain injury have twice the risk of suicide (2). Another study has shown that cognitive and motor disorders can still be present even 30 years after suffering a concussion (7).

Side note:

Head injuries are among the most common injuries in ice hockey, accounting for around 39% of all injuries. The wearing of full-face helmets is sometimes the subject of controversy. On the one hand, it can minimize injuries to the face, on the other hand, the number of concussions may increase due to a tougher style of play.

The medical check-up. In the examination of athletes, more specificity in functional examinations is needed in advance. If a collision with the head is observed from the sideline, various rapid tests such as the VBG’s Pocket Recognition Tool can be used to confirm the suspicion of a concussion through cognitive and motor tests. If a traumatic brain injury is confirmed on an outpatient basis, the aim is to build up a continuous load after a phase of six to seven days during which the brain needs to recover. Various medical tests can and should be carried out to check relevant systems such as the visual system (Fig. 1), the balance system, autonomic functions and cognitive skills. So how can it be that around 15 percent of athletes suffer from so-called “post-concussion syndrome”, i.e. despite extensive testing and guideline-compliant rehabilitation?on still have symptoms more than 12 months after the incident (1, 5)?

The brain functions according to the principle of “use it or lose it” according to neuroplastic imprinting, which means that those nerve cells that are specifically used build up and break down. This is probably a sticking point in diagnostics and intervention: minor abnormalities in diagnostics are not adequately assessed and are accepted as “normal”, even though they show functional deficits in neuronal systems. In visual tests, for example, tests are often carried out under standard conditions, while the athlete has completely different dynamic loads. The situation is similar with coordination tests: if coordination is tested at all, standard neurological tests are used. In training practice, however, coordination skills can change quickly as soon as the central nervous system is stressed. This is where a more sensitive test-retest process seems helpful.

Persistent overactivity in the midbrain. The midbrain is an essential integration center of the human nervous system, in which countless sensory information is processed. To a large extent, auditory and visual information about the position in space is processed and eye movements are controlled via cranial nerves 3 and 4. After a concussion, there are usually still minor dysfunctions of essential functions in the midbrain, but these are not noticed in detail in the diagnostics, or (the much more common case) they are not adequately trained, as there are underestimated impairments. The results show different abnormalities in the form of disorders that indicate an overactive midbrain:

• One or both eyes have deficits in convergence (movement of the eyes directly inwards or inwards/downwards to the tip of the nose). Even the difference between the left eye tiring after four seconds of maximum convergence and the right eye tiring after six seconds can play a role.
• One eye has a slightly delayed pupillary reflex (pupil contracts only with a delay when exposed to direct light).
• The ability to localize sounds without using the eyes is imprecise (also possible on one side).
• Peripheral perception is limited or faulty for part of the visual fields (also possible on one side).
• Autonomic dysregulation: For example, blood pressure on one side of the body does not rise adequately when the athlete moves from a sitting to an upright position.

In addition to these physiological parameters, psychopathological conclusions can occur, particularly in post-concussion syndrome. In the strict sense of the word

However, this also involves problematic activity patterns in the brain, because the way we deal with feelings and thoughts is regulated by a healthy frontal brain.

Solution approach. All of the problems described above can be improved by the nervous system transmitting the correct input to the midbrain. Targeted eye exercises as well as light stimuli and peripheral visual and auditory stimuli must be used to individually check how the body reacts. If the appropriate stimuli are found, functionality improves accordingly. If there are signs of an overactive midbrain, the use of raster glasses and green colored glasses can be very effective (8) ( Fig. 3). This and the use of earplugs reduce the visual input to the midbrain and cortical activation. Symptom relief can also be achieved by training peripheral perception. Targeted training stimuli can then be provided. Peripheral perception training, for example using a peripheral awareness chart, is particularly suitable here. Individual differences in the movement and perception of one or both eyes must be individually tested and optimized.

Peripheral Awareness Chart

The Peripheral Awareness Chart (see photo below) is a poster on which random letters are arranged in a circle, starting from a letter to be fixed in the center. The central letter must be fixed at eye level (start with one eye!), while you now try to recognize all the other letters from the periphery. hery and recite it. It is a good idea to work with a partner who can keep an eye on the correct execution, as there is a tendency to help out with eye jumps. In this way, underactive peripheral fields of perception can be identified and trained. The author recommends 3 rounds per eye and then 1-2 rounds with both eyes, 3-5 times/day, if there is a disturbance.

 

 

 

 

 

 

 

Other reasons for an overactive midbrain. In addition to the disorders mentioned above, overactivity in the midbrain is usually characterized by sensitivity to light and noise. These symptoms should decrease if the midbrain receives the appropriate input over several weeks. If not, it is also possible that the cortical neuronal input to the midbrain is deficient. In this case, it is crucial to find out which cortical areas (brain lobes) are underactive. Here, too, the problem of general testing and training approaches becomes apparent: General training can be applied to specific areas of the brain, but sometimes the brain needs a very specific combination of stimuli to overcome neuronal thresholds. Concussions are therefore a multidimensional problem that requires different intervention approaches:

• After concussions, breathing patterns can be permanently altered, which also changes the oxygen supply to the brain. Breathing screenings and targeted training can improve this.
• The supply and absorption of nutrients may be impaired. Individual nutrition and supplementation can make the difference between being symptom-free and being symptom-ridden.
• Neuronal inhibition patterns usually require very specific stimulus exposure. This means that a convergence exercise can only develop its effect if several stimuli act simultaneously on the midbrain (peripheral signals, exposure to light, close-up and television, accommodation)
• In the case of psychopathological findings, targeted neuronal training therapy can be useful instead of psychotherapeutic or drug interventions.

A physiotherapist or doctor with extensive experience in the field of traumatic brain injury should be consulted for a complete history of the brain lobes, for example by means of a questionnaire. A broadly trained neuroathletic trainer can also carry out important coordinative tests and then test the correct stimulation and check what training and therapy the injured person needs.

Other important points (not in the original article):

NEUROINFLAMMATION:

After concussions, the brain is in an acute inflammatory state, which can also become chronic. An anti-inflammatory diet is therefore crucial, especially in the first few weeks. This should consist of the following foods:

– Vegetables, salads and seeds, pasture-raised meat, wild fish, olive oil, coconut oil, nuts, berries

The following exemplary foods lead to further silent inflammatory processes in the body, including the brain:

– Cereal products, ready meals, dairy products, sugar, caffeine, alcohol, processed meat, additives

 

BREATHING:

After concussions, breathing is usually disturbed on a biomechanical level (breathing movement) and biochemical level (oxygen – CO2 ratio), which further promotes the inflammatory processes. A reduction of oxygen in the brain also leads to a reduced metabolism and the neural waste system (glymphatic system) cannot function optimally. Two essential things are crucial here:

– Breathing training with a focus on correct interaction between diaphragm and chest

– Breathing training with a focus on improved breathing chemistry, usually to increase CO2 tolerance through breathlessness training (conscious techniques for holding your breath)

 

SUPPLEMENTATION:

The reduction of inflammatory processes in the body and the optimal functioning of the body’s cells require a good balance of all micronutrients, vitamins and hormones. The most common and effective supplements include the following:

– Vitamin D

– Vitamin C

– Zinc

– Magnesium

– Omega-3

– Rhadiola

 

OPTIMIZATION OF CELL FUNCTION:

Cell function is very often restricted at the level of the mitochondria (energy power plants of the cells). Methods that can restore this functionality include

– Microcurrent

– Frequency therapy using patches that can be applied to the skin (AminoNeuroFrequency)

– Water-based frequency therapy

– Magnet-based frequency therapy

 

FREQUENT INTERFERENCE FIELDS:

In addition to the nerve cells, the following structures in the musculoskeletal system in particular are often disturbed after concussions and must therefore be specifically examined and trained/treated:

– Cranial sutures

– Extraocular eye muscles

– Vestibular system

– Cervical spine

– Thoracic spine

– Pine

– Diaphragm

 

Literature:

1. Quatman-Yates, C. C.; Hunter-Giordano, A.; Shimamura, K. K.; Landel, R.; Alsalaheen, B. A.; Hanke, T. A. & McCulloch, K. L. (2020). Physical Therapy Evaluation and Treatment After Concussion / Mild Traumatic Brain Injury. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopedic Sports Physical Therapy. 50(4): CPG1-CPG73.
2. Fralick, M.; Sy, E.; Hassan, A.; Burke, M. J.; Mostofsky, E. & Karsies, T. (2019). Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis. JAMA Neurology, 2019, Feb 1; 76(2):144-151.
3. Polinder, S.; Cnossen, M. C.; Real, R. G. L.; Covic, A.; Gorbunova, A.; Coormolen, D. C.; Master, C. L.; Haagsma, J. A.; Diaz-Arrastia, R. & von Steinbuechel, N. (2018). A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury. Frontiers in Neurology, December 2018, Vol. 9: 1113.
4. Davis, G. A.; Ellenbogen, R. G.; Bailes, J.; Cantu, R. C.; Johnston, K. M.; Manley, G. T.; Nagahiro, S.; Sills, A.; Tator, C. H. & McCrory, P. (2017). The Berlin International Consensus Meeting on Concussion in Sport. Neurosurgery 0:1-5, 2017.
5. Federal Institute for Sport Science (BISp) (2016). Presentation of the expertise: Craniocerebral injuries in German elite sport.
6. Gänsslen, A. & Schmehl, I. (2015). Mild traumatic brain injury in sport. Recommendations for action. Federal Institute for Sports Science. Bonn: Sportverlag Strauß.
7. De Beaumont, L.; Théoret, H.; Mongeon, D.; Messier, J.; Leclerc, S.; Tremblay, S.; Ellemberg, D. & Lassonde, M. (2009). Brain function decline in healthy retired athletes who sustained their last sports concussion in early adulthood. A Journal of Neurology: 132; 695-708, 2009.
8. Martin, L. F.; Patwardhan, A. M.; Jain, S. V.,; Salloum, M. M.; Freeman, J.; Khanna, R.; Gannala, P.; Goel, V.; Jones-MacFarland, F. N.; Killgore, W. D.; Porreca, F. & Ibrahim, M. M. (2020). Evaluation of green light exposure on headache frequency and quality of life in migraine patients: A preliminary one-way cross-over clinical trial. Cephalalgia, 2009: Sept.