You wake up on the ground with blurry vision and feeling nauseous. The last thing you remember is going up for a header – a routine play in a routine match. The trainer runs onto the field and asks some standard questions.
“What’s the score?
Which half is it now?
Did the team win the last match?
Who scored last in the match?” (1)
For some reason, you cannot answer these questions.
You are taken to the hospital where doctors diagnose you with a concussion. Over the next few weeks, you expect your concussion symptoms of headaches, nausea, and fogginess to begin fading (2). You are told to wait, and then to wait some more. Sometimes symptoms can last for three months. Three months pass; symptoms are still present.
What happens now?
Post Concussive Syndrome or PCS is the persistence of common concussion symptoms past two to three months. It is best defined not as a condition characterized by any unique factors, but as a combination of symptoms including but not exclusive to headaches, difficulty concentrating, and fatigue (4). The condition is characterized by its unknowns like why it affects only certain people and why treatments or so hit-and-miss.
In 2017, after 16 years of monitoring a group of 110 PCS cases, neurological specialists at the University of Toronto and Toronto Western Hospital published a study in The Journal of Neurotrauma titled the “Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers”. Patients were chosen on the conditions that they had a clean CT, MRI, and TOMM test and if they had concussion symptoms lasting longer than three months. The study focused on diagnostic problems with PCS, the similarity of treatments between those who recovered (REC) and those who did not (NOT-REC), and the implications of not recovering.
The first focus was on diagnostic problems. Doctors have numerous imaging techniques at there disposal. A broken bone can be diagnosed on an X-Ray. An MRI can diagnose muscle damage. But sometimes for PCS there is no imaging technique or key indicator to make an affirmative diagnosis. The normal diagnostic tests – the CT, the MRI, and TOMM testing can return a false negative. The study stated that “PCS is a clinical diagnosis without a diagnostic biomarker” (3). Furthermore, Post Concussive Syndrome can best be mitigated by accurate treatment. But this lack of definitive diagnosis makes precise, evidence-based treatment difficult or impossible and incorrect treatment decisions can lead to the permanence of symptoms.
The symptoms initially presented by the groups – REC and NOT-REC were very similar. This means that making recovery or treatments plans on initial symptoms is impossible. The study tracked the treatments chosen by the two groups looking for differences as indicators to which treatment options are more effective. Both groups underwent the same treatment but only a certain percentage of the participants found any relief. The treatment options included chiropractic manipulation, occupational therapy, physiotherapy, and psychotherapy. The study noted that the NOT-REC group preferred medication whereas the REC group preferred vestibular repositioning exercises. If all external variables are held constant, two patients presenting with the same cluster of symptoms should equally respond to a treatment. The lack of understanding as to why they do not is a grave cause for concern and needs further investigating.
For the NOT-REC group who still faced concussive symptoms the three most exhibited symptoms included headaches, inattentiveness, and fatigue. Additionally, depression occurred in 40% of the NOT-REC group. The study listed thirty-four common persisting symptoms. There was an even spread among somatic, effective, and cognitive symptoms meaning that PCS has an equal effect both mentally and physically. Notable somatic or physical symptoms included neck pain and increased sensitivity to alcohol while affective symptoms included depression and irritability and cognitive symptoms included memory problems, disorientation, and memory difficulties.
The study concluded with a few notable findings. The first being that there was a direct proportionality between the number of symptoms reported and recovery time. Furthermore, many patients suffered from a similar grouping of symptoms. But the most important finding of the study was that PCS is permanent after three years. Of the 110 patients chosen for the model, only 30 subjects became symptom-free. Of these 30 patients, 20 recovered within one year.
The study was innovative in the subset of the patients. But it highlighted a renewed need to understand what precisely happens to the brain during a concussion both mechanically and biologically. It highlights a need to define that key variable – that definable change in the brain. In the meantime, all that can be done is suggesting a band-aid solution to a bullet wound problem All that can be done is treating the symptoms, not the condition. For those afflicted, there is a definite need to redefine how Post Concussive Syndrome is treated.
Edited by: Sophia Wu
Illustrated by: Allen Chen