Those of you who are regular readers of Letters from Maine have probably noticed that concussion is one of my favorite topics. The explanation for this perseveration is personal and may lie in the fact that I played two contact sports in college. In high school we still wore leather helmets and in college the lacrosse helmets were constructed of plastic-coated cardboard. I can recall just a few of what might be now labeled as sports-related concussions. Ironically, my only loss of consciousness came on the first dinner date with the woman who would eventually become my wife. A hypotensive episode resulting from the combination of sweat loss (2 hours of basketball) and blood loss from selling some platelets earlier in the day (to pay for the dinner) led to the unfortunate meeting of my head and the beautifully tiled floor at the restaurant.
Dr. William G. Wilkoff
Postconcussion Recovery
The phenomenon of delayed symptomatic recovery has been a particular interest of mine. Within the last 12 months I have written about an excellent companion commentary in Pediatricsby Talin Babikian PhD, a psychologist at University of California, Los Angeles, in which he urges us to “Consider the comorbidities or premorbidities,” including, among others, anxiety and/or depression, post-traumatic stress, and poor sleep when we are faced with a patient who is slow in shedding his postconcussion symptoms. A short 6 months after reading Dr. Babikian’s prescient commentary, I have encountered some evidence supporting his advice.
Investigators at the Sports Medicine and Performance Center at the Children’s Hospital of Philadelphia have recently published a study in which they have found “Preexisting mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion.” In their prospective study of over 3000 children and adolescents, they found that, although patients with more mental health diagnoses were at greater risk of increased emotional symptoms after concussion, “Children and adolescents with any preexisting mental health diagnosis took longer to recover.”
Female patients and those with abnormal visio-vestibular test results at the initial postinjury evaluation took longer to recover, although boys with prolonged recovery had more emotional symptoms. In general, patients with preexisting mental health diagnoses returned to exercise later, a known factor in delayed concussion recovery.
Making Sense of It All
There are a couple of ways to look at this paper’s findings. The first is through the lens that focuses on the population of children and adolescents who have known mental health conditions. If our patient has a mental health diagnosis, we shouldn’t be surprised that he/she is taking longer to recover from his/her concussion and is experiencing an increase in symptoms. Most of us probably suspected this already. However, we should be particularly aware of this phenomenon if the patient is male.
The other perspective is probably more valuable to us as primary care physicians. Even one diagnosis so subtle that we may have overlooked it is likely to slow his/her progress toward recovery. And, of course, it may be that injury has triggered an underlying condition that none — not even the most astute diagnostician — would have found without a focused investigation.
I can’t leave this subject without wondering whether the findings in this paper should be extrapolated to other conditions of delayed recovery, including Lyme disease and COVID 19. Patients with these conditions are understandably resistant to the suggestion that their mental health may be contributing to the situation. Too many have been told too often it is “all in their head.” However, I think we as clinicians should keep open minds when symptoms are resolving more slowly than we would expect.
Finally, in their conclusion the authors of this paper reinforce a principle that has unfortunately taken some of us a while to accept. Early introduction of symptom-limited exercise should be a standard of postconcussion management, especially for patients with a mental health diagnosis.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.