SPORT PSYCHOLOGY 81:COUNSELING

Psychological Aspects of Concussion Recovery

GregJ. Chertok, EdM, CC-AASP • The Physical Medicine and Rehabilitation Center;Ira H. Martin, EdM • Boston University

T,he pathophysiological effects of sport-related concussion have been well-docu-mented in the literature,''^ but the emotionaland psychological effects of a concussionmay not be sufficiently addressed by athletictrainers and therapists (ATs). An appreciationof the socio-emotional concussion sequela,such as feelings of helplessness and social

isolation, can enhancethe care that is pro-vided.

The most widelyaccepted definition of aconcussion is a traumat-ically-induced alterationin mental status, whichmay or may not involvea loss of conscious-ness.'*'̂ A concussion isconsidered a traumaticbrain injury (TBi) and isassociated with a com-plex pathophysiologicresponse. Confusion

and/or memory loss are hallmark symptomsof a concussion, but initial symptoms aredetermined by the brain structures that areaffected.^ The word "concussion" is derivedfrom the Latin term "concutere," whichmeans "to shake violently." An imbalancebetween sympathetic and parasympatheticneural activity can result in disruption ofneurometabolic homeostasis,^ which can bemanifested by maladaptive social responses

KEY POINTSThe concussed athlete can experience avariety of psychological difficulties that canprolong recovery.

Knowledge of basic sport psycholo^**™™"concepts can facilitate successful manage-ment of post-concussion psychologicaldifficulties.

ATs provide social support for injured ath-letes, which is extremely important duringthe concussion recovery process.

such as frustration, anger, and sadness.Sport-related concussions have gained

widespread attention as a major publichealth issue that affects 1.6 to 3.8 millionindividuals annually in the U.S. and whichcost an estimated $80 billion each year."*'̂A primary care sports medicine physicianin Bergen County, New Jersey has estimatedthat he treats approximately 1800 concus-sion patients every year, which represents anaverage of 35 concussion patients per week(personal communication with T. Bottiglieri,MD, February 2012).

A study sponsored by U.S. Lacrosse andThe Sports Science and Safety Committeefound that the sport-related concussionincidence rate among high school athleteshas increased from 0.11 per 1000 athleteexposures in 1998 to 0.49 per 1000 athleteexposures in 2008, (Figure 1). This 4.6-foldincrease from 1998 to 2008 representsan average yearly increase of 16.5%.^''°Proposed explanations for the increasedincidence rate include (a) better clinicalrecognition by better-trained concussionspecialists,' sports medicine practitioners,and neuropsychologists;2 (b) more aggressiveplay;̂ and (c) heightened player athleticism(i.e., more speed derived from better con-ditioning results in greater energy transferto the brain). Collegiate athletes are biggerand stronger than high school athletes,which some suggest plays a role in concus-sion risk."

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11998

12008

H.S. Sport Concussion Rate (per100,000)

High school sport concussions.

Post-Concussion Syndrome

Athletes u'ho have sustained a concussion have ele-vated risk for a second concussion, which can resultin additional symptoms, increased symptom severity,prolonged recovery of normal function, and the pos-sibility for occurrence of second-impact syndrome.^The concussed athlete may experience a variety of psy-chological symptoms that can negatively affect dailyfunction.s Long-term effects may include depression,anxiety, psychosocial problems, physical and cognitivedisturbances, and chronic traumatic encephalopathy(CTE).8

A concussed athlete who has a history of depres-sion, anxiety, or other psychological problems, orone who continues to participate in contact sports orchallenging cognitive activities prior to full recovery,may develop post-concussion syndrome (PCS). PCS ischaracterized by symptoms that persist for more than 4weeks, but it can last for months, years, an individual'slifetime, and it can be manifested by anger, rage, fear,confusion, and isolation.''

Psychological DisturbancesFollowing a Concussion

Several factors can contribute a difficult psychologicalexperience for a concussed athlete. Because there isno well-established therapy for acceleration of con-cussion recovery, the concussed athlete often lacksa clearly defined treatment plan. Due to the lack ofreadily observable injury effects, concussions havebeen referred to as the "hidden epidemic." The inabil-ity of team physicians and ATs to accurately estimatethe duration of symptoms, predict the exact nature ofthe symptoms that may be experienced, or provide

definitive instructions for effective management canleave the athlete in a state of confusion, isolation, andhelplessness.

Because the brain trauma induced by a concussionrarely produces bleeding or bruising that can be iden-tified by standard diagnostic imaging methods (e.g.,CT scan, MRI, or radiographs), tangible evidence thata brain injury has been experienced is not available.Coaches, teammates, and even parents may questionthe legitimacy of the injury, and the concussed athletemay feel pressure to resume sport participation.^ Ath-letes who return to participation prior to full recoverymay play with less focus, intensity, confidence, andphysical comfort. Tentative play or frustration withinability to perform "normally" can limit the abilityto focus on performance, which can increase risk foranother injury.'̂

Counseling for PCS Managementand Recovery

ATs are typically focused on the physical aspects ofinjury rehabilitation, but psychological factors clearlyplay an important role in injury recovery. Psychosocialsupport, encouragement, and assurance that return tocompetition is safe is important for a confident returnto full participation.'2 An athlete engaged in post-con-cussion rehabilitation must focus on development ofcoping and relaxation skills, which can counteract feel-ings of helplessness and social isolation. ATs can teachathletes such psychological skills and can help reduceanxiety by providing information about symptoms.

ATs can play an extremely important role in con-cussion recovery. Research evidence clearly demon-strates that teaching relaxation and mental skills canreduce the incidence and duration of post-concussionsymptoms.'^•''' Athletes who have adverse emotionalresponses to concussion symptoms may experiencea prolonged recovery that is associated with muscletension, anxiety, changes in heart rate, and sleep dis-turbances.

Day-to-day interactions with athletes make ATs animportant source of social support for injured athletes.Being available for conversation, showing concern byasking open-ended questions, and simply serving asa nonjudgmental and stable source of social supporthelps concussed athletes maintain confidence whileremoved from sport participation.'^ Meaningful con-versation is facilitated when the injured athlete doesn'tfeel that he or she is labeled as concussed. The use

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of body language (i.e., making eye contact, noddingone's head appropriately in response to the athlete'swords, and mirroring the posture of the athlete) andreflective listening (i.e., focus on understanding theathlete's concerns and summarizing his or her viewsin response - "It seems to me that you're saying /might be feeling. . .", "I get the impression that . . .")will promote trust.''' ATs can introduce a concussedathlete who is feeling socially isolated from friendsand teammates to other athletes who have previouslyundergone post-concussion rehabilitation, which canbe highly beneficial.'^ Hearing that "it gets better"from those who have had the experience will promoteoptimism and reduce anxiety.

Imagery, cognitive restructuring, and goal settingare mental skills that ATs can help a concussed athleteto develop, imagery scripts (particularly relaxationor healing scripts) may have therapeutic benefit.'^Feelings of helplessness or anxiety may be overcomethrough cognitive restructuring, which can promotefeelings of relaxation, relief, and empowerment. Cogni-tive restructuring involves focus on the "right" things(i.e., compliance with instructions that promote recov-ery) and reduced mental concentration on distressingphysical symptoms and/or thoughts that create anxi-ety. Setting goals for completion of scheduled copingimagery routines can provide the athlete with a senseof control,''' and the provision of positive feedback foraccomplishment of specific goals can help to sustainmotivation over a long rehabilitation period.'^

Summary

Basic counseling skills can facilitate post-concussionrecovery. ATs should recognize that sport psychologyconcepts are important for the identification and suc-cessful management of socio-emotional difficulties thata concussed athlete may face, such as social isolationand a sense of helplessness. I

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Greg Chertok is the Director of Sport Psychology at The PhysicalMedicine and Rehabilitation Center in Englewood, NJ. He owns Pitchby Pitch Sports Camps in Congers, NY.

Ira Martin is a doctoral candidate in Counseling and Sport Psychol-ogy at Boston University. He is currently a sport psychology coach atPrepare 2 Perform.

Adam Naylar, EdD, Boston university, is the report editor for this article.

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