Coby Fleener’s Daily Struggle with Post Concussion Syndrome

Coby Fleener, who was cut by the Saints in early May, suffered a concussion in November 2017 yet still hasn’t been cleared to return, suffering through what is known as persistent post concussion syndrome (PCS).

Post concussion syndrome is brutal – it can affect you on a day by day and minute by minute basis.  Imagine having headaches every single day, feeling nauseous or dizzy when you turn or nod your head, having mood swings that you can’t seem to control, not wanting to hang out socially with your friends or do things you used to love to do….for months on end.  That’s a sliver of what PCS can feel like.

Although there’s been a spotlight on concussion in recent years, and rightfully so, the chronic phase (post concussion syndrome) is still in the shadows.  Maybe we can change that.

Through my lens as a DPT, Doctor of Physical Therapy, and having treated multiple people suffering from PCS, I’ll explore the case of Coby Fleener and persistent post concussion syndrome by examining the following questions:

  • What is a concussion?
  • What causes a concussion?
  • What happens during a concussion?
  • What separates a concussion from post concussion syndrome?
  • Are there risks for developing post concussion syndrome?
  • What’s the rehab process like?
  • What are the implications for his career?

I. What is a concussion

A concussion is a mild traumatic brain injury (MTBI).  In medical circles, concussion and MTBI are often used interchangeably.  If the term traumatic brain injury (TBI) had been used in lieu of concussion from the jump, maybe it would’ve been taken more seriously…but that’s a whole different conversation.

So what happens to the brain during a concussion/MTBI?

A. The bio-mechanics of concussion

During a concussion/MTBI, the head and neck experience high intensity motion and the head may even hit the ground or some other object.  You can see that in Coby Fleener’s concussion/MTBI in November:

(Coby wasn’t tested for a concussion/MTBI after this hit but that’s a whole other can of worms for a different day)

You might be surprised to learn that his head hitting the ground or making contact with an external object isn’t a pre-requisite for concussion/MTBI.  Studies have shown that focal brain injuries (injuries confined to one area of the brain) are largely absent in concussions/MTBIs.  However, that sudden jolt and stopping force from the head hitting the ground or an object does create significant inertia (in this case, a deceleration force) on the brain.

In fact, the key contributors to a concussion/MTBI are the inertial (acceleration and deceleration) forces (both linear and rotational) imparted onto the brain tissue during high intensity head and neck motion.

Take a look:

post concussion syndrome
Credit – WBUR

A rotational acceleration force is particularly harmful to the brain.  That’s because brain tissue – one of the softest biological materials – is particularly susceptible to shearing and rotational force applies shear throughout the brain.

When someone loses consciousness, it’s almost always due to rotational forces causing widespread shear damage.  That’s why a loss of consciousness indicates a higher severity of concussion/MTBI.

So that’s what’s happening in the brain anatomy, but what about on a physiological level?

B. The physiology of concussion/MTBI aka “the brain in crisis”

The damaged brain tissue creates a series of bad events for the brain, termed a “neurometabolic cascade”, that leave your brain very vulnerable.

For the sake of this piece (focusing on post-concussion syndrome rather than the actual concussion/MTBI), here’s what you need to know:

There’s a series of events and mechanisms that lead to a mismatch of supply and demand in the brain – it needs resources to repair but there aren’t enough available (in fact, the amount of resources is actually lower than normal).  This results in a short-term “energy crisis” and brain impairment.

You can see that mismatch in following graph, focus on the black line which shows cerebral blood flow (CBF):

post concussion syndrome
Credit – Giza, “The new neurometabolic cascade of concussion”

As you can see, the black line (CBF) is below normal and that means reduced resources for the brain.

This short-term mismatch is why any concussion/MTBI recovery protocol has an initial 24-48 hour period of no stimulus – it’s giving the brain time to recover while reducing stress on it.

If you’re interested in a more detailed look at what happens during a concussion/MTBI and the physiological changes, check out this piece.

Now that we’ve discussed the concusion/MTBI, lets move onto post concussion syndrome specifically.

II. When does concussion/MTBI become post concussion syndrome?

The criteria that separates concussion/MTBI from post concussion syndrome is the duration of the symptoms.

In general, 85-90% of concussions/MTBI’s resolve within 7-10 days. This 7-10 day timeline parallels the 7-10 days that it typically takes for the brain to get out of the energy crisis

If symptoms persist longer than 4+ weeks, that’s when the term “post concussion syndrome” (PCS) comes into play. Generally, a syndrome refers to “diagnosis of exclusion” – meaning you can’t figure out exactly what’s going on but there’s a confluence of factors that are contributing.

This post concussion syndrome phase represents the chronic phase of concussion/MTBI.  In Coby Fleener’s case, he’s been going through it for nearly 6 months now. Ugh.

So what causes or increases the risk for post concussion syndrome?

III.  The risk factors and causes of post concussion syndrome

A. Risk Factors of post concussion syndrome

Research on the risk and predictive factors of post concussion syndrome is ongoing, but so far we do have some clues.

The risk factors include:

  • Demographic
    • Gender: females are at a higher risk
    • Age: older adults are at a higher risk
    • Education: One study found in inverse relationship between years of education and likelihood to suffer from post concussion syndrome  
  • Medical history
    • Previous concussion/MTBI
      • Multiple instances may lead to more severe and drawn out cognitive deficits
      • This is Coby Fleener’s 5th reported concussion/MTBI
    • Prolonged history
    • Mood, anxiety, seizure, or learning disorder
    • Migraine headaches
  • Extent of injury
    • Severe impact
    • Double impact (two concussions/MTBI in relatively short time span)
    • Long duration of initial symptoms
    • Type of symptoms
      • Major visual symptoms
      • Cluster of nausea, headache, and dizziness

B. What causes post concussion syndrome

The cause of post concussion syndrome is likely multi-factorial – it was initially attributed to cognitive and behavioral/emotional factors but recently we’ve seen some evidence that physical changes may also underly the syndrome.

To start, here’s a visual model of how cognitive and behavioral/emotional factors contribute to the development of post concussion syndrome:

post concussion symptoms
Credit – HeadInjurySymptoms

1 – Cognitive

From a cognitive perspective, a history of depression may play a major role in developing post concussion syndrome. For example, one study found that the perception of the concussion/MTBI can contribute directly to the development of post concussion syndome – those who believed their concussion/MTBI had serious consequences were more likely to develop chronic symptoms.

To measure cognitive factors, there are a series of standardized tests and questionnaires that are used to measure attention, language, cognitive functioning, memory, and other cognitive parameters.

Examples of these tests include:

  • The Rivermead post concussion symptoms questionnaire which is used to calculate and quantify post-concussion syndrome symptoms
  • Wechsler adult intelligence scale
  • Trail making test
  • Complex drawing
  • Copy and memory test
  • Oral word association
  • Wisconsin card sorting
  • Category testing
  • Paced auditory serial addition task.

Each of these tests or series of tests are used to quantify and compare post-concussion syndrome symptoms

2 – Behavioral/Emotional

From a behavioral/emotional perspective, individuals with high anxiety, previous pre-morbid conditions (panic attacks, PTSD), poor coping skills, and/or with certain personality types may be at higher risk for developing post concussion syndrome.

Just like the cognitive category, there are tests to measure behavioral/emotional factors.  These include:

  • Minnesota Multiphasic Personality Inventory (MMPI2)
  • Hospital Anxiety and Depression Scale
  • Impact of Event Scale
  • Galveston Orientation and Amnesia Test
  • Other specific questionnaires

In one research study that used a 19-point questionnaire (divided into 3 sections), patients who had symptoms 14 days after the original concussion/MTBI scored worse on the emotional section than those who didn’t have symptoms after 14 days.  Additonally, females and patients with anxiety disorders scored significantly worse on each of the 3 sections.

3- Physical

For years, there have been theories about the physical underpinnings of PCS but no real evidence. 

One of the main theories attributes the underlying physical cause of PCS to axonal injury that occurs during the initial concussion/MTBI; specifically, as we talked about earlier, the shearing of the neurons leads to diffuse axonal injury (DAI). However the research and data on this theory are still up in the air.

In addition, the physical exam and CT scan for individuals suffering from post concussion syndrome frequently comes out as normal, possibly with some slight neurological deficits.

However, recent imaging studies using MRI, SPECT, and MEG testing (which are more sensitive to detecting brain injuries associated with PCS) have shown possible changes in the brain anatomy and function of individuals with PCS.

These imaging studies have shown changes in brain anatomy and function that may be linked to some of the physical symptoms of post concussion syndrome.  However, none of these physical changes have been able to account for the cognitive or behavioral changes (which is often the case in most chronic condition or chronic pain profiles – pain and symptoms aren’t as simple as the physical tissue!)

Further, some studies have shown long-term changes in cerebral blood flow (blood flow to the brain). One study took an MRI of kids between the ages of 8 to 18 years old who were still suffering from concussion/MTBI symptoms at day 40.  The MRI showed increased cerebral blood flow (CBF) in this PCS group compared to the others (the controls).

Take another look at the graph that I showed earlier regarding CBF after initial concussion/MTBI:

post concussion syndrome
Credit – Giza, “The new neurometabolic cascade of concussion”

Following the initial “energy criss” of the brain after concussion/MTBI, CBF usually returns to normal levels within 7-10 to restore equilibrium of the brain.  Based on the study I just mentioned, it could indicate that the brain is still trying to restore itself by diverting more resources.

In general, the physical evidence for PCS remains debatable but the case for physical evidence is progressing (albeit, very slowly).

4 – Other factors (possible misattributions)

There are some factors that may point to conflation and misattribution of post concussion syndrome with other issues.  These include:

  • Chronic pain
    • Research has shown that individuals with chronic pain have similar symptoms to individuals with PCS, including cognitive deficits.  We don’t know if this reflects a shared prevalence of symptoms or if PCS is possibly a subset of chronic pain.
  • Confirmation bias
    • Extensive surveying has shown that individuals who haven’t experienced a head injury actually identify PCS symptoms as common and expected after a concussion/MTBI.  This leads to confirmation bias in which patients who experience any subsequent symptoms, attribute them to PCS, regardless of their true origin.
  • Litigation
    • Studies show that there’s a relationship between ongoing post concussion syndrome and financial compensation from litigation. Naturally, this can lead to over-reported and exaggerated claims of PCS.

Now that we’ve reviewed the possible causes and potential misattributions of post concussion syndrome, what are the actual symptoms?

IV. The symptoms of post concussion syndrome

The symptoms of PCS are similar to a standard concussion/MTBI but last for a longer duration of time (4+ weeks as we talked about before). The cognitive and emotional/behavioral changes that accompany/cause PCS may serve to exacerbate the symptoms and create a vicious cycle of conditioning.

Here’s a list of commonly reported symptoms:

  • Behavioral/emotional
    • anxiety/nervousness
    • irritability
    • depression
      • each of these can last days to weeks
    • changes in daily habits like exercise, nutrition, drug usage
  •  Cognitive
    • confusion
      • usually lasts minutes to hours
    • difficulty concentrating
    • difficulty remembering
    • disoriented
      • these 3 can last days to weeks
    • feeling foggy
    • feeling slowed down
  •  Sleep (generally, any sleep alteration can last days to weeks)
    • drowsiness
    • increased sleep quantity
  •  Sensory/physical
    •  headache
      • can last from minutes to hours to days to weeks
    • dizziness
    • nausea
      • these 2 usually last minutes to hours
    • fatigue
    • light sensitivity
      • these 2 usually last days to weeks
    • A few noteworthy symptoms
      •  Vomiting
        • can last minutes to hours
      • light-headedness
      • tinnitus (ringing of the ears)
        1. these 2 can last days to weeks

Here’s the full list if you’re interested.

And here’s a good visual breakdown of common PCS symptoms in a percent format:

post concussion syndrome
Credit – MentalHealth.va

It’s really tough to imagine having any of these, let alone multiple of them, for a few days.  Now imagine having them for 4+ week or in the case of Coby Fleener, for 6 straight months.  The mental and physical toll that PCS takes on you and how it interferes with daily life cannot be understated or emphasized enough.

I’ve personally witnessed this toll while treating individuals suffering from post concussion syndrome – it’s truly brutal.  Here are some of the rehab treatments and techniques that can be used to help:

V. Rehab for post concussion syndrome

The rehab for post concussion syndrome is, for lack of a better word, tough.  You’re dealing with a condition that is multi-factorial and often exacerbated by the frustration, fixation, and anger that go along with it.

The rehab should take place amongst a team of medical professionals – often times the primary physician, a neurologist, psychologist, and physical therapist.  Additionally, if there are explicit visual symptoms, then a neuro-opthalmologist may also be involved.

Having interned at Banner University Medical Concussion Center, I had the privilege to witness this inter-disciplinary approach and teamwork in dealing with PCS.

The specific rehab and treatment chosen depends on that specific symptoms.  As you read about above, there’s a large spectrum of symptoms that can exist within the syndrome so there’s naturally a large spectrum of treatments.

Some examples include medication interventions that an be used to help with headaches and dizziness.  If the headaches are the result of tension and cervical (neck) issues, then physical therapy can help address the musculoskeletal causes.

Additionally, if the patient is experiencing dizziness deficits that are related to the vision or vestibular (a system in your inner ear that provides equilibrium, temporal, and spatial awareness about your body to your brain – it’s often called the “organ of balance”) systems, then you can implement visual and balance habituation techniques that gradually challenge these impaired systems.

Here’s a video showing gaze stabilization techniques (go to the 1:50 mark):

And here’s a video I created on balance progressions:

These targeted activities re-acclimate your vision and vestibular system.

In recent years, there’s an emerging paradigm in the treatment of post concussion syndrome – gradual graded exercise.

There’s increasing evidence that a graded exercise program can help restore the brain’s natural function and regulation. Here’s what one of the leading researchers on this new treatment, Karl Kozlowski PHD and assistant professor of kinesiology at Canisius College in Buffalo, had to say:

“We found that gradual exercise, rather than rest alone, actually helps to restore the balance of the brain’s auto-regulation mechanism, which controls the blood pressure and supply to the brain”

It’s a promising new treatment but research is still ongoing to assess the effectiveness.

However, there is one treatment, across the board, that’s proven to be very effective when it comes to preventing or dealing with post concussion syndrome – EDUCATION.

Research shows that early education and support can affect the course of PCS. Specifically, those individuals who believed their initial concussion/MTBI would result in long-term consequences were more likely to actually have those symptoms when compared to those who didn’t have that belief.

Therefore, education after the initial concussion/MTBI , throughout the course of symptoms, and during PCS may help mitigate or alleviate the cognitive and behavioral/emotional factors.

The patient may feel less fixated on the issue, feel like they aren’t the only one going through it, and it could improve their social support as family or friends may be more accepting. Unfortunately, I’ve seen family and friends think the individual is “making things up” or “being dramatic” – it’s hard to relate to an injury that you can’t see.

VI. The Takeaway

The reality with post concussion syndrome is that both the short-term and long-term implications can be far-reaching.  It’s somulti-factorial and variable in nature that each person’s timeline and effectiveness of treatment is going to vary.

For Coby Fleener, recovery may be even tougher because his history of concussions/MTBIs, the fact that he’s nearing 6 months of symptoms, and that he plays a sport with the highest risk for subsequent concussions/MTBI.

In sum – PCS really freaking sucks. It interferes on a day to day and often times minute to minute basis with simple things that you wouldn’t expect to be difficult, affects foundational health factors like sleep and activity, involves an often uncomfortable and disconcerting rehab process, and is an “invisible” condition with a variable timeline that can be quite frustrating for the patient and support system – which feeds right back into the syndrome.

I don’t wish it on my worst enemy.

I do hope Coby Fleener can reign in and lasso his ongoing PCS symptoms.  I can’t say with any confidence or certainty that he’ll be able to return to the NFL or even if he’ll be completely symptom free at some point. Lets hope he can get back to living a normal life in the not too distant future.

Thanks for reading and until next time.

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