Precisely when athletes are considered to have moved from a typical concussion recovery to PCS is not specifically defined, but athletes who are symptomatic for more than 4 weeks are considered to be beyond the typical recovery period, particularly if they are older adolescents or collegiate or professional athletes. The NATA position statement 2 notes that adult males typically recover within 14 days, whereas females and younger patients may require more time to recover. 8 The various definitions of PCS reflect a syndrome characterized by nonspecific cognitive and symptom criteria rather than by a specific diagnosis based on pathophysiological evidence. 6 After 3 weeks, patients (and especially athletes) begin to worry about when they will recover, and if symptoms persist for 6 weeks, PCS can alter how individuals live their lives. 6 Use of a broader definition of PCS (eg, the World Health Organization's International Classification of Disease- 10 7 clinical criteria are the persistence of 3 or more of the following symptoms: fatigue, headache, dizziness, irritability, insomnia, concentration difficulty, or memory difficulty) is much more sensitive for identifying PCS patients but does not specify a time frame. As defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, 5 PCS refers to (1) cognitive deficits in attention or memory and (2) at least 3 or more of the following symptoms: fatigue, sleep disturbance, headache, dizziness, irritability, affective disturbance, or apathy or personality change that persists for 3 months or longer. Postconcussion syndrome describes patients who do not recover after concussion within the expected time frame, 4 which depends on the patient and the circumstances of the injury. Therefore, for the purposes of this paper, concussion refers to the condition that clinically resolves within 30 days of injury, whereas PCS is present when symptoms persist for 30 days or longer. Thus, although athletes who are symptomatic for more than 10 days may be considered atypical with respect to the expected recovery time, recent investigators, 3 using an approach accounting for concussion heterogeneity that incorporates symptoms and neurocognitive and vestibular-oculomotor outcomes, suggested that recovery time for adolescents with SRC may be as long as 3 to 4 weeks. The Zurich guidelines 1 state that persistent symptoms (>10 days) are reported in 10% to 15% of patients with SRC. Concussion is a functional disturbance rather than a macrostructural brain injury, the resolution of which requires 7 to 10 days in the typical athlete (80%–90% of cases). The most recent international consensus statement on concussion in sport, the Zurich guidelines, 1 and the 2014 National Athletic Trainers' Association (NATA) position statement on the management of sport-related concussion (SRC) 2 define concussion as a brain injury resulting from biomechanical forces producing a complex pathophysiological process that typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. A case report highlights how athletic trainers can be key members of the medical team in assessing and treating the athlete with prolonged recovery after concussion. We discuss the current best available evidence for the pathophysiology of postconcussion syndrome (PCS) and for the efficacy of subthreshold aerobic exercise and of cervical, ocular, and vestibular rehabilitation for treating the athlete with prolonged recovery after concussion. This paper presents emerging thought about assessing exercise tolerance as a potential physiological biomarker to establish or confirm the diagnosis of concussion and, perhaps more importantly, to help practitioners decide when the physiological dysfunction of concussion has resolved. Identifying the symptom generator(s) in the athlete with a prolonged recovery is essential to prescribing appropriate active therapy. New research is challenging the traditional approach of “rest until symptoms resolve” and suggests, in fact, that prolonged rest adversely affects the pathophysiology of concussion, delays the institution of effective therapies, and may be detrimental to recovery.
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