Stephen  A.  Russo,  Ph.D.  

 Clinical  Sport  Psychologist   Concussion  Management  Specialist  

 Thomas  Jefferson  University  

 Philadelphia,  PA  

.

  Dr. Russo has no relevant financial relationships to disclose.

  Dr. Russo was Director of Sport Psychology at the University of Pittsburgh Medical Center (UPMC) from 1999-2003 and is married to a former ImPACT Applications employee.

Disclosure Statement  Stephen  A.  Russo,  Ph.D.  

.

Presentations Goals

  Highlight Potential Emotional and Mental Health Outcomes that Can Influence Athletes Compliance Practices and Their Rehabilitation Results

  Explain How a Health Psychology Paradigm and an Inter-Disciplinary Approach to the Clinical Management, of Concussion is Ideal for Healthcare Professionals

  Illustrate Ways the Psychosocial Components of Athletics and the Culture of Sport Participation Influences the Response and Recovery from Concussion

Physical / Mental Recovery From Injury

Physical  /  Psychological    Readiness  to  Return                            to  Sport  Don’t                              Always  Coincide!  

Mental  Factors  Can    Influence  Response                              to  Injury  as  Well  as    Physical  Outcome!!  

The  Impact  of  Psychological  Factors  Post-­‐Concussion  is  Not  Well  Understood!!!  

Kontos,  A.P.  (2017).  Sport,  exercise,  and  performance  psychology,  6  (3),  215–219.  

Mood and Emotions

Motivation

Trust in Treatment

Self-Efficacy Athletic Identity

Social Support

Cognitions

Recovery

Concussion in A Health Psychology Context

Pain Intensity is One of the Most Powerful Predictors of Activity Tolerance, Particularly within Rehabilitation

However, CATASTROPHIZING, is Associated with Higher Levels of Subjective Pain Intensity, Disability, and Emotional Distress

CATASTROPHIZING is a Way of Thinking about an Injury Where People:

Ruminate about Painful Sensations: “I Can’t Stop Thinking About How Much It Hurts”

Magnify Values of Pain Sensations: “I Worry Something Serious May Be Wrong”

Feel Helpless To Cope Effectively: “There’s Nothing I Can Do About It”

The Development of any CHRONIC PAIN CONDITION Involves Psychological Factors:

Perception of Pain is the Result of Interpretation of the Injury and Its Sensations

Believing a Stimulus is Harmful or Attributing Greater Meaning to Painful Sensations Cause People to Experience More Pain

People Who are Worried, Anxious, Depressed, or Have a Negative Outlook Have a Higher Sensitivity to Pain

Operant Conditioning, Social Reinforcement, and Secondary Gain Issues All Contribute to the Persistence of Pain Behaviors

Factors Associated with Faster Recovery from Injury Include:

(1) Maintaining a Positive Attitude and Outlook

(2) Being Self-Motivated / Having Desire to Heal

(3) Having Social Support in Primary Social Network and Rehabilitation Facility

Factors Associated with Rehabilitation Outcomes

� Injury-Related Cognitions Can Influence Mood and Emotions. Research Has Shown That Personal and Situational Factors That Influence Thoughts Also

Have an Impact on Recovery

Injury-Related Emotions Injury-Related Thoughts Injury-Related Behaviors

� Research Has Shown That The Emotional

Reactions Which Follow The Occurrence of Injury

Can Have An Impact On The Outcome of Rehabilitation

� Coping Strategies, Social Interactions, and Exercise Adherence Are

All Examples of Behavior Patterns That Can Directly

Impact Rehabilitation Outcomes

Injury-Related Emotions Associated with Rehab Outcomes

� Athletes Say That Frustration, Confusion, Anger, and Fear Are Common Early Reactions to Injury. However, Negative Emotions Generally Decrease as Rehabilitation Progresses

Emotional Reactions Are Not As Fixed or Orderly As Has Been Suggested by “Grief” Models

� A Reluctance to Discuss Emotions Related to Being Injured with Peers or Coaches Was Associated with:

  Persistent Feelings of

Isolation and Alienation

  Reduced Long-term

Psychological Rehabilitation

Persistent Post-injury Emotional Disturbance is Associated With:

  Poor Adherence To Rehabilitation

Regimen

  Poor Rehabilitation Outcome

� Emotional Distress after Injury Was also Associated with Decreased Confidence in:

  A Full Recovery

  Success In Sport

  Ability to Adhere to Rehab

� Athletes Also Have Heightened Fears During The Transition Back to Sport. Commonly Reported Fears Include:

  Fear of Re-injury

  Fear of Falling Behind Others

  Fear of Underperforming

  Fear of Missing Out

� Injury is a Significant Stressor That Athletes Are Sometimes Ill-prepared (or Unwilling) To Face

� Injured Athletes Are More Likely to Experience Depression, Anxiety, and Reduced Self-esteem When Compared to Non-Injured Peers

� Athletes with Lower Self-esteem and Greater Emotional Reactions After Injury Were:

  Generally More Invested in

Playing Professional Sports

  Had A Greater Identification

with Being an Athlete

  Rarely Had Other Interests,

Activities, or Motivations Outside

of Sports

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Collins  et  al.,  2007;  McCrory  et  al.,  2008  

Concussion Management Guidelines

General Criteria Used for Return to Play Following Sport-Related Concussion Has Been Established for Almost Two Decades

  Symptom-­‐Free  At  Rest  

  Symptom-­‐Free  with  CogniXve  /  Physical  ExerXon  

  “Normal”  Neuro-­‐cogniXve  Data  /  ObjecXve  EvaluaXons  

Being “Asymptomatic” is at the Core of

Proper Concussion

Management, But it is Not an Easily Defined

State

.

3-Year Prospective Study of 17 HS American Football Teams: N=2,141; Total Concussions: N=134

Recovery From HS Football-Related Concussion: How Long Does it Take?

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

40% RECOVERED

60% RECOVERED

80% RECOVERED

 Collins  et  al.  (2006).  Neurosurgery,  Vol.  58(2),  275-­‐286.  

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Kontos  et  al.  (2012).  American  Journal  of  Sports  Medicine,  Vol.  40(10),  2375-­‐2384  

Factor Analysis Post-Concussion Symptom Scale

Five Items Failed to Clearly Load on Any Factor, But Were Strongly Associated:   Nausea   Balance Problems   Sleeping More Than Usual   Irritability   Vision Problems

Strong C-M-F Factor (40.0% of Variance) Suggests a “Global” Symptom Pattern w/in First Week of Injury

Concentration Problems and Mental Sluggishness Contributed to C-M-F Factor More Than Headache!!

Females Athletes Tended to Score Higher on the Affective Cluster

AFFECTIVE  Sadness  

Feeling  More  EmoTonal  Nervous  

SLEEP  Trouble  Falling  

Asleep  Sleeping  Less  Than  Usual  

SOMATIC  VomiTng  Numbness  

COGNITIVE  -­‐  MIGRAINE                    FATIGUE  

Headache – Dizziness - Fatigue Drowsiness - Photophobia

Phonophobia - Feeling Slowed Down Mentally Foggy

Difficulty Concentrating

Difficulty Remembering

High School and College Athletes w/in 7 Days of Concussion, N = 1,438

Four-Factor Solution Accounted for 58.3% of Variance and 17 of 22 Items

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VESTIBULAR

ANXIETY / MOOD

OCULAR

COGNITIVE / FATIGUE

MIGRAINE

CERVICAL SPINE

Using Trajectories to Inform Treatment

•   Previous Concussions

•   Migraine History (Family / Personal)

•   Age

•   LD / ADHD History

•   Sex

•   Ocular History

•   Motion Sensitivity

•   Litigation

•   Prior Functioning: Physical

•   Prior Functioning: Psychological

FACTORS THAT INFLUENCE RECOVERY

Collins  et  al.  (2014).  Knee  Surgery,  Sports  Traumatology,  Arthroscopy,  Vol.  22(2),  235-­‐246.  

Anxiety and Mood Clinical Profile Following SRC

� MENTAL HEALTH HISTORY:

� Several Studies Found That A Diagnosed Mental Health History or Previous Mental Health Tx Predicts Greater Symptom Endorsement and A Protracted Recovery from A Concussion

� BIOLOGICAL SEX:

� Females Tend To Report More Emotional Symptoms than Males Before and After Injury (Iverson et al., 2015; Kontos, Elbin, et al., 2012)

� Sex Differences Have Been Attributed to Biological Factors and Cultural Phenomena, but No Consensus Explanation for Differences in SRC-Symptom Reporting Exists at This Time (Covassin et al, 2007, 2012)

� Anxiety / Mood Clinical Profile is Characterized By Emotional Disturbance (e.g., Anxiety, Dysphoria), Hypervigilance of Somatic Complaints, and Sleep Dysregulation

� General Indicators of Emotional Disturbance after Injury Include:

  Inconsistencies in Subjective Sx Reporting vs. Objective Deficits

  Worsening of Symptoms and Deficits Over Time, as These Patterns Are Not Consistent With Typical SRC Recovery

BRAIN ALTERATIONS: The Overlap of SRC-Symptoms and Mental Health Disorders are Partially Due To Physiological Changes That Occur in The Emotional Centers of The Brain after Concussion

SOCIAL SUPPORT:

Perceived Stress Post-Concussion Has Been Positively Associated with Levels of Anxiety and Depressive Symptoms

High Levels of Parental Pre-injury Anxiety and Child Reported Stress after Concussion Was Predictive of Greater Symptoms at 18 months

Covassin et al. (2014) Reported That Concussed Athletes Who Endorsed High Levels of Social Support Reported Low Levels Post-Injury Anxiety

Sandel  et  al.  (2017).  Sport,  exercise,  and  performance  psychology,  Vol.  6  (3),  304–323.  

Sports No Longer A Prize Unto Itself •   Educational Component Diminished

•   Greater Focus on “Destinations” Such as College and Professional Sports, Particularly for Parents w/o H.S. Degrees

•   Prevailing Mindset for Success in College Admissions has Become Sport Specialization

  Other Pursuits (e.g., Music, Art) Have Also Adopted Specialization Approach

•   Dedication, Time, and Money Required To Play Year-round is Far Beyond What Previous American Youth Experienced

Kids Are Not Just Picking One Sport at The Expense of Other Sports ... They’re Picking One Sport at The Expense of Any Other Extracurricular Interests!

Early Specialization Actually Narrows Development and Increases Risk of Injury

Specialized Athletes More Susceptible To Injury Because They Are “Exposed” To Their Sport More Often and Put More Stress on The Concentrated Group of Muscles, Ligaments and Bones Related To Their Sport (i.e., “Overtrained”)

Douglas  Brunt  –  Time  Magazine;  May,  2017  “Money  is  Ruining  Youth  Sports”  Jacob  Bogage  –  Washington  Post;  Jan,  2017  “Sport  SpecializaTon  Increases  Injury  Risk  For  HS  Athletes,  Study  Finds”  

The Culture of Youth Athletics

Familial Expectations for NCAA Football Players

Predictor of Overuse Injuries: Training Volume

Injury Rates in High School Athletes Have A Direct Relationship to Exposure by Hours Per Week and Higher Training Intensity / Volumes

Have Consistently Been Shown To Increase The Risk of Overuse Injuries

   Injury  

Scheduling Multiple Events on Same Day or Several Events over Consecutive Days is Considered A Risk Factor for an Overuse Injury

Yearly Volume Kids (9-14) Who Pitched More Than 100 Innings A Year Were

3.5 Times More Likely To Suffer An Overuse Injury

Yearly Volume There Is an Increased Risk for Shoulder and

Elbow Injuries in Youth Pitchers Who Pitch More

than 8 Months A Year

Yearly Volume There Was 42% Increase in Overuse Injuries in High School Athletes Who Participated All Year Versus 3 Seasons or Less Per Year

Weekly Volume Training More than 16 Hours A Week Was Associated with A Significantly

Increased Risk of Overuse Injury

The Current Culture of Adolescence

Today’s Adolescents: Post-9/11 Generation, Raised in Era of Insecurity   Never Known a Time when Terrorism and School Shootings Weren't the Norm

  Grew Up Watching Their Parents Weather a Severe Recession

  Hit Puberty when Technology and Social Media Were Transforming Society

  Significantly More Standardized Testing Protocols Implemented in the Past Decade

For Today’s Adolescents, "No Firm Line” between Real and Online Worlds   Technology and Online Bullying Are Affecting Kids as Early as Fifth Grade

  Every Fight / Slight is Documented Online for Hours or Days after the Incident

  Managing a Social-Media Identity Plus Fretting about Unique Cultural and Societal Pressures

Anxiety and Depression in High School Has Been on the Rise Since 2012   Statistic Cuts Across All Demographics - Suburban, Urban and Rural

  Mental Illness Impacts Those Who Are College Bound And Those Who Aren‘t

  Family Financial Stress Can Exacerbate These Issues

  Studies Show That Girls Are More At Risk Than Boys

Susanna  Schrobsdorff  –  Time  Magazine;  Oct.,  2016  “Teen  Depression  and  Anxiety:  Why  the  Kids  Are  Not  Alright”  

The Current Culture of Adolescence

In 2015, HHS Reported that about 3 Million Teens (Ages 12-17) Experienced at Least One Major Depressive Episode in the Preceding Year

  More Than 2 Million Report Experiencing Depression that Impairs Daily Function

According to the NIMH, about 30% of Girls and 20% of Boys (Almost 6.3 Million Teens) Have Had an Anxiety Disorder

  Child Mind Institute (2015) Found Only 20% of Youth with a Diagnosable Anxiety Disorder Get Treatment

Susanna  Schrobsdorff  –  Time  Magazine;  Oct.,  2016  “Teen  Depression  and  Anxiety:  Why  the  Kids  Are  Not  Alright”  

Student Athletes and Stress

College Student-Athletes Experience More Psychological Pressure and Stress than their Non-Athletic peers, But are Significantly Less Likely to Seek Mental Health Services

When Student-Athletes Seek Counseling, They Have More Stress-Related Physical Illnesses and Higher Rates of Depression and Anxiety

Examination of Student-Athlete Sleep Patterns Show they Experience, on Average, Four Nights of Insufficient Sleep per Week

� Issues Such as Pressure to Perform, Time-constraints, High Training Volumes, and Limited Sleep Exemplify Their Heightened Stress Levels.

CLINICAL  

ASSESSMENT      

CLINICAL  INTER

VIEW  

NEUROCOGNIT

IVE    

TEST  SCORES  

ACADEMIC    

MODIFICATIONS  

WORK/  ACTIVE  

DAILY  LIVING  

TREATMENT  &  R

EHAB  

Questions To Ask Patient  

Collins et al, KSST, 2014; Reynolds et al, Neurosurgery, 2014 Covassin et al. (2017). Sport, exercise, and performance psychology, 6 (3), 220–229.

Concussion in A Health Psychology Context

ANXIETY / MOOD

Amotivation

Athletic Identity

Quality of Social Support

Performance Anxiety

Motivational Climate of

Coach / Parent

O’Rourke et al. (2017). Sport, exercise, and performance psychology, 6 (3), 262–276.

Restoration Of Athletic Ability and Return To Play Are Primary Objectives Following Any Injury!!

Severity of Original Injury Does Not Directly Correlate with Risk Of PCS! Often, PCS Symptoms Are Worse Than The Initial Concussion

Athletes w/ High Athletic Identity, Amotivation, and Performance Anxiety Had Continued Symptoms Up To 28 Days Post-Concussion

Larger Social Network Size Predicted Greater Improvements In Symptoms

High Mastery / Low Ego Coach Environment And Low Mastery / High Ego Parent Environments Predicted Symptoms Reductions

Psychosocial Variables Accounted for 23 - 31% of Symptom Change Over Time

� Concussion Symptoms Typically Worst In First 7-10 Days, But Usually Resolve Within A Month Following The Injury

Turner et al (2017) Documented Similar Psychological Response in Concussion and MSK Injuries, Where Both Groups Showed Gradual Improvement In Mood State Throughout The Recovery Process

Conclude That Psychological Factors Play A Larger Role Than Physiological Response To Concussion

  Time Loss From Practice / Games

  Social Isolation

  Withdrawal From ADLs

Concussion in A Health Psychology Context

Depressive Symptoms Associated with Concussion

� Several Studies Have Documented Increased Depression Symptoms In Athletes w/ SRC

(Hutchinson et al., 2009, Manwaring et al., 2004, Kontos et al., 2012).

Yang et al. (2015) Found:

  20% of Concussed College Athletes Had Increased Depression Sxs after SRC

  College Athletes w/ Baseline Depression Sxs Were 4.59 Times More Likely To Suffer Dysphoria After SRC

� Appears Depression Symptoms In HS and College Athletes w/ SRC Follow A Similar Trajectory as Cognitive Sequela of SRC … Typically Resolving w/in One Month of Injury

(McCrory et al., 2013, Roiger et al., 2015)

� Depression Also Shown To Be A Long-Term Consequence of SRC

  Guskiewicz et al. (2007): Dose-Response Relationship Between Self-Reported SRCs and Clinical Depression Later in Life

  Retired NFL Players w/ 1-2 SRCs Had 1.5X Greater Depression Risk for Depression

  Retired NFL Players w/ 3+ SRCs Had 3X Greater Depression Risk

In One of The Few Studies To Examine Suicide Following SRC, Only 10% of Athletes with A Post-Injury Psychiatric Outcome Had Suicidal Ideation (Ellis et al., 2015)

Numerous Researchers And Experts Have Called For Clinicians To Incorporate Depression and Mood Screening Assessment Into Their Pre-and Post SRC Management

Depression Is Common Feature of PCS and Chronic Pain, But It’s Difficult To Determine A Causal Direction Between Emotional Disturbance And Pain Fixation

SRC’s Shared Symptoms of Depression Include (Iverson, 2006):

  Sadness   Mental Sluggishness   Fatigue   Concentration Difficulties

� Armstrong & Oomen-early (2009) Reported 33.5% of Collegiate Athletes Exhibit Depression Symptoms ... Found No Difference Between College Athletes and Non-College Students

Yang et al. (2015) Found 21.4% of Collegiate Athletes Report Depression Symptoms at Baseline

Covassin  et  al.  (2017).  Sport,  exercise,  and  performance  psychology,  6  (3),  220–229.  

Anxiety Symptoms Associated with Concussion � Covassin et al. (2014) Posit That High Prevalence of Anxiety in SRCs Due To:

  Heightened Perception of Severity

  Lack of Prognostic Timeline for RTP

  Loss of Athletic Identity

In A Pediatric Population, Concussed Patients w/ No Premorbid HX of Anxiety Took ∼ 76 Days To Recover

Patients Diagnosed w/ Premorbid Anxiety Took ∼ 6 Months To Recover (Corwin et al., 2014)

� Youth And Collegiate Athletes Who Exhibited Early Signs Of Anxiety Should Be Targeted For Interventions To Decrease Their Chances Of Prolonged Recovery From SRC (Collins, Kontos, Reynolds, Murawski & Fu, 2014)

Yang et al. (2015) Reported Over One-Third of Concussed College Athletes Experienced State Anxiety Following Their SRCs

Turner et al.’s (2017) Comparison of CONC and MSK Groups:

  73.3% of Participants Exceeded

Threshold for State Anxiety during Acute

Phase of Post-Injury … REGARDLESS

OF TYPE OF INJURY

  Both Groups Demonstrated Gradual

Improvement in Mood State Throughout

The Recovery Process

  Over Half of Participants in Each Group

Scored Above Cutoff During ACUTE and

RETURN TO PLAY Phase!!

Children w/ Post-Concussion SXS for Longer Than One Month Reported More Anxiety Than Children Whose Symptoms Resolved Within One Week (Grubenhaff et al., 2016)

Anxiety Symptoms Often Difficult To Disentangle from SRC Symptomatology (Bloom et al, 2004)

SRC’s Shared Anxiety Symptoms:   Anxiousness   Fatigue   Nervousness   Sleep Difficulties

Fear / Anxiety in Athletic Injuries Can Be Directed At:

  Uncertainty about Clearance Process

  Uncertainty about Long-term Career

  Thoughts of Current / Future Health

  Concerns of Death, Disability, and

Reduced Quality-of-Life

  Concerns about Maintaining Elite

Level of Performance or Intensity

  Loss of Control, Pride, or Identity By

A Forced Alteration of Playing Style

� SLEEP:

� Sleep Disturbance Common After Concussion, But is Also Associated w/ Reduced Cognitive Functioning, Anxiety, and Depression in General Population

� PHYSICAL ACTIVITY AND DESENSITIZATION:

� Positive Influence of Physical Activity on Mood / Anxiety SXS is Multifactorial while Avoidance Behaviors Can Become “Conditioned” Quickly

� Avoidance Results in Loss of Outlets for Coping w/ Stress as well as Limited Engagement In Meaningful, Social Interactions and Loss of Daily Routine

� Prescription of Prolonged, Strict Rest Has Been Associated w/ Development of Emotional Difficulties That, For Some, Require Formal Psychological Intervention

� Behavioral Reregulation is Practice of Maintaining Healthy Lifestyle Factors To Prevent PCS Symptoms From Becoming Chronic Impairment:

  Sleep Schedule

  Adequate Nutrition and Hydration

  Daily Movements / Physical Activity

  Management of Stress

COPING STYLE: Active, Problem-Focused Coping Style Shown To Be Beneficial In Reducing PCS Symptom Burden

Individuals w/ Higher Levels of Resiliency Demonstrated Less Emotionality as well as Better Quality-of-Life after Concussion

PSYCHOEDUCATION:

Reassurance; Provision of Support; and Appropriate Education Shown To Reduce PCS Symptoms in Several, Replicated RCT Studies

Discussion of SXS In Positive Context; Cognitive Reattribution of Symptoms; and Gradual Activation Associated w/ Better Psychological Outcomes

Education Has Included Informing Patients about Concussion SXS To Medication Management Issues and Expected Recovery Times

Sandel  et  al.  (2017).  Sport,  exercise,  and  performance  psychology,  Vol.  6  (3),  304–323.  

Psychological / Counseling Interventions for Concussion

.

CLINIICAL  ASSESSMENT  CLINICAL  INTERVIEW  NEUROCOGNITIVE  TEST  SCORES  ACADEMIC  MODIFICATIONS  WORK  /  ACTIVE  DAILY  LIVING  

TREATMENT  &  REHAB  

ANXIETY / MOOD Collins et al. (2014). Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 22(2), 235-246. Sandel et al. (2017). Sport, Exercise, and Performance Psychology, Vol. 6 (3), 304–323.

  Cognitive Behavioral Psychotherapy

Treatment  Typically  Includes  Graded  Exposure,  AcXvity  Scheduling,  RelaxaXon  Exercises,  Social  Skills  Training,  and  CogniXve  Restructuring  

CogniXve  Training  Focuses  On:    Altering  ProblemaTc  Beliefs    Helping  Clients  Improving  Problem-­‐Solving  Skills    Self-­‐Monitoring  Their  Thoughts,  EmoTons,  and  Behaviors  

Improving  Coping  Strategies  Involve  Teaching  PaXents:      Mental  Disengagement    PosiTve  ReinterpretaTon    EmoTonal  VenTng  And  Re-­‐processing    RelaxaTon  Training,  Mindfulness,  And  Guided  Imagery  

Psychological / Counseling Interventions for Concussion

.

Sport Concussions: What Have We Learned

  Psychosocial Components of Athletics and the Culture of Today’s Sports Environments Have a Direct Influence on Emotional and Psychological Reactions to Concussive and MSK Injuries

  The Influence of Psychological Factors on Concussion Recovery is Not Currently Understood, but Evidence Suggests a Similarity with Chronic Pain Literature

  Symptoms of Anxiety and Depression Appear to be Common Responses to Concussion as well as Risk Factors for Protracted Recovery

  Clinicians Must Balance Tenants of Concussion Management w/ the Risk of Fostering Emotional Difficulties That May Require Formal Treatment in the Future

Concussion  is  a  Heterogeneous  Injury  with  Divergent  Trajectories  

Stephen  A.  Russo,  Ph.D.  

 Clinical  Sport  Psychologist   Concussion  Management  Specialist  

 Thomas  Jefferson  University  

 Philadelphia,  PA  

27

REFERENCES / FURTHER EXPLORATION

� Anderson, M.B. & Fawkner, H.J. (2005). Returning to Self: The Anxieties of Coming Back After Injury. In Anderson, M. B. (Ed.). Sport Psychology in Practice. Champaign, IL: Human Kinetics.

� Brewer, B. W (2001). Psychology of Sport Injury Rehabilitation. In Singer, R. N., Hausenblas, H. A., & Janelle, C. M. (Eds.) Handbook of Sport Psychology (2nd Edition, pp.787-809). New York: John Wiley & Sons, Inc.

� Brewer, B. W & Petrie, T. A. (2014). Psychopathology in Sport and Exercise. In Van Raalte, J. L. & Brewer, B. W. (Eds.) Exploring sport and exercise psychology (3rd Edition, pp. 311-336). Washington, DC: American Psychological Association.

� DiFiori, J.P., Benjamin, H.J., Brenner, J., Gregory, A., Jayanthi, N., Landry, G.L., & Luke, A. (2014). Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine. Clinical Journal of Sport Medicine, 24(1), 3-20.

� Evans, L. & Hardy, L. (1995). Sport Injury and Grief Responses: A Review. Journal of Sport & Exercise Psychology, 17, 227-245.

� Ferguson, R. W. Green, A., & Hansen, L. M. (2013). Game Changers: Stats, Stories, and What Communities Are Doing to Protect Young Athletes. Washington DC: Safe Kids Worldwide

� Forsdyke, D., Smith, A., Jones, M. & Geldhill, A. (2016). Psychosocial Factors Associated with Outcomes of Sports Injury Rehabilitation in Competitive Athletes: A Mixed Studies Systematic Review. British Journal of Sport Medicine, 50, 1-10.

� .

Take a deeper dive into the world of sport psychology and injury by reviewing the following:

Green, S. L. & Weinberg, R. S. (2001). Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational participants. Journal of Applied Sport Psych, 13, 40-59

Grandner, M. (2014). Sleeping Disorders. In Brown, G. T. (Ed.) Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. (p. 58-61). Indianapolis, IN: NCAA.

Gutkind, S. M. (2004). Using Solution-focused Brief Counseling to Provide Injury Support. The Sport Psychologist, 18, 75-88.

Hinkle, J. S. (1996). Depression, Adjustment Disorder, Generalized Anxiety, and Substance Abuse: An overview for Sport Psychologists working with college student-athletes. In Etzel, E. F., Ferrante, A.P., and Pinkney, J.W. (Eds.) Counseling College Student Athletes: Issues and Interventions (2nd Ed, pp. 110-136). Morgantown, WV: Fitness Information Technology, Inc.

Knowles et al., (2006). A Prospective Study of Injury Incidence Among North Carolina High School Athletes. American Journal of Epidemiology, 164, 1209-1221.

Kontos, A. P. (2004). Perceived Risk, Risk Taking, Estimation of Ability and Injury Among Adolsecent Sport Participants. J of Pediatric Psychology, 29, 447-445.

Madrigal, L. & Gill, D. L. (2014). Psycholoigical Responses of Division I Female Athletes Throughout Injury Recovery: A Case Study Approach. Journal of Clinical Sport Psychology, 8, 276-298.

Nelson, M.B. (2009). The Damage I have Done to Myself: Physical Intelligence Among College Athletes. Journal of Intercollegiate Sports, 2, 127-144.

Petrie, T. A., Deiters, J. & Harmison, R. J. (2014). Mental Toughness, Social Support, and Athletic Identity: Moderators of the Life Stress-Injury Relationship in Collegiate Football Players. Sport, Exercise, and Performance Psychology, 3, 13-27.

Putukian, M. (2014). How Being Injured Affects Mental Health. In Brown, G. T. (Ed.) Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. (p. 72-75). Indianapolis, IN: NCAA.

Putukian, M. (2016). The Psychological Response to Injury in Student Athletes: A Narrative Review with a Focus on Mental Health. British Journal of Sports Medicine, 50, 145-148.

Simon, J. E. & Docherty, C. L. (2013). Current Health-Related Quality of Life is Lower in Former Division I Collegiate Athletes than in Non-Collegiate Athletes. The American Journal of Sports Medicine, 42(2), 423-429.

Sullivan, M. J., Tripp, D. A., Rodgers, W. M., & Stanish, W. (2000). Catastrophizing and pain perception in sport participants. Journal of Applied Sport Psychology, 12, 151-167.

Weinberg, R. S. & Gould, D. (2015). Athletic Injuries and Psychology. In Weinberg, R. S. & Gould, D. (Eds.) Foundations of Sport and Exercise Psychology (6th Edition, pp. 457-472). Champaign, IL: Human Kinestics.

Wolanin, A., Hong, E., Marks, D., Panchoo, K. & Gross, M. (2016). Prevalence of Clinically Elevated Depressive Symptoms in College Athletes and Differences by Gender and Sport. British Journal of Sports Medicine, 50, 167-171.

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REFERENCES / FURTHER EXPLORATION

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� Baillargeon A, Lassonde M, Leclerc S, Ellemberg D. Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults. Brain Inj. 2012;26(3):211-220.

� Breedlove, S.M. & Watson, N.V. (2013). Hearing, vestibular perception, taste, and smell. In Breedlove, S.M. & Watson, N.V. (Eds.) Biological psychology: An introduction to behavioral, cognitive, and clinical neuroscience (7th edition). Sunderland, MA: Sinauer Associates, Inc.

� Breedlove, S.M. & Watson, N.V. (2013). Vision: From eye to brain. In Breedlove, S.M. & Watson, N.V. (Eds.) Biological psychology: An introduction to behavioral, cognitive, and clinical neuroscience (7th edition). Sunderland, MA: Sinauer Assoc., Inc.

� Camiolo Reddy C, Collins MW, Lovell M, Kontos AP (2013) Efficacy of Amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. J Head Trauma Rehab 28(4):260–265

Take a deeper dive into the world of sport concussion by reviewing the following:

� Capo-Aponte JE, Urosevich TG, Temme LA, Tarbett AK, Sanghera NK. Visual dysfunctions and symptoms during the subacute stage of blast-induced mild traumatic brain injury. Mil Med. 2012;177(7):804-813.

� Centers for Disease Control and Prevention (CDC). Heads up: Facts for physicians about mild traumatic brain injury. Atlanta (GA): Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/physicians/mtbi/mtbi.pdf

� Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):235-246.

� Covassin, T., Elbin, R.J., Biedler, E., LaFavor, M., & Kontos, A.P. (2017). A review of psychological issues may be associated with a sport-related concussion in Houston

collegiate athletes. Sport, exercise, and performance psychology, 6 (3), 220–229.

� Covassin T, Elbin RJ, Harris W, Parker T, Kontos A. The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after concussion. Am J Sports Med. 2012;40(6):1303-1312.

� Cullen KE. The vestibular system: multimodal integration and encoding of self-motion for motor control. Trends Neurosci. 2012;35(3):185-196.

� .

� Elbin RJ, Kontos AP, Kegel N, Johnson E, Burkhart S, Schatz P. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin Neuropsychol. 2013;28 (5):476-484.

� Erdal K. Neuropsychological testing for sports-related concussion: how athletes can sandbag their baseline testing without detection. Arch Clin Neuropsychol. 2012; 27(5):473-479.

Field, M., Collins, M.W., Lovell, M.R. & Maroon, J. (2003) Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. The Journal of Pediatrics, Vol. 142 (5), 546-553. DOI:10.1067/mpd.2003.190

Furman GR, Lin CC, Bellanca JL, Marchetti GF, Collins MW, Whitney SL. Comparison of the balance accelerometer measure and balance error scoring system in adolescent concussions in sports. Am J Sports Med. 2013;41(6):1404-1410.

Galetta, K. M., Barrett, J., Allen, M., Madda, F., Delicata, D., Tennant, A. T., . . . Balcer, L. J. (2011). The king-devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology, 76(17), 1456-1462.

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Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.

Guskiewicz, K.M., Marshall, S.W., Bailes, J., McCrea, M., Harding, Jr., H.P., Mattihews, A., … Cantu, B. (2007). Recurrent Concussion and Risk of Depression in Retired Professional Football Players. Medicine & Science in Sports & Exercise, Vol. 39 (6), 903-909. DOI: 10.1249/mss.0b013e3180383da5

Guskiewicz KM. Balance assessment in the management of sport-related concussion. Clin Sports Med. 2011;30(1):89-102, doi:10.1016/j.csm.2010.09.004.

Khan S, Chang R. Anatomy of the vestibular system: a review. Neuro-Rehabilitation. 2013;32(3):437-443.

Take a deeper dive into the world of sport concussion by reviewing the following:

Knowles et al., (2006). A Prospective Study of Injury Incidence Among North Carolina High School Athletes. American Journal of Epidemiology, 164, 1209-1221.

King D, Brughelli M, Hume P, Gissane C. Concussions in amateur rugby union identified with the use of a rapid visual screening tool. J Neurol Sci. 2013;326(1-2):59-63.

King, D., Clark, T., & Gissane, C. (2012). Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study. Journal of the Neurological Sciences, 320(1-2), 16-21.

Kontos, A.P. (2017). Concussion in Sport: Psychological perspectives. Sport, exercise, and performance psychology, 6 (3), 215–219.

Kontos AP, Elbin RJ, Lau B, et al. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med. 2013;41(7):1497-1504.

Kontos AP, Elbin RJ, Schatz P, et al. A revised factor structure for the Post-Concussion Symptom Scale: baseline and postconcussion factors. Am J Sports Med. 2012; 40(10): 2375-2384

Lau BC, Collins MW, Lovell MR. Cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes. Neurosurgery. 2012;70(2):371-379.

� .

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Lovell, M.R., Echemendia, R.J., Barth, J.T., & Collins, M.W. (Eds., 2004) Traumatic brain injury in sports: An international neuropsychological perspective. Lisse, The Netherlands: Swets & Zeitlinger B.V.

McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47(5):250-258.

McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP (2013) Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Inj 27(1):103–113

Meehan WP III, d’Hemecourt P, Collins CL, Taylor AM, Comstock RD. Computerized neurocognitive testing for the management of sport-related concussions. Pediatrics. 2012;129(1):38-44.

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Mucha, A., Collins, M.W., Elbin, R.J., Furman, J.M., Troutman-Enski, C., DeWolf, R.M., MArchetti, G. & Kontos, A.P. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions. American Journal of Sports Medicine, Vol 42(10), pp. 2479 – 2486.

Naguib MB, Madian Y, Refaat M, Mohsen O, El Tabakh M, Abo-Setta A. Characterisation and objective monitoring of balance disorders following head trauma, using videonystagmography. J Laryngol Otol. 2012;126(1):26-33.

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O’Rourke, D.J., Smithe, R.E., Punt, S., Coppel, D.B., & Brieger, D. (2017). Psychosocial correlates of young athletes’ self-reported concussion symptoms during the course of recovery. Sport, exercise, and performance psychology, 6 (3), 262–276.

Sandel NK, Lovell MR, Kegel NE, Collins MW, Kontos AP. The relationship of symptoms and neurocognitive performance to perceived recovery from sports-related concussion among adolescent athletes. Appl Neuropsychol Child. 2013;2(1):64-69.

Sandel, N., Reynolds, E., Cohen, P.E., Gillie, B.L., & Kontos, A.P. (2017). Anxiety and mood clinical profile following sport-related concussion: From Risk Factors to Treatment. Sport, exercise, and performance psychology, 6 (3), 304–323.

Schatz P, Sandel N. Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes. Am J Sports Med. 2013;41(2):321-326.

Schatz P, Glatts, C. “Sandbagging” baseline test performance on ImPACT, without detection, is more difficult than it appears. Arch Clin Neuropsychol. 2013;28(3):236-244.

Solomon G.S., Johnston, K.M., & Lovell, M.R. (2006). The heads-up on sport concussion. Champaign, IL: Human Kinetics.

Turner, S., Langdon, J., Shaver, G., Graham, V., Naugle, K., & Buckley, T. (2017). Comparison of psychological response between concussion and musculoskeletal injury and collegiate athletes. Sport, exercise, and performance psychology, 6 (3), 277–288.

US Army Traumatic Brain Injury Task Force. Report to the SurgeonGeneral. Available at: www.armymedicine.army.mil/reports/tbi/TBITaskForceReportJanuary2008.pdf. Accessed July 18, 2013.

REFERENCES / FURTHER EXPLORATION Take a deeper dive into the world of sport concussion by reviewing the following: