Brain Injury

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How long is too long? The lack of consensus

regarding the post-concussion syndrome diagnosis

Sean C. Rose, Anastasia N. Fischer & Geoffrey L. Heyer

To cite this article: Sean C. Rose, Anastasia N. Fischer & Geoffrey L. Heyer (2015) How long
is too long? The lack of consensus regarding the post-concussion syndrome diagnosis, Brain
Injury, 29:7-8, 798-803, DOI: 10.3109/02699052.2015.1004756

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Published online: 14 Apr 2015.

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ISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2015; 29(7–8): 798–803

! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2015.1004756

ORIGINAL ARTICLE

How long is too long? The lack of consensus regarding the

post-concussion syndrome diagnosis
Sean C. Rose1, Anastasia N. Fischer2, & Geoffrey L. Heyer1
1
Departments of Pediatrics and Neurology and 2Departments of Pediatrics and Sports Medicine, Nationwide Children’s Hospital and
The Ohio State University, Columbus, OH, USA
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Abstract Keywords
Background/aim: A standard definition of Post-concussion Syndrome (PCS) does not exist. The Concussion, head injury, mild brain injury,
objective was to determine consensus regarding the definition of PCS among physician post-concussion syndrome, traumatic brain
members of the American College of Sports Medicine (ACSM). injury
Methods: Physician members of the ACSM were sent an electronic survey to determine opinions
regarding the PCS diagnosis. History
Results: Five hundred and ninety-seven physicians completed the survey. When asked the
minimum duration of symptoms required to diagnose PCS, respondents answered: 52 weeks Received 15 July 2014
(26.6%), 2 weeks to 1 month (20.4%), 1–3 months (33%) and43 months (11.1%). Physicians who Revised 21 November 2014
see 10% concussion patients in their practise, as well as physicians whose concussion Accepted 4 January 2015
population consists of 450% paediatric patients, were more likely to require 41 month of Published online 14 April 2015
symptoms (p50.001). When asked the minimum number of symptoms required to diagnose
PCS, responses varied: one symptom (55.9%), two symptoms (17.6%), three symptoms (14.6%)
and four or more symptoms (3.2%). Respondents from the US were more likely than non-US
respondents to require only one symptom for the PCS diagnosis (p ¼ 0.01).
Conclusions: There is a lack of consensus regarding the definition of PCS among physician
members of the ACSM. A standard definition would improve consistency in concussion
research and in clinical practise.

Introduction proposed that post-concussion symptoms lasting more than 10

days be considered ‘persistent’ [4]. The American Medical
It is estimated that 1.6–3.8 million sport-related traumatic
Society for Sports Medicine’s position statement refers to
brain injuries (TBIs) occur in the US each year, the majority
PCS as ‘symptoms and signs of a concussion that persist for
of which are concussions [1]. Most concussions resolve
weeks to months’ [10]. Recent observational studies have
within 7–10 days of injury, although concussions in children
defined persistent post-concussion symptoms using various
may resolve more slowly [2–6].
symptom durations: 7 days [11], 10 days [12], 3 weeks [13],
A minority of patients continue to have post-concussion
4 weeks [14, 15], 30 days [16] and 3 months [17].
symptoms that persist for months and sometimes years. This
The two most commonly cited PCS definitions come from
abnormal persistence of symptoms has been referred to as
the Diagnostic and Statistical Manual of Mental Disorders-4th
Post-concussion Syndrome (PCS). This manuscript uses PCS
edition (DSM-IV) [18] and the International Classification of
to describe the abnormal persistence of post-concussion
Diseases (ICD-10) [19] (Table I). Both sets of PCS criteria
symptoms, although it is recognized that disagreement about
include the occurrence of a proximate head injury as the cause
this terminology exists. Estimates of the incidence of PCS
of symptoms. The DSM-IV requires memory or attention
vary, ranging from 1.4–29.3%, among different populations
difficulties, at least three other symptoms that interfere with
and using inconsistent diagnostic criteria [4, 7–9].
social or occupational functioning and persistence of symp-
Several publications have proposed durations of post-
toms for at least 3 months. In contrast, the ICD-10 criteria
concussion symptoms that should be considered ‘abnormal’,
require at least three symptoms, but do not specify symptom
but few sources agree. For example, the expert consensus
duration. A preference for one set of diagnostic criteria has
statement from the Zurich Concussion in Sport conference
not been established in research or in clinical practise. The
limitations of these criteria in terms of diagnostic reliability
Correspondence: Geoffrey L. Heyer, Departments of Neurology and and specificity have been described [20–24].
Pediatrics, Nationwide Children’s Hospital, 700 Children’s Drive,
Columbus, OH 43205, USA. Tel: 614-722-4625. Fax: 614-722-4633. It is unclear if a consensus about the definition of PCS
E-mail: geoffrey.heyer@nationwidechildrens.org exists among physicians who manage concussion patients.
 DOI: 10.3109/02699052.2015.1004756
Table I. DSM-IV criteria for post-concussional disorder and ICD-10 research criteria for post-concussion syndrome.
DSM-IV
1. History of head trauma with significant cerebral concussion
2. Difficulty with attention or memory based on objective testing
3. Three or more of the following symptoms occur shortly after
trauma and last at least 3 months:
a. headache
b. dizziness or vertigo
c. becoming easily fatigued
d. irritability or aggression
e. disordered sleep
f. anxiety, depression or affective lability
g. changes in personality
h. apathy or lack of spontaneity
4. These symptoms start or substantially worsen after head trauma
5. Significant impairment in social, occupational or school
functioning
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This study surveyed physician members of the American
College of Sports Medicine (ACSM), which is the largest
professional sports medicine organization, to determine if
diagnostic consensus for PCS exists.
Methods
A list of 2192 physician members of the ACSM was obtained.
All individuals on this list were eligible to participate except
for one, who is a study author (AF). A cross-sectional internet
survey was conducted of the 2191 eligible physicians. From
September–October 2013, email invitations containing a
unique survey link were sent, with up to two reminder
emails sent at 2–4 week intervals.
The survey contained seven multiple-choice questions
addressing respondent demographics, clinical specialty and
clinical practise. Question 8 asked: ‘In your opinion, at
what point should ongoing symptoms following concussion
be referred to as ‘‘Post-concussion Syndrome’’?’ Answer
options ranged from 510 days to 46 months. Question 9
asked: ‘In your opinion, how many persistent symptoms
must be present to meet the definition for ‘‘Post-concussion
Syndrome’’?’ Answer options ranged from 1 symptom to 45
symptoms. Both questions included an answer option:
‘I do not use the diagnosis ‘‘Post-concussion
Syndrome’’’. For added clarification, the following statement
was included:
We understand that terminology has evolved. To decrease
confusion in this survey, we use the term ‘Post-concussion
Syndrome’ to describe the abnormal persistence of symp-
toms following concussion. Similar terms include
‘Persistent Post-concussion Symptoms’ and ‘Prolonged
Post-concussion Symptoms.
By design, certain answer selections resulted in the blocking
of subsequent questions, so not all respondents completed all
questions. For example, if a respondent answered that he or she
does not manage patients clinically, they were not asked what
percentage of their patients are paediatric. The survey was
face-validated by 10 physicians at the institution who were
study-ineligible. This study was approved by the Institutional
Post-concussion syndrome diagnosis 799
ICD-10
1. History of head trauma with loss of consciousness
2. No clouding of consciousness or significant objective memory
deficit
3. Three or more of the following symptoms:
a. headache, dizziness, malaise, fatigue or noise intolerance
b. irritability, emotional lability, depression or anxiety
c. subjective difficulty in concentration, mental tasks or memory
impairment
d. insomnia
e. reduced tolerance to alcohol
f. preoccupation with the above symptoms or adoption of the
sick role
Review Board at Nationwide Children’s Hospital and consent
was indicated by survey completion.
Data analysis
Data were analysed using SPSS Version 21 (SPSS Inc.,
Chicago, IL). Comparisons of categorical data were made
using the chi-squared test. The two outcome variables (post-
concussion symptom duration and post-concussion symptom
number) were dichotomized and predictor variables were
modelled using binary logistic regression. Odds ratios (ORs)
and 95% confidence intervals (CIs) were calculated.
Significance was set at 5%.
Results
Respondents
Eighty-five emails automatically returned as ‘undeliverable’.
Of 2106 remaining participants, 601 responded to the survey.
Four respondents were removed because they only answered
demographic questions. Therefore, 597 (28.3%) respondents
were included in the analysis. Respondent demographics are
shown in Table II.
Duration of symptoms
When asked how long symptoms should persist to meet
diagnostic criteria for PCS, the most commonly selected time
frame was ‘41 month to 3 months’ (33%, n ¼ 197). Fifty-three
respondents (8.9%) denied using the PCS diagnosis. The
distribution of all responses is depicted in Figure 1. ACSM
physicians who see 410% patients with concussion in their
practise were more likely to require that post-concussion
symptoms persist 41 month to diagnose PCS (p50.001,
OR ¼ 1.83, 95% CI ¼ 1.25–2.67). Similarly, those who
reported that 450% of their patients with concussion are
paediatric aged were more likely to require41 month symptom
duration for PCS (p50.001, OR ¼ 1.94, 95% CI ¼ 1.31–2.88).
In contrast, respondents with410 years of experience were
more likely to diagnose PCS when symptoms persist51 month
(p ¼ 0.02, OR ¼ 0.61, 95% CI ¼ 0.41–0.91). There were no
differences in symptom duration based on country of origin,
medical specialty or self-reported academic status (Table III).
 800 S. C. Rose et al. Brain Inj, 2015; 29(7–8): 798–803

Number of symptoms ‘1 symptom’ (55.9%, n ¼ 334), whereas 35.4% (n ¼ 211) of

respondents required two or more symptoms. Figure 2 shows
When asked the number of symptoms that must be present
the distribution of all responses. ACSM physicians from the
to diagnose PCS, the most commonly selected answer was
US were more likely than physicians from other countries to
diagnose PCS with one persistent post-concussion symptom
Table II. Respondent demographics. (p ¼ 0.01, OR ¼ 0.47, 95% CI ¼ 0.26–0.85). There were no
other differences based on years of experience, overall
n (%) percentage of patients with concussion seen in practise,
Country percentage of paediatric patients with concussion, medical
US 518 (86.8) specialty or academic status (Table III). Table IV shows the
Other 79 (13.2) cross-comparison of post-concussion symptom numbers with
Medical specialty* symptom durations from all respondents who use the PCS
Sports Medicine 459 (76.9)
Family Practise 246 (41.2) diagnosis (n ¼ 527).
Physical Medicine 62 (10.4)
Paediatrics 59 (9.9) Discussion
Internal Medicine 47 (7.9)
Orthopaedics 40 (6.7) Physician members of the ACSM lack consensus about the
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Emergency Medicine 22 (3.7) duration and the number of post-concussion symptoms that
Neurology 5 (0.8)
define PCS. This lack of agreement is also apparent in the
Neurosurgery 2 (0.3)
Other 50 (8.4) literature. Different researchers have used various criteria to
Years in practise designate when (and how many) persistent post-concussion
510 184 (30.8) symptoms should be considered abnormal [4, 7–19].
10–20 154 (25.8)
420 240 (40.2)
However, to define the PCS incidence and to better study
Other (in training or not practicing) 19 (3.2) the potential causes of persistent post-concussion symptoms,
Practise setting agreement needs to be established: How long is too long?
Solo 58 (9.7) Since most concussions resolve within 7–10 days, the
Group 164 (27.5)
Hospital-based 98 (16.4) Zurich expert consensus statement considers symptoms
Government 12 (2.0) lasting longer than 10 days to be persistent [4]. In this
Academic, clinical 212 (35.5) study, 15.8% of the respondents who use the PCS diagnosis
Academic, research only 10 (1.7) selected ‘410 days to 2 weeks’ as the minimum symptom
Other 28 (4.7)
Do not practise 15 (2.5) duration to diagnose PCS, indicating some agreement with
Percentage of concussion patients in practise the Zurich statement. However, the most commonly selected
510% 361 (60.5) symptom duration was ‘41 month to 3 months’, chosen by
10–50% 186 (31.2) 33% of respondents. Physicians with more experience in
450% 22 (3.7)
Other (retired or do not practise) 28 (4.7) concussion management were more likely to require that
Percentage of concussion patients are paediatric symptoms persist for more than 1 month before considering
(518 years old) them abnormal. Clinical variation exists and not all patients
550% 208 (34.8)
who fall outside of the normal recovery time frame should be
450% 300 (50.3)
Other (do not manage concussions) 89 (14.9) diagnosed with PCS. For research purposes, conservative
criteria will help to ensure that those diagnosed with PCS
*Percentages sum to 4100% because more than one specialty could be represent a different population than those who recover within
selected.

Figure 1. Minimum duration of symptoms required by respondents to diagnose post-concussion syndrome (PCS).
 DOI: 10.3109/02699052.2015.1004756 Post-concussion syndrome diagnosis 801
Table III. Duration of symptoms required by respondents to diagnose post-concussion syndrome: 51 month vs 41 month; and number of symptoms
required by respondents to diagnose post-concussion syndrome: 1 symptom vs 41 symptom.

OR 95% CI p
Duration of symptoms required by respondents to diagnose post-concussion syndrome:
51 month vs 41 month
US vs non-US 0.82 0.45–1.5 0.51
Sports med vs other 1.21 0.78–1.88 0.4
Academic vs other 1.28 0.87–1.89 0.21
410% concussion patients vs 510% 1.83 1.25–2.67 50.001
410 years experience vs 510 years 0.61 0.41–0.91 0.02
450% paediatric concussion vs 550% 1.94 1.31–2.88 50.001
Regression constant 1.13 0.82
Number of symptoms required by respondents to diagnose post-concussion syndrome:
1 symptom vs 41 symptom
US vs non-US 0.47 0.26–0.85 0.01
Sports med vs other 0.96 0.61–1.49 0.84
Academic vs other 1.16 0.79–1.71 0.44
410% concussion patients vs 510% 1.11 0.76–1.62 0.6
410 years experience vs 510 years 1.24 0.82–1.86 0.31
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450% paediatric concussion vs 550% 1.19 0.8–1.77 0.39

Regression constant 0.71 0.52

Figure 2. Minimum number of symptoms required by respondents to diagnose post-concussion syndrome (PCS).

Table IV. Number of respondents who require each combination of number and duration of symptoms to diagnose post-
concussion syndrome (n ¼ 527)*.

1 symptom 2 symptoms 3 symptoms 4 symptoms 5 symptoms

10 days or less 53 9 9 0 0
410 days to 2 weeks 46 28 10 0 0
42 weeks to 1 month 78 21 15 1 3
41 month to 3 months 111 31 38 5 6
43 months to 6 months 30 9 11 2 1
More than 6 months 6 2 1 1 0

*Among respondents who use the post-concussion syndrome diagnosis.

 802 S. C. Rose et al.
(or near) the expected time-frame following concussion. It
is interesting that physicians with more clinical experience
(10 years or more) were more likely to diagnose PCS when
symptom duration was less than 1 month. The reasons for this
difference are not clear.
Paediatric patients generally recover from concussion
more slowly than adult patients [4–6]. Brown et al. [25]
found that the mean duration of post-concussion symptoms in
high school and junior high patients referred to a specialty
clinic was 43 ± 55 days. In patients with concussion aged
11–22 years who presented to the ER, the median duration
of sleep disturbance and irritability was 16 days and 32% of
patients still had symptoms 1 month after concussion [26]. In
a study of patients with TBI aged 5–17 years identified from
the ER and inpatient hospital services, 43% of the patients
with mild TBI had headaches 3 months after injury, which
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was statistically different from controls (23% of whom
reported headaches) [27]. The present study shows that
physicians who manage paediatric patients with concussion
were more likely than those who manage adult patients to
require more than 1 month symptom duration before
diagnosing PCS. The longer paediatric recovery times
following concussion may cause physicians in paediatrics to
require longer symptom durations for PCS than their coun-
terparts who manage only adult patients.
Although not a consensus, better agreement was found
among physicians regarding the number of post-concussion
symptoms required to diagnose PCS. Over 55% of respond-
ents would diagnose PCS with only one symptom present and
physicians from the US were more likely than physicians
from other countries to do so. This was unexpected because a
‘syndrome’ generally implies the presence of a constellation
of signs and symptoms. The lack of post-concussion symptom
specificity has been demonstrated [20–24]. The results
indicate that physicians from the ACSM prefer to use the
PCS diagnosis if any number of post-concussion symptoms
persists. However, a more permissive PCS definition that
allows fewer overall symptoms will have poor specificity. It is
advised that more than one symptom be present when using
the PCS label. Persistent symptoms affecting more than one
of the somatic (e.g. headache, nausea, poor balance),
neurobehavioural (e.g. drowsiness, fatigue, sadness) and
cognitive (e.g. mental fog, poor concentration, memory
impairment) domains better support a PCS-type diagnosis
[28]. Other terminology could be used when only one
symptom persists. For example, when only headaches persist
following concussion, clinicians should consider the
International Headache Society diagnosis of ‘chronic post-
traumatic headache’ [29]
Of the survey respondents who use the PCS diagnosis, only
11 (2.1%) answered in a way that matched DSM-IV PCS
criteria, which include at least three symptoms for at least
3 months (Table IV) [18]. Only 84 (15.9%) answered in a way
consistent with the much less specific ICD-10 criteria of at
least three symptoms for any duration [19]. It is apparent that
the majority of physicians from the ACSM do not use either
of the two most cited sets of PCS criteria.
In order to perform comparable research addressing
concussion natural history and symptom persistence, a
standard definition for PCS is needed. Since recovery is
Brain Inj, 2015; 29(7–8): 798–803
longer in children than in adults, a separate definition may be
needed for paediatric patients. In addition to aiding research,
establishing a standard definition has clinical relevance.
Nearly 95% of general paediatricians choose to refer patients
with persistent post-concussion symptoms to a specialist [30].
Knowing how long is too long for post-concussion symptoms
will allow the practitioner to counsel the patient on expected
recovery and to refer at an appropriate time.
Several limitations to this study are acknowledged. The
subjects were from one professional organization, which may
limit generalizability. The overall response rate was low,
which may have biased the results. Several survey emails
were returned as undeliverable. The ACSM list had not been
validated, so the overall number of physicians who received
the study email and could participate may have been over-
estimated. The study was also limited because it assessed the
number of symptoms following concussion, but did not
distinguish between specific symptoms. Had specific symp-
toms or symptom categories been listed, respondents might
have required more symptoms overall for a PCS diagnosis.
Lastly, survey self-report may not accurately reflect clinical
practises.
Conclusions
There is a lack of consensus about the definition of PCS
among physician members of the ACSM. Opinions vary
regarding the number of post-concussion symptoms and the
duration of post-concussion symptoms required to diagnose
PCS. Survey responses did not coincide with either the ICD-
10 or DSM-IV criteria for PCS. A standardized set of criteria
for PCS is needed to bolster comparable research studies and
to inform clinical management.
Acknowledgements
We thank the ACSM for kindly providing the list of physician
members. We also thank the physicians at Nationwide
Children’s Hospital who participated in face-validation of
the survey and pilot runs to look for technical difficulties.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
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