Treatment and Recovery Paths

 Concussions and Post-Concussion Syndrome

Surprisingly, the underlying mechanisms involved in concussions is little understood, with new research initiaves launching to develop "clinical interventions that could improve recovery" such as the new 2018 project at the University of Pennsylvania funded by the Paul G. Allen Family Foundation. 

 

Persistent symptoms should be managed by a multidisciplinary team

Failure of normal recovery, i.e. persistent symptoms which are defined as >10 – 14 days in adults and >4 weeks in children (2016 consensus statement on concussion in sport) should be managed by an individualized program consisting of multidisciplinary care.

"It is recommended that all athletes should have a clinical neurological assessment (including evaluation of mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function and balance) as part of their overall management. This will normally be performed by the treating physician, often in conjunction with computerized NP (Neuropsychological assessment) screening tools." 

"(SRCs (sports-related concussions can result in diverse symptoms and problems, and can be associated with concurrent injury to the cervical spine and peripheral vestibular system. The literature has not evaluated early interventions, as most individuals recover in 10–14 days. A variety of treatments may be required for ongoing or persistent symptoms and impairments following injury. The data support interventions including psychological, cervical and vestibular rehabilitation.

In addition, closely monitored active rehabilitation programs involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery. A collaborative approach to treatment, including controlled cognitive stress, pharmacological treatment, and school accommodations, may be beneficial.

Treatment should be individualzsed and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of:

  1. an individualised symptom-limited aerobic exercise programme in patients with persistent post-concussive symptoms associated with autonomic instability or physical deconditioning, and

  2. a targeted physical therapy programme in patients with cervical spine or vestibular dysfunction, and

  3. a collaborative approach including cognitive behavioural therapy to deal with any persistent mood or behavioural issues.

Currently, there is limited evidence to support the use of pharmacotherapy. If pharmacotherapy is used, then an important consideration in return to sport is that concussed athletes should not only be free from concussion-related symptoms, but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of SRC. Where pharmacological therapy may be begun during the management of an SRC, the decision to return to play while still on such medication must be considered carefully by the treating clinician.

Overall, these are difficult cases that should be managed in a multidisciplinary collaborative setting, by healthcare providers with experience in SRC."

 

Dr. Chris Giza quoted Dr. David Brody as saying "Using only medications to treat chronic #TBI symptoms is like delivering a pizza and only giving your patients 1/3 of the pie". Dr. Giza: "Remember professional therapies, mental health & lifestyle interventions." Dr. Giza leads the Pediatric TBI/Sports Concussion program at UCLA.

The recommended Professional Therapies, as outlined by Dr. David Brody, a neurologist and concussion/TBI specialist:

  • Outpatient Physical Therapy (PT), Speech Therapy (ST), and Occupational Therapy (OT)
  • Return to work programs such as occupational performance centers
  • Return to school programs
  • Psychology
    • Cognitive behavioral therapy for depression (CBT)
    • Cognitive behavioral therapy for insomnia (CBT-i)
    • Family Coping
  • Return to driving
    • evaluate for contraindications (seizures, changes in levels of consciousness, visual impairments, motor impairments, cognitive impairments)
    • on the road driving test from specialized occupation therapy service
    • car modifications (special mirrors)

The Lifestyle aspects Dr. David Brody refers to are:

  • Alcohol. There is no solid evidence base concerning alcohol use but the Expert Opinion is:
    • None in the first year, max 1 drink per 24 hours after that unless there is a history of addiction, compulsive use, or alcohol interacting with medication. 
  • Drugs
    • Cannabis cognitive risk vs. potential benefit for anxiety and pain (Dr. Brody was referring to the recreational use of marijuana)
    • Stimulants, narcotics clearly harmful
    • Hallucinogens, designer drugs unknown effects but probably harmful
  • Sleep: critical 'top of the cascade' for recovery
  • Exercise: gentle reintroduction of cardiovascular exercise
  • Meditation/mindfulness: useful for mood disorders and for coping with fundamental change in self-identity.