Thursday, June 11, 2015

Concussion management

Once immediate risk is eliminated, physical and cognitive rest until acute symptoms have resolved is typically recommended.   However, the evidence for this protocol is limited, and in particular, there is no consensus period for which rest should be prescribed, and the exact recommendations of "rest" are not clear.

When discussing the recovery process, reassurance and education of the individual must be provided. This brief psychological intervention has been termed cognitive structuring; in a pediatric setting it is akin to anticipatory guidance. Cognitive restructuring has been shown to be effective in mTBI (mild TBI) as a preventative measure for the development of persistent symptoms, and specifically may be helpful in sleep issues and mood disorders as suggested by studies in uninjured youth. This type of anticipatory guidance may also involve a reattribution of symptoms, which may decrease the risk of developing chronic postconcussion syndrome. 

See:   Meeryo C. Choe, MD; Christopher C. Giza, MD.  Diagnosis and Management of Acute Concussion. Semin Neurol. 2015;35(1):29-41.

Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics 2001;108(6):1297–1303
OBJECTIVE: The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury.
METHODS:   A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet.
RESULTS:  Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury.
CONCLUSIONS:   Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.

Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR. Cognitive-behavioral prevention of postconcussion syndrome. Arch Clin Neuropsychol 1996;11(2):139–145

The symptoms of postconcussion syndrome (PCS) are persistent, and no empirically tested treatment is available. The treatment group (n = 29) in this study received a printed manual and met with a therapist prior to hospital discharge to review the nature and incidence of expected symptoms, the cognitive-behavioral model of symptom maintenance and treatment, techniques for reducing symptoms, and instructions for gradual resumption of premorbid activities. The control group (n = 29) received routine hospital treatment and discharge instructions. Both groups had sustained mild head injuries characterized by Glascow Coma Scale scores of 13-15 on admission without any measurable period of posttraumatic amnesia. Group assignment was random. Groups did not differ significantly on age, Glascow scores, litigation status, gender, or initial number of PCS symptoms. Patients were contacted 6 months following injury by an interviewer who was unaware of group assignment to obtain outcome data. Treated patients reported significantly shorter average symptom duration (33 vs. 51 days) and significantly fewer of the 12 symptoms at followup (1.6 vs. 3.1). Subjects were also asked how often each symptom had occurred in the previous week, and how severe the symptom typically was. The treatment group experienced significantly fewer symptomatic days (.5 vs. 1.3) and lower mean severity levels. Results suggest that brief, early psychological intervention can reduce the incidence of PCS.

1 comment:

  1. Bock S, Grim R, Barron TF, Wagenheim A, Hu YE, Hendell M, Deitch J, Deibert E.
    Factors associated with delayed recovery in athletes with concussion treated at a
    pediatric neurology concussion clinic. Childs Nerv Syst. 2015 Aug 5. [Epub ahead
    of print]



    With the increase in knowledge and management of sport-related concussion over the last 15 years, there has been a shift from a grading scale approach to an individualized management approach. As a result, there is an increased need to better understand the factors involved in delayed recovery of concussion. The purpose of this retrospective study was to examine factors that may be associated with recovery from sport-related concussion in student athletes aged 11 to 18 years old.


    Of the 366 patients who met the inclusion criteria, 361 were included in our analysis. The primary dependent variable included days until athlete was able to return to play (RTP). Independent variables of interest included age, gender, academic performance, comorbid factors, sports, on-field markers, days until initial neurological evaluation, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) scores, acute headache rescue medications, chronic headache medication, sleep medication, and referral to concussion rehabilitation program.


    Variables associated with longer median RTP were being female (35 days), having a referral to concussion rehabilitation program (53 days), being prescribed acute headache rescue therapy (34 days), and having chronic headache treatment (53 days) (all p < 0.05). Variables associated with shorter RTP were on-field marker of headache (23 days) and evaluation within 1 week of concussion by a concussion specialist (16 days) (Both p < 0.05).


    This study supports the need for a concussed athlete to have access to a provider trained in concussion management in a timely fashion in order to prevent delayed recovery and return to play.