Wednesday, August 17, 2016

Concussion management 2

Individuals usually recover from sports related concussions ( SRCs) within days to weeks, with complete resolution of symptoms and cognitive improvement.  General management of SRCs focuses on mental and physical rest until an athlete is symptom free. Following this clinical improvement, a graduated increase in physical activity is instituted before an individual may return to play.

In its "Heads Up to Health Care Providers" campaign, the Centers for Disease Control and Prevention published return-to-play steps adapted from the International Concussion Consensus Guidelines to help safely return athletes to play. This graduated, stepwise return-to-play protocol is also supported by the American Academy of Pediatrics.  Each stage of the graduated increase is expected to take 24 hours, and the athlete must remain asymptomatic to qualify to proceed to the next tier of activity. If any symptoms return, the athlete is probably pushing too hard to return and should stop all physical activity. In that situation, the athlete is instructed to rest for 24 hours, and then return to the previous phase and resume activity at that level. Once the athlete is again asymptomatic at that level, they may continue to proceed to gradually increasing levels of activity and continue toward returning to play, as long as they remain symptom free.  Most athletes will recover quickly and fully after a concussion, but should symptoms worsen at any time, remain present for greater than 10–14 days, or if athletes have a history of multiple concussion or mood disorders, a referral to a concussion specialist is warranted. It is the current practice of the senior author to evaluate athletes with a suspected SRC in a formal clinical setting before clearing them to return to the field of play.

The American Academy of Neurology has also published an evidence-based guideline for managing athletes with concussion. This guideline recommends immediate removal from play of an athlete with a concussion until they can be assessed by a licensed health care professional trained in recognizing concussion. The guideline recommends assessing each athlete individually, with no set timeline for safe return to play. For example, high school and younger athletes should be managed more conservatively, because they can take longer to recover than college athletes. This guideline also concludes that absolute rest during concussion recovery is not supported with sufficient evidence, and therefore activities that do not worsen symptoms and do not pose a risk of repeat concussion may be included in the concussion management plan…

To date, there have been no studies that demonstrate that pharmacological treatments are effective at speeding the recovery from a concussion or diminishing the deficits attributed to the injury.  In fact, there is a great need for large-scale, multicenter studies to evaluate the benefits of medications for treating prolonged postconcussion symptoms and to determine if there is any benefit to neuroprotective therapies. Nevertheless, patients who are experiencing prolonged symptoms (either PCS or PPCS) that significantly impact their daily activities may benefit from medical treatment of their ongoing symptoms. The decision to treat with pharmacological agents must be made on an individual basis and should take into account the degree and duration of impairment from the symptoms and the potential adverse effects of starting a medication.

Petraglia et al. provide an excellent review of the pharmacotherapeutics used to treat the somatic complaints, sleep disturbances, emotional difficulties, and cognitive difficulties that may exist following mTBI.  In general, agents should be started at their lowest effective dose and slowly titrated up to maximize clinical response and minimize side effects. Furthermore, agents that may contribute to the confusion and cognitive slowing seen in the patient should be avoided so as to not confound the patient's clinical examination with a drug's adverse effects. Furthermore, it is advisable to attempt to avoid medications that are known to lower the seizure threshold.

Considerable effort has been expended to investigate whether naturally occurring supplements and compounds that may possess antiinflammatory or neuroprotective effects could be beneficial in the aftermath of a concussion.  Although human studies are lacking, these agents may address the underlying pathophysiological processes responsible for the long-term symptoms following concussions, and offer a relatively limited side-effect profile.

For instance, long-chain polyunsaturated fatty acids are an important structural component of the neuronal synaptosomal plasma membrane, but they are underrepresented among the other lipids consumed via our dietary intake. The benefit of pretraumatic supplementation of docosahexaenoic acid (DHA), a long-chain polyunsaturated fatty acid, has been demonstrated in multiple rodent models of TBI. In rodents, DHA supplementation has been shown to be neuroprotective following either focal or diffuse TBI, to reduce the number of damaged axons, to reduce excitotoxicity, and to provide numerous other multimechanistic benefits to the posttraumatic brain. Well-designed trials will be required to determine whether DHA supplementation in athletes may improve outcomes following SRCs. Green tea is another commonly discussed product that contains many natural compounds that have been investigated for their potentially neuroprotective antioxidant and antiinflammatory properties.  One study demonstrated that green tea reduced the amount of tau phosphorylation and beta-amyloid deposition in a mouse model of Alzheimer disease, which may be relevant given the pathological findings in CTE. These substances provide a small snapshot of the potential value of natural supplements for both the prevention and treatment of concussions, and human studies are necessary to determine how and when their use will benefit athletes in a practical, cost-effective, and well-tolerated manner.

In the future, there is the potential for advanced imaging techniques such as fMRI to help guide our use of medications in the management of postconcussion symptoms. For example, fMRI studies have shown that postconcussion depression shares underlying pathophysiological features with the limbic-frontal model of depression and may be amenable to treatment with traditional antidepressive agents. Biomarkers may also serve a future role in the identification of patients whose symptoms are likely to persist and who thus may require upfront management with pharmacological agents rather than a watchful waiting approach.

Hobbs JG, Young JS, Bailes JE. Sports-related concussions: diagnosis,
complications, and current management strategies. Neurosurg Focus. 2016

Sports-related concussions (SRCs) are traumatic events that affect up to 3.8 million athletes per year. The initial diagnosis and management is often instituted on the field of play by coaches, athletic trainers, and team physicians. SRCs are usually transient episodes of neurological dysfunction following a traumatic impact, with most symptoms resolving in 7-10 days; however, a small percentage of patients will suffer protracted symptoms for years after the event and may develop chronic neurodegenerative disease. Rarely, SRCs are associated with complications, such as skull fractures, epidural or subdural hematomas, and edema requiring neurosurgical evaluation. Current standards of care are based on a paradigm of rest and gradual return to play, with decisions driven by subjective and objective information gleaned from a detailed history and physical examination. Advanced imaging techniques such as functional MRI, and detailed understanding of the complex pathophysiological process underlying SRCs and how they affect the athletes acutely and long-term, may change the way physicians treat athletes who suffer a concussion. It is hoped that these advances will allow a more accurate assessment of when an athlete is truly safe to return to play, decreasing the risk of secondary impact injuries, and provide avenues for therapeutic strategies targeting the complex biochemical cascade that results from a traumatic injury to the brain.


  1. Graduated return-to-play protocol in athletes with concussions

    Baseline: no symptoms
    The first step in the return-to-play progression requires that the athlete complete physical and cognitive tests and be symptom free for a minimum of 24 hours. For younger athletes more conservative restrictions can be used.
    Step 1: light aerobic activity
    5–10 minutes of light aerobic activity, such as walking, light jogging, or riding an exercise bike, with the goal of increasing the heart rate.
    Step 2: moderate activity
    Moderate jogging, brief running, or moderate-intensity weightlifting that is reduced from the typical routine, with a goal of limited body and head movement.
    Step 3: heavy, non-contact activity
    Intense activity that is close to the typical routine but non-contact. There may be some added cognitive component to practice during this step.
    Step 4: practice and full contact
    Reintegrate the athlete into full-contact practice.
    Step 5: competition
    Return to competition.

    McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvořák J, Echemendia RJ, et al: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. J Am Coll Surg 216:e55–e71, 2013

  2. May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014 Apr;9(2):242-55.

    In 2010, the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. The guidelines include a six-step process that provides structure to guide an athlete who is recovering from a concussion in a gradual return to play (RTP) by allowing participation in increasingly difficult physical activities. Unfortunately, the guidelines fail to take into account the variability that occurs within different sports and the resulting challenges medical professionals face in making sure each athlete is able to withstand the rigors of their specific sport, without return of symptoms. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines.
    The intention of the sport specific guidelines is to maintain the integrity of the current six-step model, add a moderate activity phase highlighted by resistance training, and to provide contact and limited contact drills specific to the athlete's sport and/or position. The drills and activities in the proposed seven-step programs are designed to simulate sport specific movements; the sports include: football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey. These activities will provide sports specific challenges to each athlete while simultaneously accomplishing the objectives of each stage of the RTP progression. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions.
    There have been significant strides in the management and care of concussed athletes. However, there continues to be a lot of confusion among, athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed several sports-specific RTP guidelines.

  3. The U.S. Food and Drug Administration today permitted marketing of two new devices to assess a patient’s cognitive function immediately after a suspected brain injury or concussion. The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and ImPACT Pediatric are the first medical devices permitted for marketing that are intended to assess cognitive function following a possible concussion. They are intended as part of the medical evaluation that doctors perform to assess signs and symptoms of a head injury.

    ImPACT and ImPACT Pediatric are not intended to diagnose concussions or determine appropriate treatments. Instead the devices are meant to test cognitive skills such as word memory, reaction time and word recognition, all of which could be affected by a head injury. The results are compared to an age-matched control database or to a patient’s pre-injury baseline scores, if available.

    “These devices provide a useful new tool to aid in the evaluation of patients experiencing possible signs of a concussion, but clinicians should not rely on these tests alone to rule out a concussion or determine whether an injured player should return to a game,” said Carlos Peña, Ph.D., M.S., director of the division of neurological and physical medicine devices at the FDA’s Center for Devices and Radiological Health.

    ImPACT software runs on a desktop or laptop and is intended for those ages 12 to 59, while the ImPACT Pediatric runs on an iPad and is designed for children ages 5 to 11. Only licensed health care professionals should perform the test analysis and interpret the results…

    The manufacturer submitted over 250 peer-reviewed articles, of which half were independently conducted clinical research studies. The research publications analyzed the scientific value of the ImPACT devices including the devices’ validity, reliability and ability to detect evidence of cognitive dysfunction that might be associated with a concussive head injury. The FDA concluded that these studies provide valid scientific evidence to support the safety and effectiveness of the ImPACT and ImPACT Pediatric devices.

    The FDA reviewed the ImPACT device through its de novo classification process, a regulatory pathway for novel, low- to-moderate-risk medical devices that are first-of-a-kind, for which special controls can be developed, in addition to general controls, to provide a reasonable assurance of safety and effectiveness of the devices. The device is manufactured by ImPACT Applications, located in Pittsburgh, Pennsylvania.

    Courtesy of Doximity