What Everyone Should Know About Concussion

Some practical pointers for practitioners and patients

 

By David Brody

There has been a huge wave of interest in concussion in recent years. Sports, military, school policy, state laws, and lots of popular press articles have raised attention. It seems like we’re discovering new ways to assess concussion patients and trying new ideas for treatments all the time.

So what should every health care provider know about concussion? Here’s my top 10 list, taken from the second edition of the Concussion Care Manual.

  1. Concussion is a clinical diagnosis based on history. You don’t need a scan or other test to make the diagnosis. Blood and quantitative EEG tests can help determine who doesn’t need a CT scan, but are not used for the diagnosis of concussion.
  2. Concussion is the same thing as “mild” traumatic brain injury.
  3. Athletes should not return to play after concussion until cleared by a qualified health professional, according to the consensus statement from the 5th International Conference on Concussion.
  4. Strictly enforced rest (“cocooning”) is not necessary. After 2 days it may even be harmful, according to a small randomized controlled study in concussion patients presenting to a pediatric emergency department.
  5. Carefully monitored, moderate cardiovascular exercise can speed up recovery from concussion, according to a recent randomized controlled trial in adolescents with sport-related concussion.
  6. Most people recover well from concussions without any specific treatment over 1-4 weeks. Initially, it was believed that recovery occurred within 7 days, based on studies of varsity contact sport athletes. Since then, we have learned that people in the general population may recover more slowly. In those who don’t recover well, the most common problems include persistent headaches, trouble sleeping, mood problems, and trouble concentrating. All of these are at least partially treatable, according to a recent statement of agreement from concussion care providers. There are now a substantial number specialty concussion clinics that provide multidisciplinary care for concussion patients.
  7. Post-concussive headaches can often be treated similarly to migraine, based on expert opinion. While there is some evidence that ibuprofen, acetaminophen or both improves headaches compared to no treatment, there is a clear need for more evidence-based research in the domain of post-concussive headache. Some special features of post-concussive migraine include cogniphobia (hurts to think), a wide variety of neurological auras (vestibular, cognitive, emotional regulation), and sensitivity to cognitive side effects of prophylactic medications.
  8. Post-concussive sleep problems and fatigue can often be treated with cognitive behavioral therapy for insomnia, morning blue light therapy, melatonin, and modafinil. Small randomized controlled trials in concussion patients are beginning to influence care patterns. A multimodal approach including therapy, lifestyle modification, and sometimes medication is generally beneficial, and cognitively impairing medications should not be first-line treatments.
  9. Post-concussive mood problems can often be treated with cognitive behavioral therapy, lifestyle modifications, medications, and a good plan to get work/school/sport/life back on track. Often mood dysregulation can be the domain most strongly correlated with overall outcome. However, most of the treatment recommendations are based on expert opinion, and there is a clear need for more evidence-based research in this domain. An exciting emerging area is the use of transcranial magnetic stimulation for depressive symptoms in TBI patients. So far, this approach appears to be safe, and in some cases, effective.
  10. Post-concussive trouble concentrating can often be treated by addressing sleep, mood, and headache issues, with cognitive rehabilitation, and with stimulants (when there are no safety contraindications). Stimulants such as methylphenidate can be beneficial for both concentration and mental fatigue issues. Concussion patients can usually take these stimulants safely, as long as there are no uncontrolled seizures, anxiety disorders, severe headaches, active cardiovascular disease, active cerebrovascular disease, psychosis, or serious drug abuse/criminal behavior. Often, other issues such as headaches and anxiety may need to be managed first, before treatment with stimulants is started. Again, most of the treatment recommendations are based on expert opinion, and there is a clear need for more evidence-based research.

David L. Brody, MD, PhD is Professor of Neurology at Uniformed Services University of the Health Science and Director of the Center for Neuroscience and Regenerative Medicine (CNRM): The USU/NIH Military Traumatic Brain Injury Research Group in Bethesda, MD.

References:

Richieri, SP. Evaluation of Automatic Class III Designation for Banyan Brain Trauma Indicator: Decision Memorandum. accessdata.fda.gov. Updated February 2018. Accessed September 2019.

Singer, ME. Premarket Notification: Brain Injury Adjunctive Interpretive Electroencephaolgraph Assessment Aid. accessdata.fda.gov. Updated May 2018. Accessed September 2019.

McCroy P, Meeuwisse W, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine.2018;51:838-847.

Thomas, Danny George, et al. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics, 135, 2.

Leddy J, Haider MN, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion. JAMA Pediatrics. 2019;173(4):319-325.

Collins MW, Kontos AP, et al. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79(6):912-929.

Petrelli T, Farrokhyar F, et al. The use of buprofen and acetaminophen for acute headache in the postconcussive youth: A pilot study. Paediatrics & Child Health. 2017;22(1):2-6.

Nguyen S, McKay A, et al. Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2017;98(8);1508-1517.

Grima N, Rajaratnam S MW, et al. Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomised controlled trial. BMC Medicine. 2018;16(8).

Kaiser PR, Valko PO, et al. Modafinil ameliorates excessive daytime sleepiness after traumatic brain injury. Neurology. 2010;75(20);1780-5.

Siddiqi SH, Trapp NT, et al. Repetitive Transcranial Magnetic Stimulation with Resting-State Network Targeting for Treatment-Resistant Depression in Traumatic Brain Injury: A Randomized, Controlled, Double-Blinded Pilot Study. Journal of Neurotrauma. 2019;36(8).