A Treatment Paradigm for Sports Concussion
Cara Camiolo Reddy, MD and Lisa A. Lombard, MD
It should be noted in this text we mention the use of several medications in indications that are not currently FDA approved. Clinicians should educate themselves of potential benefits and side effects of all medications before prescribing. Introduction In recent years, the management of sports concussion has been an active topic in the media and medical literature. Considerable energy and resources have been devoted to the development of return to play guidelines. Despite these efforts, a void still exists in guidelines for treating individuals with persistent post concussion symptoms. Here, we present our clinical views on the management of persistent mild traumatic brain injury (mTBI) symptoms. Acute Management Management of mTBI should begin immediately after the injury is sustained. While athletes who have sustained loss of consciousness often are seen in emergency departments, the majority of persons sustaining mTBI from athletic contests are evaluated by athletic trainers or primary care physicians. In the initial days following injury, individuals should be instructed on the benefits of proper sleep hygiene, physical rest, and cognitive rest. Avoiding physical and cognitive exertion when individuals are symptomatic is of utmost importance when recovering from mTBI. The majority of athletes will recover within 3-4 weeks post-injury, as demonstrated by improvement on self-reported symptom scales and neurocognitive testing (Yang et al., 2007; Collins et al., 2006). Unfortunately, approximately 10-15% will have prolonged symptoms. It is in this group of individuals that postconcussion symptoms can become functionally limiting and disabling. Persons with prolonged or worsening symptoms greater than 3 weeks or more warrant further medical evaluation. 24 BRAIN INJURY PROFESSIONAL
Postconcussion Symptoms The diagnosis of postconcussion syndrome is controversial in the medical community, as the symptoms associated with mTBI can appear quite vague and be mistaken for other clinical issues. Despite this debate, distinct symptom clusters and neurocognitive deficits following mTBI have been identified (Potter et al., 2006). For this discussion, we take a clinical approach that identifies symptoms consistent with concussive injury and tailor intervention accordingly. A detailed history is imperative for evaluation and treatment of mTBI, including mechanism of injury, location of the impact, length of loss of consciousness (if present), presence of retrograde and/or anterograde amnesia (lack of memory before or after the event, respectively), initial symptoms and treatment. A comprehensive review of ongoing symptoms should be undertaken. Symptoms consistent with mTBI fall into four categories: cognitive (difficulty with short term memory, poor concentration, taking longer to think, feeling foggy), somatic (body centered complaints, including headaches, dizziness, nausea, sensitivity to light and noise, blurred or double vision), emotional (irritability, frustration, depression, anxiety), and sleep disturbance (difficulty falling and/or staying asleep, too much or too little sleep). Cognitive Neuropsychological testing has provided objective data illustrating the multitude of cognitive derangements following mTBI. Clinically, these individuals may complain of feeling foggy, not being able to think quickly or not being able to focus attention to complete everyday tasks. Students will often complain of declining academic performance. Short term memory deficits and prolonged reaction times are also apparent. There is clear evidence that the cognitive deficits following TBI are improved with the addition of neurostimulant medications (Warden et al.,