Interventions

Clinicians working with patients in the early sub-acute stage of recovery will be most successful with the use of strategies aimed at preventing the development of persistent post-concussion syndrome.

  1. Psychoeducation
    1. Psychoeducation may be the key to prevention of long-term symptoms in patients following concussion. It was not too long ago that the public at large had very little information about concussion, making the effects of the injury somewhat of a mystery, both to patients and clinicians. Now, with the explosion of information provided by the media and the internet, most people have expectations of what might be expected following concussion, with many of these expectations guided not so much by research findings but by misconceptions based on dramatic accounts of celebrities, athletes, and soldiers who have experienced difficult recoveries.

      • The role of the clinician is therefore to relay information from the evidence-based literature while providing reassurance to their patients that, after a brief period of headache and other short-lived symptoms, the vast majority of individuals sustaining a concussion achieve full recovery, enabling them to resume their lives with no long term effects.

      There are indications that psycho-educational interventions aimed at patients with a concussion are best initiated as early as possible following the injury. Findings from research studies have indicated that providing information sheets or a single session intervention to patients at the time of the ER visit will reduce symptom expression and level of distress at longer-term follow-up. Communication to the patient that he or she will benefit from rest while they undergo a brief period of symptoms can prevent them from suffering setbacks as a result of a premature resumption of their regular activities. Most concussion experts advocate a common sense approach for an initial return to activity, adapting concepts borrowed from return-to-play guidelines developed in the sports setting. This generally involves a graduated resumption of activities, as tolerated, until a full return to a pre-injury level of functioning can be achieved unaccompanied by symptoms (McCrory et al., 2013 ).

      For education-related issues in the sports environment, please see School Accomadations

  2. Cognitive and Psychological Rest
    1. The issue of complete cognitive and physical rest has become a controversial topic in the clinical management of concussion. Recommendations for rest are based loosely on concepts obtained from animal studies where it is known that a premature activation of physiological activity during a period when the brain is undergoing a restorative process can have a negative effect on many of the neural factors important for recovery.

      Based on this information, it makes sense to recommend a few days rest following an injury. However, the clinician must be careful not to overextend recommendations of rest, which could have the potential of placing the recovering patient at risk for developing a maladaptive focus on their symptoms. Indeed, a recent randomized control trial suggests that strict rest following concussion in adolescents may actually lead to slower recovery (Thomas, Apps, Hoffman, McCrea & Hammeke, 2015 ). At the current time, further information is needed on the long-term benefits of rest and the optimal amount and types of rest that are required for optimal recovery from concussion (Schneider, Iverson, Emery, McCrory, Herring, & Meeuwisse, 2013 ).

      Please see the section on Rest for more detailed information on rest following sports-related concussion

Interventions for Persistent Post-Concussion Syndrome

Most health care professionals are well aware that patients with persistent post-concussion syndrome are difficult to treat. Interventions aimed at treating persistent postconcussive symptoms can be divided roughly into physiological and psychological approaches. It is not surprising that there is no consensus on what physiologic approaches to treatment should be used for treatment of postconcussive symptoms, given the fact that its underlying physiologic causes remain undetermined. Based on findings from the research literature, there is more empirical support for the use of psychological interventions, although there is clearly a need for more work in this area.

  1. Pharmacological Treatment
    1. Pharmacological approaches to the treatment of patients with postconcussive symptoms focus primarily on treatment of comorbid depression and anxiety, as no medication has been shown to be effective in treating the primary symptoms of postconcussive symptoms (Makdissi, Cantu, Johnston, McCrory, & Meeuwisse, 2013 ) (McAllister, 2009 ).

  2. Psychological Treatment
    1. There is now a growing trend to use cognitive behavioral therapy (CBT) for treatment of concussion patients who have postconcussive symptoms. The theoretical basis for CBT interventions with this population is that:
      1. The symptoms that predominate are subjective in nature
      2. These symptoms overlap substantially with those seen in other psychological conditions
      3. There are a number of cognitive-behavioral processes underlying the evolution and maintenance of symptoms (Potter & Brown, 2012 ).

      While previous psychotherapeutic approaches to postconcussive symptoms emphasized a sequence of validation and identifying alternative interpretations for the attribution of symptoms, use of CBT enables the clinician to address maladaptive behavioral responses, cognitive appraisals, and the impact of symptoms on daily life (Sayegh, Sanford, & Carson, 2010 ).

      A 12-session framework for CBT with postconcussive patients has been developed by (Potter & Brown, 2012 ). Beginning sessions utilize and extend the use of materials from psycho-educational interventions by providing information on the course of symptom recovery seen in the majority of patients. This is followed by a number of sessions identifying problem areas and developing appropriate responses. The goal is to help develop positive expectations while limiting the negative impact of perceived errors or mistakes. Later sessions focus on the techniques that worked and did not work in addition to developing longer-term behavioral plans for the future. In a recent systematic review of the research literature, it was determined that all 10 randomized controlled trials demonstrated a therapeutic benefit, although small numbers and short durations of follow-up prevent the formation of robust conclusions about the ultimate efficacy of CBT with the concussed population.

Interventions Under Investigation

  1. There is a growing interest in identifying oculomotor (Galetta et al., 2011 ) and vestibular disturbances (Alsalaheen et al., 2010) in postconcussed patients, based on the possibility that these types of disturbances are often overlooked in this population. However, large-scale studies looking at the efficacy of vision and vestibular therapy are clearly needed.
  2. This is also growing interest in the utility of aerobic exercise in treating symptomatic postconcussed individuals (Leddy et al., 2013 ) (Tan et al., 2014 ). There is some evidence that exercise training may reduce symptoms but randomized, controlled trials are needed.

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