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Management of concussion and post-concussion syndrome

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Opinion statement

Concussion and mild traumatic brain injury (mTBI) are common clinical problems. However, the literature is not consistent in defining how concussion and mTBI are related. Although most patients with concussion recover within days to weeks, approximately 10% develop persistent signs and symptoms of post-concussion syndrome (PCS). There are no scientifically established treatments for concussion or PCS and thus rest and cognitive rehabilitation are traditionally applied, with limited effectiveness. This article presents a clinical model to suggest that concussion evolves to become mTBI after PCS has developed, representing a more severe form of brain injury. The basic pathophysiology of concussion is presented, followed by a recommended approach to the clinical evaluation of concussion in the emergency department and the physician’s office. We evaluate the limited evidence-based pharmacologic treatment of acute concussion symptoms and PCS symptoms and also discuss return to activity recommendations, with an emphasis on athletes. Lastly, we suggest a promising new direction for helping patients recover from PCS.

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References and Recommended Reading

  1. Kraus JF, Sorenson S: Epidemiology. In Neuropsychiatry of Traumatic Brain Injury. Edited by Silver JM, Yudofsky SC, Hales RE. Washington, DC: American Psychiatric Press Inc.; 1994:3–41.

    Google Scholar 

  2. Bazarian JJ, McClung J, Cheng YT, et al.: Emergency department management of mild traumatic brain injury in the USA. Emerg Med J 2005, 22:473–477.

    Article  PubMed  CAS  Google Scholar 

  3. Bazarian JJ, Blyth B, Cimpello L: Bench to bedside: evidence for brain injury after concussion--looking beyond the computed tomography scan. Acad Emerg Med 2006, 13:199–214. Bazarian et al. provide an excellent summary of the recent research on emergency care of those with mTBI and a precise description of the pathophysiology of mTBI.

    Article  PubMed  Google Scholar 

  4. Kelly JP, Rosenberg JH: The development of guidelines for the management of concussion in sports. J Head Trauma Rehabil 1998, 13:53–65.

    PubMed  CAS  Google Scholar 

  5. Lovell MR, Collins MW, Iverson GL, et al.: Grade 1 or “ding” concussions in high school athletes. Am J Sports Med 2004, 32:47–54.

    Article  PubMed  Google Scholar 

  6. Thurman DJ, Branche CM, Sniezek JE: The epidemiology of sports-related brain injuries in the United States: recent developments. J Head Trauma Rehabil 1998, 13:1–8.

    PubMed  CAS  Google Scholar 

  7. Longhi L, Saatman KE, Fujimoto S, et al.: Temporal window of vulnerability to repetitive experimental concussive brain injury. Neurosurgery 2005, 56:364–374.

    Article  PubMed  Google Scholar 

  8. Lovell M, Iverson G, Collins M, et al.: Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med 1999, 9:193–198.

    Article  PubMed  CAS  Google Scholar 

  9. Guskiewicz KM, Bruce SL, Cantu RC, et al.: Research based recommendations on management of sport related concussion: summary of the National Athletic Trainers’ Association position statement. Br J Sports Med 2006, 40:6–10. Important recent study.

    Article  PubMed  CAS  Google Scholar 

  10. Giza CC, Hovda DA: The neurometabolic cascade of concussion. J Athl Train 2001, 36:228–235.

    PubMed  Google Scholar 

  11. Pellman EJ, Lovell MR, Viano DC, Casson IR: Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing--part 12. Neurosurgery 2006, 58:263–274.

    Article  PubMed  Google Scholar 

  12. McCrory P, Johnston K, Meeuwisse W, et al.: Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 2005, 15:48–55. The authors provide an excellent description of the signs and symptoms of concussion and how to assess these on the field and in the examining room.

    Article  PubMed  Google Scholar 

  13. Boake C, McCauley SR, Levin HS, et al.: Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci 2005, 17:350–356. This paper provides a current discussion and research on the varying criteria for defining and diagnosing PCS.

    PubMed  Google Scholar 

  14. Iverson GL, Gaetz M, Lovell MR, Collins MW: Cumulative effects of concussion in amateur athletes. Brain Inj 2004, 18:433–443.

    Article  PubMed  Google Scholar 

  15. Iverson GL, Brooks BL, Lovell MR, Collins MW: No cumulative effects for one or two previous concussions. Br J Sports Med 2006, 40:72–75.

    Article  PubMed  CAS  Google Scholar 

  16. McCauley SR, Boake C, Levin HS, et al.: Postconcussional disorder following mild to moderate traumatic brain injury: anxiety, depression, and social support as risk factors and comorbidities. J Clin Exp Neuropsychol 2001, 23:792–808.

    PubMed  CAS  Google Scholar 

  17. Bazarian JJ, Atabaki S: Predicting postconcussion syndrome after minor traumatic brain injury. Acad Emerg Med 2001, 8:788–795.

    PubMed  CAS  Google Scholar 

  18. Korn A, Golan H, Melamed I, et al.: Focal cortical dysfunction and blood-brain barrier disruption in patients with postconcussion syndrome. J Clin Neurophysiol 2005, 22:1–9. Important recent study.

    Article  PubMed  Google Scholar 

  19. McCrory PR, Berkovic SF: Video analysis of acute motor and convulsive manifestations in sport-related concussion. Neurology 2000, 54:1488–1491.

    PubMed  CAS  Google Scholar 

  20. Peterson CL, Ferrara MS, Mrazik M, et al.: Evaluation of neuropsychological domain scores and postural stability following cerebral concussion in sports. Clin J Sport Med 2003, 13:230–237.

    Article  PubMed  Google Scholar 

  21. Guskiewicz KM: Assessment of postural stability following sport-related concussion. Curr Sports Med Rep 2003, 2:24–30. This study describes a test of postural ability after concussion and highlights the important role of this type of assessment in the neurologic examination.

    Article  PubMed  Google Scholar 

  22. Dunning J, Stratford-Smith P, Lecky F, et al.: A metaanalysis of clinical correlates that predict significant intracranial injury in adults with minor head trauma. J Neurotrauma 2004, 21:877–885.

    Article  PubMed  Google Scholar 

  23. Stiell IG, Clement CM, Rowe BH, et al.: Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005, 294:1511–1518.

    Article  PubMed  CAS  Google Scholar 

  24. Guskiewicz KM, Bruce SL, Cantu RC, et al.: Recommendations on management of sport-related concussion: summary of the National Athletic Trainers’ Association position statement. Neurosurgery 2004, 55:891–895; discussion 896.

    Article  PubMed  Google Scholar 

  25. de Louw A, Twijnstra A, Leffers P: Lack of uniformity and low compliance concerning wake-up advice following head trauma. Ned Tijdschr Geneeskd 1994, 138:2197–2199.

    PubMed  Google Scholar 

  26. de Kruijk JR, Leffers P, Meerhoff S, et al.: Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry 2002, 73:167–172.

    Article  PubMed  Google Scholar 

  27. Ponsford J, Willmott C, Rothwell A, et al.: Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry 2002, 73:330–332.

    Article  PubMed  CAS  Google Scholar 

  28. Wade DT, King NS, Wenden FJ, et al.: Routine follow up after head injury: a second randomised controlled trial. J Neurol Neurosurg Psychiatry 1998, 65:177–183.

    PubMed  CAS  Google Scholar 

  29. Lee ST, Liu TN, Wong CW, et al.: Relative risk of deterioration after mild closed head injury. Acta Neurochir (Wien) 1995, 135:136–140.

    Article  CAS  Google Scholar 

  30. Solomon S: Posttraumatic headache. Med Clin North Am 2001, 85:987–996, vii-viii.

    Article  PubMed  CAS  Google Scholar 

  31. Weight DG: Minor head trauma. Psychiatr Clin North Am 1998, 21:609–624.

    Article  PubMed  CAS  Google Scholar 

  32. Hall RC, Hall RC, Chapman MJ: Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics 2005, 46:195–202.

    Article  PubMed  Google Scholar 

  33. Saran A: Antidepressants not effective in headache associated with minor closed head injury. Int J Psychiatry Med 1988, 18:75–83.

    Article  PubMed  CAS  Google Scholar 

  34. Tyler GS, McNeely HE, Dick ML: Treatment of posttraumatic headache with amitriptyline. Headache 1980, 20:213–216.

    Article  PubMed  CAS  Google Scholar 

  35. McBeath JG, Nanda A: Use of dihydroergotamine in patients with postconcussion syndrome. Headache 1994, 34:148–151.

    Article  PubMed  CAS  Google Scholar 

  36. Jensen OK, Nielsen FF, Vosmar L: An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache. Cephalalgia 1990, 10:241–250.

    Article  PubMed  CAS  Google Scholar 

  37. Comper P, Bisschop SM, Carnide N, Tricco A: A systematic review of treatments for mild traumatic brain injury. Brain Inj 2005, 19:863–880. This review of the literature on treatment of mTBI is useful for various reasons but most specifically for the concise review of pharmacologic interventions.

    Article  PubMed  CAS  Google Scholar 

  38. Cobb S, Battin B: Second-impact syndrome. J Sch Nurs 2004, 20:262–267.

    Article  PubMed  Google Scholar 

  39. Agrawal D, Gowda NK, Bal CS, et al.: Is medial temporal injury responsible for pediatric postconcussion syndrome? A prospective controlled study with singlephoton emission computerized tomography. J Neurosurg 2005, 102(Suppl 2):167–171.

    PubMed  Google Scholar 

  40. Stalnacke BM, Bjornstig U, Karlsson K, Sojka P: Oneyear follow-up of mild traumatic brain injury: postconcussion symptoms, disabilities and life satisfaction in relation to serum levels of S-100B and neurone-specific enolase in acute phase. J Rehabil Med 2005, 37:300–305.

    Article  PubMed  Google Scholar 

  41. Gaetz M, Weinberg H: Electrophysiological indices of persistent post-concussion symptoms. Brain Inj 2000, 14:815–832.

    Article  PubMed  CAS  Google Scholar 

  42. Arciniegas DB, Topkoff JL: Applications of the P50 evoked response to the evaluation of cognitive impairments after traumatic brain injury. Phys Med Rehabil Clin N Am 2004, 15:177–203, viii.

    PubMed  Google Scholar 

  43. Ho MR, Bennett TL: Efficacy of neuropsychological rehabilitation for mild-moderate traumatic brain injury. Arch Clin Neuropsychol 1997, 12:1–11.

    Article  PubMed  CAS  Google Scholar 

  44. Cicerone KD: Remediation of “working attention” in mild traumatic brain injury. Brain Inj 2002, 16:185–195.

    Article  PubMed  Google Scholar 

  45. Mittenberg W, Canyock EM, Condit D, Patton C: Treatment of post-concussion syndrome following mild head injury. J Clin Exp Neuropsychol 2001, 23:829–836. Important study.

    Article  PubMed  CAS  Google Scholar 

  46. Fann JR, Uomoto JM, Katon WJ: Sertraline in the treatment of major depression following mild traumatic brain injury. J Neuropsychiatry Clin Neurosci 2000, 12:226–232.

    PubMed  CAS  Google Scholar 

  47. Zasler ND: Mild traumatic brain injury: medical assessment and intervention. J Head Trauma Rehabil 1993, 8:13–29.

    Google Scholar 

  48. Zafonte RD, Cullen N, Lexell J: Serotonin agents in the treatment of acquired brain injury. J Head Trauma Rehabil 2002, 17:322–334.

    Article  PubMed  Google Scholar 

  49. Griffin SL, van Reekum R, Masanic C: A review of cholinergic agents in the treatment of neurobehavioral deficits following traumatic brain injury. J Neuropsychiatry Clin Neurosci 2003, 15:17–26.

    PubMed  CAS  Google Scholar 

  50. Cardenas DD, McLean A Jr, Farrell-Roberts L, et al.: Oral physostigmine and impaired memory in adults with brain injury. Brain Inj 1994, 8:579–587.

    PubMed  CAS  Google Scholar 

  51. Levin HS, Peters BH, Kalisky Z, et al.: Effects of oral physostigmine and lecithin on memory and attention in closed head-injured patients. Cent Nerv Syst Trauma 1986, 3:333–342.

    PubMed  CAS  Google Scholar 

  52. Levin HS: Treatment of postconcussional symptoms with CDP-choline. J Neurol Sci 1991, 103(Suppl):S39-S42.

    Article  PubMed  Google Scholar 

  53. Rogers SL, Doody RS, Mohs RC, Friedhoff LT: Donepezil improves cognition and global function in Alzheimer disease: a 15-week, double-blind, placebo-controlled study. Donepezil Study Group. Arch Intern Med 1998, 158:1021–1031.

    Article  PubMed  CAS  Google Scholar 

  54. Masanic CA, Bayley MT, VanReekum R, Simard M: Open-label study of donepezil in traumatic brain injury. Arch Phys Med Rehabil 2001, 82:896–901.

    Article  PubMed  CAS  Google Scholar 

  55. Whelan FJ, Walker MS, Schultz SK: Donepezil in the treatment of cognitive dysfunction associated with traumatic brain injury. Ann Clin Psychiatry 2000, 12:131–135.

    Article  PubMed  CAS  Google Scholar 

  56. Henninger N, Dutzmann S, Sicard KM, et al.: Impaired spatial learning in a novel rat model of mild cerebral concussion injury. Exp Neurol 2005, 195:447–457.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. University at Buffalo, G 96 Farber Hall, 3435 Main Street, 14214, Buffalo, NY, USA

    Barry Willer PhD

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  1. Barry Willer PhD
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  2. John J. Leddy MD
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Willer, B., Leddy, J.J. Management of concussion and post-concussion syndrome. Curr Treat Options Neurol 8, 415–426 (2006). https://doi.org/10.1007/s11940-006-0031-9

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