Persistent Post-Concussion Symptoms

IN PROGRESS …..

Persistent Post-Concussion Symptoms

Definition:  Symptoms that have occurred secondary to a concussion and that are persisting beyond 14 days in adults and 4 weeks in children.(12)
Medical conditions predisposing patients to prolonged concussion symptoms:

Neurological:  Epilepsy, Meningitis, Headaches, Migraines, Seizure Disorders
Psychological:  Anxiety, Depression, Post-Traumatic Stress Disorder
Learning:  Learning Deficits, Attention Deficit Hyperactivity Disorder
A history of prior concussions.

Persistent post-concussion symptoms can fall into any one or combination of the following 8 domains:

1. Post-traumatic Headaches
2. Psychological
3. Sleep
4. Cognitive
5. Cervical Spine
6. Oculomotor
7. Vestibular
8. Autonomic

1) Post-traumatic headaches are classified as per ICHD 1 however typically follow the patterns of other commonly classified headaches.

Tension type – bilateral tension band, that can last minutes to hours.  Typically intensity, frequency, and duration reduce with time from the concussion.

Migraine – 4-72 hours, 2 of the 4 following characteristics:  unilateral, pulsating, avoidance of physical activity, moderate or severe pain intensity, and any one of the two during the headache:  photosensitivity and/OR nausea/vomiting.

Occipital Neuralgia – Headaches typically one sided- occasionally bilateral, and radiate from occiput anteriorly towards temples and can be reproduced with pressure over the occipital nerve outlet

Cervicogenic (Whiplash associated disorder)- typically the headache is worsened with neck movements or held postures.

Secondary benign exertional headache:(3)

If patient has a preexisting headache condition, a concussion can cause a temporary worsening of those symptoms.

2)  Psychological – there is a significant psychological impact secondary to concussions.  Both new onset cases of anxiety and/or depression may occur, as well as a worsening of pre-existing anxiety/depression.

3)  Sleep dysfunction may include increased time to sleep, interrupted sleep and/or new vivid dreams

4) Cognitive dysfunction is common after concussions and is often transient.  The dysfunction can involve reduce reaction time, memory deficits, decreased attention and difficulty focusing.  Neuropschological testing can be helpful in determining the extent and its implications on returning to learn and work.

5)  Cervical spine involvement is often in the form of a mild whiplash associated disorder, given that the forces required to cause a concussion often involve similar forces to the neck.   These can include, neck pain, neck tightness/stiffness, associated headaches, nausea, and dizziness.

6) Oculomotor dysfunction can also occur post concussion.  There are several complex neurological pathways involved, however coordination of vision, vestibularocular pathway, ability to track moving objects, near-point convergence, ability to accommodate, focus and read can all be affected negatively after a concussion.  Symptoms can include headache, feeling foggy, light headed, dizzy, nauseous and eye-fatigue.   These typically occur with reading, watching screens, and being exposed to moving landscapes – (passenger in a car, walking through crowded areas).  These oculomotor symptoms typically resolve themselves with time, but may benefit from specialist assessment and certain treatments.

7)  Vestibular dysfunction – The vestibular system is similar to an inner gyroscope and helps coordinate balance as well as visual movements.   Symptoms can include poor balance, dizziness, light headed, difficulty progressing with exercise, and difficulty tracking objects or with eye movements.

8)  Autonomic dysfunction is one of the more recent to be described post concussion.  Effects include changes in heart-rate variability, orthostatic hypotensive effects and can included the following symptoms:  dizziness, light headedness, feeling fatigued and difficulty with progressing with exercise.

Differential Diagnosis:  Epidural hematoma, Subdural hematoma, subgaleal hemorrhage, facial fracture, whiplash associated disorder, post traumatic stress disorder, generalized anxiety disorder, major depressive disorder, subarachnoid hemorrhage, intracranial hypertension, chiari malformation.

 

 

Examination:  (Similar to Concussion with psychological assessment and additional neurological tests to rule out differentials)

Should include a neurological exam including Cranial Nerves, Head and scalp exam, Neck exam, Upper limbs, Coordination, Balance assessment and a neurocognitive assessment.

Neuro Exam:  Fundoscopy, PERLA, Visual Fields, Occulomotor exam, facial sensation, motor control, oral examination, shoulder shrug and neck exam.

Head And Scalp Exam:  Check for contusions, lacerations, aural and nasal for cerebral spinal fluid.

Neck Exam:  If on field, stabilize, then palpate posterior neck for midline boney tenderness, if none, proceed to neurological screen, and questioning about neck pain and sensation.  If normal proceed to AROM.  If normal, may clear neck.  If abnormal, stabilize and collar prepare for transportation to nearest hospital for further assessment.  If ambulatory – continue after AROM to have patient lying and assess for boney tenderness from C2-C7 and paracentral tenderness, often tender despite no complaints of neck pain.

Upper Limb:  Neurological assessment for power, sensation, reflexes, and coordination (finger to nose).

Balance:  modified BESS – Balance Error Scoring System.  see concussion article (http://sportmedschool.com/concussion/)

Cognitive Assessment:

Immediate Recall of 3-5 words (no hints)

World or Twirl spelled backwards

Months of the year in reverse order

Number sequences asked in reverse order (4,6,8 – “8,6,4”)

Serial 7’s – taking 7 away from 100

Delayed Recall of 3-5 words (no hints)

Neuropsychological Testing:

Neuropsychological assessment can be of great assistance in determining specific deficits that could be addressed for return to learn and return to work scenarios.  Although not necessary for routine sport-related concussions with patients with persistent symptoms can give a more in-depth picture of how the symptoms are affecting the patient functionally.

Investigations:
Concussion is a clinical diagnosis based on history and examination, investigations are not necessarily required.  In prolonged cases, may consider bloodwork, CT, MRI:

Bloodwork:  CBC (rule out occult infection, anemia), ferritin (Treat if ferritin < 30ng/mL in males, 50 ng/mL in females, if less than 2o consider venofer infusion …. see journal club on anemia), extended electrolytes (rule out hyponatremia, hypo/hypercalcemia), TSH, testosterone levels in males.

CSpine imaging:  If patient is having cervical spine symptoms, consider Cspine xrays with Flexion/extension views, CT cspine or MRI neck to look for associated injuries.

MRI/CT head – although not required to diagnose concussion, can be helpful in ruling our some more sinister causes of patient’s symptoms such as intracranial hypertension, subdural hematoma, epidural hematoma, and chiari malformations.  CT head rules – don’t apply to persistent symptoms of concussion.

Management:

Management or persistent symptoms should be targeted towards the deficits found during assessment.
The newer guidelines (12) from Berlin on sport concussion are recommending resting (not complete rest as insufficient evidence) for only a short period of time after injury ideally less than 48 hours.    Gradual progression of cardiovascular exercise can be started as patient tolerates, often within 24 hours of injury.  For persistent symptoms, the author strongly recommends a multidisciplinary team involving physiotherapy for physical symptoms and psychotherapy for psychological symptoms when appropriate.

Light and Sound Sensitivity:
Sunglasses can assist with light sensitivity, as can hearing protection with noise sensitivity.   Screens should be modified to avoid symptoms or avoided until the symptoms abate but if not possible or symptoms persist, the screen contrast can also be turned down.

Neck Symptoms:
Neck physiotherapy consisting of accupressure, ice/heat, passive massage and isometric exercises may assist a patient suffering an acute concussion.  Generally, mild cardiovascular exercise (walking, biking) is safe to do even with patients with whiplash associated disorders related to their injury.

Oculomotor Dysfunction:
Visual therapy may be of benefit for patients struggling with visual distress.  This can range from basic oculomotor and dolls-eye exercises to more formal computer software programs.  The former may be initiated if not causing or worsening symptoms.   These may consist of performing isolated eye movements (ie. with chin resting on a counter) following a union-jack formation at arm’s length in sets of clockwise and counter clockwise motions.   The distance may progressively shorten as tolerated by the patient.  Dolls-eye exercises are isolated neck movements in the same formation while the eyes stay focused in the middle of the union-jack.   Consider referring to a neuro-optometrist or a neuro-ophthalmologist.

Sleep Dysfunction:
Patients often will begin to have difficulty falling asleep starting as early as the first week and depending on symptoms up to the first couple of months.   As time to sleep increases, an increase in asymptomatic activity should be considered.   Also a discussion regarding sleep hygiene may help.  Encouraging cardiovascular exercise has also been show to be helpful with this.

Table 1 Sleep Hygiene Recommendations:

Low light/Dark room

Avoid bright lights/screentime 2 hours before bed

Avoid caffeine in afternoon

Avoid daytime napping

Afternoon cardiovascular exercise

Sexual Intercourse

Wake-training – set same wake-up time every day

Reduce awake time in bed

Going to bed when tired

If it persists despite increased activity/sleep hygiene modifications, a sleeping-aid may be considered:
First line:  Melatonin 3 or 6mg po qhs
Second line:  Amitriptyline 10mg po qhs (may increase 10mg per week to max 50mg) if having coexisting headache symptoms.

Headaches:
Depending on type of headache, intensity and time elapsed since the injury management may involve: activity modification, sunglasses, avoiding screens, or if persistent and higher intensity – medication.  Psychological support in the form of psychotherapy modalities such as CBT can also be helpful.  Medication is usually advised against acutely, to allow the patient to become aware of symptoms and curb his/her activity to control symptoms while recovering.  Also medications are reserved for patients whose symptoms are affecting their ability to function during the day.  In these cases the goal is to reduce symptomotology not necessarily erase symptoms completely.

Table 2 – Pharmacological options for post traumatic headaches (3,4,5,6,7,8,9,10,11)

Headache Type	Medication	Dose	Frequency
Tension
–       Acetaminophen	Acetaminophen	500mg-1gram po	q6h prn headache
–       NSAIDs (don’t combine NSAIDs)	Ibuprofen	400mg po	q6h prn headache
	Naproxen	500mg po	q6h prn headache
	Diclofenac     (Cambia – effervescent)	75mg po Or 50mg po   50mg	q12h prn headache   q8h prn headache   q8h prn headache
–       Prophylactic
	Amitriptylline	10mg po	To max 50mg po qhs
	Nortriptylline	10mg po	Up to 30mg po qhs
	Pregababiln	75mg po OR 50mg po	BID TID (Lexicomp)
Migraine
–       Acetaminophen	Acetaminophen	500mg-1gram po	q6h prn headache
–       NSAIDs (don’t combine NSAIDs)	Ibuprofen	400mg po	q6h prn headache
	Naproxen	500mg po	q6h prn headache
	Diclofenac     (Cambia – effervescent)	75mg po Or 50mg po   50mg	q12h prn headache   q8h prn headache   q8h prn headache
–       Triptans	Almotriptan	6.25mg, 12.5mg	Max daily dose 25mg
	Naratriptan	1mg, 2.5mg	Max daily dose 5mg
	Rizatriptan	5, 10mg	Max daily dose 30mg
	Sumatriptan   Sumatriptan Spray	25, 50, 100mg   5, 10, 20 mg	Max daily dose 200mg Max daily dose 40mg
	Zolmitriptan	1.25, 2.5, 5mg	Max daily dose 10mg
–       Prophylactic	Riboflavin (Vit B2)	200mg po	BID (Lexicomp)
	Magnesium oxide	400mg po	Daily (Merison,Lexicopm)
	Magnesium citrate	300mg po	BID (TOP)
	Coenzyme Q10
–       Beta-blockers	Propranolol	20mg po	BID
	Metoprolol	50mg po	BID
–       Anticonvulsants	Topiramate	25mg po	Increase to BID after 1 week (TOP)
Exercise Induced Headache
	Indomethacin*	25-50mg	Take before exercise
	Propranolol*	10-20mg	Take before exercise
Occipital Neurlagia
–       Local anesthetic	Xylocaine/lidocaine	1-2% – 2-4 mL	For diagnostics
–       Corticosteroid (Don’t combine corticosteroids)	Methylprednisolone (Depomedrol)	40mg	For local injection
	Betamethasone (Celestone)	0.5mL (6mg/mL)	For Local injection

 

*Off label use

Psychological Symptoms
Concussion is associated depression and anxiety post-injury.  These symptoms are likely a combined effect from the injury and the withdrawal from activity.  If they increase a trial of increased activity – preferably symptomatic activity may be considered.  Low-intensity exercise should be considered – stationary bike at an intensity no greater than 60% of maximum heart rate.  Conservative measures include optimizing sleep, maintaining cardiovascular exercise, regular social interactions with friends and family as tolerated, and some for of cognitive tasking similar to school or work as tolearted.

A multi-disciplinary approach here is most important, and early referral to a sport psychologist is recommended.  Cognitive behavioural therapy can be employed to assist the patient in coping with the stresses of returning to school/work with symptoms.   Closely monitoring patient’s symptoms and risks is also important and selective serotonin re-uptake inhibitor (SSRI) or selective norepinephrine re-uptake inhibitor (SNRI) medication may be required to help reduce the patient’s symptoms.  See related webpage on review of medications: http://sportmedschool.com/concussion-psychological-dysfunction/

Supplements (13,14):
A statement from the FDA sums up our current evidence for supplements post concussion:
“There is simply no scientific evidence to support the use of any dietary supplement for the prevention of concussions or the reduction of postconcussion symptoms that would allow athletes to return to play sooner.”13
Omega 3’s are commonly recommended as are flavanoids, reducing high glycemic indices.  These are based on animal studies regarding traumatic brain injury and brain-derived growth factor studies.  Other supplements although not specifically for concussion may help with concussion symptoms riboflavin, magnesium and melatonin (see above medication table).

Resources:

http://onf.org/system/attachments/223/original/ONF_mTBI_Guidelines_2nd_Edition_COMPLETE.pdf
(These are soon to be updated for 2017)

Dr. Neil Dilworth (September 14, 2017)

References:

1.  International Headache Society’s International Classification of Headache Disorders https://www.ichd-3.org/1-migraine/1-1-migraine-without-aura/

2.  http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

3.  McCrory P  Headaches and Exercise.  Sports Med. 2000 Sep;30(3):221-9

4.  Targett C.  Exercise-induced headache. Emerg Med J. 2014 May;31(5):438. doi: 10.1136/emermed-2013-202725. Epub 2013 May 16.

5.  Nadelson C.  Sport and exercise-induced migraines.  Curr Sports Med Rep. 2006 Feb;5(1):29-33.

6.  Singh RK1, Martinez A, Baxter P.  Head cooling for exercise-induced headache.  J Child Neurol. 2006 Dec;21(12):1067-8.

7.  Merison K, Jacobs H.  Diagnosis and Treatment of Childhood Migraine.  Curr Treat Options Neurol. 2016 Nov;18(11):48.

8. http://pharmacistsletter.therapeuticresearch.com/pl/ArticlePDF.aspx?DocumentFileID=0&DetailID=270610&SegmentID=YYY

9.  Lexicomp

10. http://www.topalbertadoctors.org/file/quick-reference-pdf

11.   Modi S, Lowder DM.  Medications for migraine prophylaxis.  Am Fam Physician. 2006 Jan 1;73(1):72-8. Review. Erratum in: Am Fam Physician. 2006 Nov 15;74(10):1685.

12.  McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA, Ellenbogen R, Emery C, Engebretsen L, Feddermann-Demont N, Giza CC, Guskiewicz KM, Herring S, Iverson GL, Johnston KM, Kissick J, Kutcher J, Leddy JJ, Maddocks D, Makdissi M, Manley GT, McCrea M, Meehan WP, Nagahiro S, Patricios J, Putukian M, Schneider KJ, Sills A, Tator CH, Turner M, Vos PE.  Consensus statement on concussion in sport-the 5^th international conference on concussion in sport held in Berlin, October 2016.  Br J Sports Med. 2017 Apr 26. pii: bjsports-2017-097699. doi: 10.1136/bjsports-2017-097699. [Epub ahead of print] No abstract available.

13.  Administration USFaD [Internet]. U.S. Food and Drug Administration. [cited 2017 19 June]. Available from:http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm378845.htm

14. Trojian TH, Wang DH, Leddy JJ.  Nutritional Supplements for the Treatment and Prevention of Sports-Related Concussion-Evidence Still Lacking.  Curr Sports Med Rep. 2017 Jul/Aug;16(4):247-255. doi: 10.1249/JSR.0000000000000387.