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Post-Concussion Syndrome: Possible Therapies

 

The majority of youth athletes with a sport-related concussion will spontaneously recover quickly following a period of cognitive and physical rest, most within 7 to 10 days, in some cases symptoms persist for weeks, months and years beyond the initial injury. [15] If your child is suffering from post-concussion syndrome), then additional therapies may need to be considered.

Although no medicine has been shown in double-blind randomized control trials to effectively speed the recovery from concussive brain injury, many of the symptoms can be treated medically, new therapies are being tested, and some non-traditional therapies have been shown to help some suffering from post-concussion syndrome. 

Whatever therapies parents consider for a child with post-concussion syndrome, they need to weigh the potential risks and adverse effects against the likelihood of benefit, and whether they are tailored to address the athlete's most bothersome symptoms, says William P. Meehan, III, MomsTeam's concussion expert and Director of the Sports Concussion Clinic in the Division of Sports Medicine at Boston Children's Hospital. In addition, says Dr. Meehan, athletes engaging in these potential therapies should be closely monitored by a clinician experienced in the assessment and management of sport-related concussions or concussive brain injuries in general.

Reassurance, discussion, compensatory strategies

The foundation of postconcussion syndrome management is time. Recovery from PCS can be a long and slow process that is often frustrating for patients and removes them their normal activities, including school and sports. [15]  Management is ideally done by a multi-disciplinary team of concussion specialists. [15,16] 

Reassurance, discussion of expected recovery time, and compensatory strategies to address difficulties with aspects of cognition, such as attention, memory, and executive functioning can improve symptoms of PCS, according to a recent meta-analysis of the literature. [10]  While psychological intervention was found in one study to reduce PCS symptoms at 3 to 6 months after injury, [11] a recent systematic review of psychological intervention for PCS concluded that there was limited evidence of benefit. [10,12]  An information booklet on strategies for dealing with posttraumatic symptoms in children resulted in fewer symptoms and less behavioral changes in children 3 months after injury. [10,13]

Neurocognitive rehabilitation

Noting studies showing the successful use of modified forms of cognitive behavioral therapy in adults with chronic symptoms and problems following mTBI, and a "large and mature literature" showing the effectiveness of psychological treatments in reducing symptoms and improving functioning in adults with depression and generalized anxiety disorder, and the use of behavioral and psychological treatments in improving sleep and reducing psychological distress in people with insomnia, a 2013 study [9] found it "plausible that psychological treatment for athletes who are slow to recover may be of benefit and should be studied more systematically." 

Interventions to improve cognition have improved performance on selected neuropsychological test scores and cognitive function following neurocognitive rehabilitation in patients with mild- or mild-to-moderate-TBI.  Neurocognitive rehabilitation uses cognitive tasks to improve cognitive processes, or it may involve developing compensatory strategies to address difficulties with aspects of cognition, such as attention, memory, and executive functioning. [10](citing studies)

Cognitive rest

While cognitive and physical rest is often prescribed for concussed athletes in the period immediately after injury, the conventional wisdom among clinicians has been that such rest is of limited use for patients with post-concussion syndrome. 

That belief, however, has been brought into question.  In a study of concussed high school students reported in the Journal of Pediatrics [1] researchers, led by MomsTeam concussion expert neuropsychologist Rosemarie Scolaro Moser, Ph D, found that not only did concussed athletes score significantly better on neurocognitive tests and report statistically significant decreases in the number and severity of post-concussion symptoms after a week of strict cognitive and physical rest, but that the beneficial effects of such rest were seen whether such rest came soon after a concussion or weeks to months later.

Indeed, more than a quarter of the sample which continued to experience concussion symptoms past the 31-day mark (defined by some as the point at which post-concussion syndrome is diagnosed) still demonstrated improvements with prescribed rest which were comparable to those experienced by concussed athletes in the study who were still in the early stages of concussion.

"Our results represent the first data documenting the efficacy of prescribed rest for the treatment of post-concussion symptoms and cognitive dysfunction, whether the rest is applied in the early or prolonged stages of recovery," Dr. Moser notes. The idea that cognitive and physical rest may help improve the condition of patients with post-concussion syndrome is [also] noteworthy," she writes, because "there may be a perception among clinicians that once the 7- to 10-day time period in which the neurometabolic "cascade" (2) has passed, and a patient continues to experience concussive symptoms, cognitive and physical rest is of limited use."

That recent research suggests that blood flow to the brain was still reduced in more than a third of 11- to 15-year-olds even at 1 month or more post-concussion, Dr. Moser argues, not only "supports an even longer recovery period than typically thought but is consistent with the notion that a period of rest may be therapeutic" in treating post-concussion syndrome.

It is signficant to note that Dr. Moser's study involved 1 week of rest.  Prolonged rest, especially in athletes, however, can lead to physical deconditioning, metabolic disturbances, anxiety and stress, irritability, fatigue and mild depression. [9,10]  There is no scientific evidence that prolonged rest for more than several weeks in concussed patients is beneficial. [10]   In the absence of good scientific evidence, doctors must decide when to transition an athlete from activity restrictions and watchful waiting to more active treatment and rehabilitation, including exercise (see below). [9]

 

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