emerging treatments in concussion management

emerging treatment in concussion management

case presentation

A healthy 15 year old male presents to your clinic one week after an injury during soccer.  He jumped up to head the soccer ball and collided heads with another player.  He did not lose consciousness and attempted to stay in the game.  He was pulled out and evaluated by the athletic trainer.  He was sent for further evaluation for a possible sports related concussion.  He has not vomited and overall reports mild fogginess, loss of concentration and mild headache.  Which of the following is the most correct statement in regards to concussion management?

A. He needs further imaging including a CT scan
B. He should rest completely for two weeks
C. He would benefit from a through balance, neurologic, vestibular and visual system examination
D. He can progress into non-contact practice in the next week

introduction

Mild traumatic brain injury (mTBI), which includes sport-related concussion (SRC), is a significant public health problem with no proven effective intervention. Up to 30% of children and adolescents remain symptomatic 1 month after injury [1].  There remains significant public concern due to the nature of the injury and the recent football season that saw widespread images and clips of Tua Tagovailoa’s injury during the NFL season.

According to data released by the NFL, there were 149 concussions suffered over 271 games this season. That’s an 18% jump from 2021 (126) and 14% higher than the three-year average (130) between 2018 and 2020.  It was also reported that there were 1.6 concussion evaluations per game, which is higher than recent years. [2]

There was also new data from the NFL over the past two to three years for concussions suffered in preseason and practice.  The Guardian Caps were introduced to certain position groups and a 52 percent reduction was shown in 2022 when compared to the same time period in 2021 [2]. 

Tua Concussion sideline on stretcher

Image 1: Tua Tagovailoa being carted off the field

Overall, players suffered a total of 52 concussions from the start of training camp to the beginning of the regular season. The combined total of 213 preseason and regular season concussions was 14% higher than 2021 but within range of the three-year average from 2018 to 2020 (203).

Further attempts are being made to classify concussion into subtypes.  These include the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance).  One review reported the most prevalent concussion subtypes for pediatric and adult populations were headache/migraine and cognitive. In pediatric patients, the reported prevalence of the vestibular subtype was also high.  Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls [7].

Further studies are also supporting the importance of visual and vestibular therapies after concussion depending on the examination and symptoms of the patient, as previously discussed.  More in-depth data and exam techniques are becoming more known and widespread to further classify these issues [8].  Another review reported individually tailored multimodal interventions have a worthwhile effect in providing faster return to sport and clinical improvement, specifically in those with persistent symptoms [9].  This paired patients with cervical, oculomotor or vestibular therapy depending on their subtype. 

The role of salivary small non-coding RNAs (sncRNAs) in the diagnosis of sport-related concussion was also evaluated in England.  One thousand twenty eight players were assessed in game, post game and 36-48 hours post game.  One hundred and six players were diagnosed with a sports related concussion and a panel of 14 sncRNAs were shown to differentiate concussed subjects from control subjects during the time periods.  High predictive accuracy was conserved and this was dubbed the “SCRUM” study.  More trials will be needed to further evaluate this diagnostic tool [10].

Studies continue to support subthreshold aerobic activity with treadmill and biking. In a recent large observational study [3], pediatric patients who reported engaging in moderate levels of physical activity within 7 days of injury had a significant reduction in the rate of delayed recovery compared with those who reported no physical activity. The prevention of delayed recovery is very important because of the negative influence of persistent symptoms on academic and social functioning in adolescents [4]. Another randomized trial with 103 adolescents showed individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery [5]. 

Despite the incidence of concussion among children and adolescents, identifying young people at risk of ongoing difficulties after concussion remains a prominent challenge in the field.  Mental health has also been studied with adolescents and seems to be a contributing factor to prolonged recovery.  A recent systematic review also reported children with concussion (total 6,819 patients) experienced significantly higher levels of internalizing, externalizing and overall mental health difficulties compared with controls (total 56, 271) with effects decreasing over time [6].

Vision evaluation concussion

Figure 2.  Visual and vestibular system evaluation for suspected concussion.  Adopted from [6].

Another recent review was performed for treatment for PPCS (persistent post concussive symptoms) and reported that cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PPCS. There is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. It encouraged clinicians to propose a tailored treatment to patients according to the type and severity of PPCS and could encourage further research with larger groups [11].

Hyperbaric oxygen therapy (HBOT) has been researched as a treatment method for PCCS. HBOT involves a chamber that is slowly pressurized to 1.5–3 times higher than normal air pressure with pure oxygen [15].  One recent randomized trial evaluated twenty-five children were randomized to receive 60 daily sessions of HBOT (n = 15) or sham (n = 10) treatments. The study was performed on children (age 8–15) suffering from PPCS from mild-moderate TBI events six months to 10 years prior.  Following HBOT, there was a significant increase in cognitive function including the general cognitive score, memory, and executive function.  There were also decreased PPCS symptoms including emotional score, behavioral symptoms including hyperactivity, global executive composite score, planning/organizing score. Clinical outcomes correlated with significant improvements in brain MRI microstructural changes in the insula, supramarginal, lingual, inferior frontal and fusiform gyri. The study suggested that HBOT improves both cognitive and behavioral function, PPCS symptoms, and quality of life in pediatric PPCS patients at the chronic stage, even years after injury. Additional data is needed to optimize the protocol and to characterize the children who can benefit the most [15].

Hyperbaric O2 in concussion

Figure 3.  Example of hyperbaric oxygen chamber .  Adopted form [17].

Acute concussion and persistent post concussive symptoms can result in autonomic dysfunction in heart rate variability (HRV), but less information is available on blood pressure variability (BPV).  One case series with four female patients evaluated the HRV and BPV after daily administration of CBD or a combination of CBD and THC.  High frequency systolic BPV parameters increased every assessment period, unless altered due to external circumstances and symptoms [13].

Otherwise there have been limited studies in regards to pharmacologic management of concussion recently.  Anti-Calcitonin Gene-Related Peptide monoclonal antibodies (anti-CGRP mAbs), fremanezumab, galcanezumab, and erenumab, was evaluated in 168 concussion patients with post-traumatic headache (PTH) with a migraine phenotype .  Patients experienced less symptoms when measured at 3 months of treatment and had fewer headache days per month.  It was also shown to improve headache severity and frequency [14].

One recent single blind trial also evaluated the effects of osteopathic manipulative medicine (or OMT) on new onset impairments following concussion.  This involved twenty patients and utilized impact scores and two OMM treatments.  Visual memory and reatction time following concussion significantly improved in the OMM group compared to the education group [16]. 

Non pharmacologic concussion evidence

Image 4: Table reviewing recent non-pharmacologic options for concussion management.  Adopted from [12].

Summary

In conclusion, the prevalence of mTBIs and the lack of evidence-based treatments is a growing public health concern.  There remains a large amount of treatment and practices that are in need of further research in all areas of concussion diagnosis and management.  A multifaceted approach that involves physical activity has been emerging as a staple of treatment.  One randomized trial has shown promise with hyperbaric oxygen therapy in children with persistent post concussive symptoms.  It is important for sports medicine providers to continue to follow along and provide the most up to date evidence-based care.

CASE CONCLUSION

C.  Concussion diagnosis and management continues to evolve.  More recent studies have shown that complete rest is unlikely beneficial after 48 hours.  Imaging with a CT scan is usually not required for mild symptoms after one week.  His return would be guided by a thorough evaluation and physical examination and this would help to prescribe any needed cervical, vestibular or vision therapy.  The patient may be able to progress into a graded return to play, but this would start in a progression and would not be judged by time.

Kohler’s disease is another term for avascular necrosis of the navicular bone and is seen almost exclusively in pediatric patients.  It would also present with pain over the midfoot most likely.

References

  1. Zemek  R, Barrowman  N, Freedman  SB,  et al; Pediatric Emergency Research Canada (PERC) Concussion Team.  Clinical Risk score for persistent postconcussion symptoms among children with acute concussion in the ED.  JAMA. 2016;315(10):1014-1025
  2. https://www.espn.com/nfl/story/_/id/35582897/nfl-says-regular-season-concussions-increased-18-2022
  3. Grool  AM, Aglipay  M, Momoli  F,  et al; Pediatric Emergency Research Canada (PERC) Concussion Team.  Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents.  JAMA. 2016;316(23):2504-2514.
  4. Iverson  GL, Gioia  GA.  Returning to school following sport-related concussion.  Phys Med Rehabil Clin N Am. 2016;27(2):429-436.
  5. Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319–325. doi:10.1001/jamapediatrics.2018.4397
  6. Gornall A, Takagi M, Morawakage T, et alMental health after paediatric concussion: a systematic review and meta-analysisBritish Journal of Sports Medicine 2021;55:1048-1058.
  7. Lumba-Brown A, Ghajar J, Cornwell J, et al. . Representation of concussion subtypes in common postconcussion symptom-rating scales. Concussion 2019;4:CNC65. 10.2217/cnc-2019-0005 
  8. Master, Christina L., et al. “Vision and concussion: symptoms, signs, evaluation, and treatment.” Pediatrics 150.2 (2022).
  9. Reid, Susan A., Joshua Farbenblum, and Shreya McLeod. “Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis?.” British journal of sports medicine 56.5 (2022): 292-298.
  10. Di Pietro V, O’Halloran P, Watson CN, et alUnique diagnostic signatures of concussion in the saliva of male athletes: the Study of Concussion in Rugby Union through MicroRNAs (SCRUM)British Journal of Sports Medicine 2021;55:1395-1404.
  11. Galeno, E.; Pullano, E.; Mourad, F.; Galeoto, G.; Frontani, F. Effectiveness of Vestibular Rehabilitation after Concussion: A Systematic Review of Randomised Controlled Trial. Healthcare 2023, 11, 90.
  12. Lee, M.J.; Zhou, Y.; Greenwald, B.D. Update on Non-Pharmacological Interventions for Treatment of Post-Traumatic Headache. Brain Sci. 2022, 12, 1357.
  13. Singh, Jyotpal, et al. “Effects of phytocannabinoids on heart rate variability and blood pressure variability in female post-concussion syndrome patients: case series.” Canadian Journal of Physiology and Pharmacology 100.2 (2022): 192-196.
  14. Jennifer McVige, Megan Rooney, Dylan Lis.  Neurology Jan 2022, 98 (1 Supplement 1) S9;
  15. Hadanny, A., Catalogna, M., Yaniv, S. et al. Hyperbaric oxygen therapy in children with post-concussion syndrome improves cognitive and behavioral function: a randomized controlled trial. Sci Rep 12, 15233 (2022). https://doi.org/10.1038/s41598-022-19395-y
  16. Mancini, Jayme D., Angelo, Nicole, Abu-Sbaih, Reem, Kooyman, Patricia and Yao, Sheldon. “Concussion-related visual memory and reaction time impairment in college athletes improved after osteopathic manipulative medicine: a randomized clinical trial” Journal of Osteopathic Medicine, vol. 123, no. 1, 2023, pp. 31-38.
  17. https://www.medscape.com/viewarticle/982816