How do you best manage delayed recovery from concussion?

From the Guidelines

Managing delayed recovery from concussion requires a comprehensive approach that prioritizes nonpharmacological interventions, including early information and advice, graded physical exercise, vestibular rehabilitation, and psychological treatment, as these have been shown to be effective in reducing persistent postconcussion symptoms. According to the systematic review and meta-analysis published in JAMA Network Open in 2021 1, nonpharmacological interventions are recommended for the treatment of persistent postconcussion symptoms in adults. The guideline recommends the following interventions:

• Early information and advice to patients and their families about the nature of concussion and the expected course of recovery
• Graded physical exercise to improve physical function and reduce symptoms
• Vestibular rehabilitation to address balance problems and dizziness
• Psychological treatment, such as cognitive behavioral therapy, to address emotional and behavioral symptoms
• Interdisciplinary coordinated rehabilitative treatment to address the complex needs of patients with persistent postconcussion symptoms

It is essential to note that each patient's recovery process is unique, and treatment should be tailored to their specific needs and symptoms. Regular follow-ups with healthcare providers are crucial to monitor progress and adjust treatment as needed. Additionally, maintaining proper nutrition and hydration, and avoiding alcohol and recreational drugs, which can worsen symptoms and delay recovery, are also important aspects of managing delayed recovery from concussion.

The American Academy of Pediatrics also recommends cognitive rest during the acute phase of concussion, which may include a temporary leave of absence from school, shortening of the school day, reduction of workloads, and allowance of more time to complete assignments or take tests 1. However, the most recent and highest-quality study 1 prioritizes nonpharmacological interventions over cognitive rest alone, emphasizing the importance of a comprehensive approach to managing delayed recovery from concussion.

In terms of specific treatments, the guideline recommends considering the following:

• For headaches, acetaminophen (500-1000mg every 6 hours as needed) is preferable to NSAIDs
• For sleep disturbances, practicing good sleep hygiene and considering short-term melatonin (3-5mg before bedtime) may be helpful
• For mood issues like anxiety or depression, cognitive behavioral therapy may be beneficial before considering medication
• Physical therapy focusing on vestibular rehabilitation can address balance problems and dizziness, while vision therapy may help with visual disturbances.

From the Research

Management of Delayed Recovery from Concussion

Delayed recovery from concussion can be managed through various approaches, including:

• Identifying underlying symptom generators and treating them accordingly 2, 3
• Using a multidisciplinary approach to clinical management, involving specialists from sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care 3
• Implementing individualized treatment plans based on predominant signs and symptoms, which can include:
  • Sub-symptom threshold aerobic exercise
  • Cervical physical therapy
  • Vestibulo-ocular rehabilitation
  • Behavioral and cognitive psychotherapy
  • Symptom-specific pharmacological therapies 2, 3

Importance of Early Evaluation and Management

Early evaluation and management of concussion are crucial in promoting better recovery and reducing persisting concussion symptoms:

• Delayed clinical evaluation (≥ 30 days post-injury) has been associated with a greater number and severity of concussion symptoms, as well as greater aggravation of symptoms from physical and cognitive activity at three-month follow-up 4
• Education to improve adults' recognition of concussions and obtaining earlier clinical evaluation may represent important opportunities in promoting better recovery and reducing persisting concussion symptoms 4

Treatment Options for Concussion and Persistent Post-Concussive Symptoms

Treatment options for concussion and persistent post-concussive symptoms (PPCS) include:

• Sub-symptom threshold aerobic exercise
• Cervical physical therapy
• Vestibular therapy
• Vision therapy
• Cognitive rehabilitation
• Cognitive behavioral therapy
• Pharmacological management, or a combination of these treatments 2
• Symptomatic treatment, such as management of headaches, dizziness, sleep disturbance, psychiatric symptoms, and cognitive issues 5, 6