Experts provide tips on diagnosing, treating concussions

Robert Franks
Robert Franks

A prompt diagnosis is critical when encountering a patient who might have a concussion, a sports medicine doctor who specializes in sports-related concussion management told Healio Family Medicine.

“Timing is everything,” Robert Franks, DO, FAOASM, director, Rothman Institute Concussion Program in Philadelphia said. “We need to get these patients into treatment as quickly as possible.”

“The most important thing in concussion management is the correct diagnosis and then proper early treatment,” agreed Joseph C. Maroon, MD, co-creator of the ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) used by many professional sports organizations, and professor of neurological surgery at the University of Pittsburgh Medical Center.

Joe Maroon
Joseph C. Maroon

The Brain Injury Research Institute estimates between 1.6 million and 3.8 million recreation- and sports-related concussions occur annually in the United States, but Franks said many more may occur.

“Not only are concussions underreported in primary care, they are underrecognized,” Franks said.

Healio Family Medicine recently spoke to several retired professional athletes whose careers were affected by concussions. A former previous NHL player, All-Star Keith Primeau suggested primary care physicians may need to educate themselves more on concussions as they affect more children and school-age athletes.

To help primary care physicians make accurate, timely diagnoses of concussions, Healio Family Medicine asked neurological, orthopedic, sports medicine and psychiatry experts to provide information on concussion symptoms, treatments, broaching the subject with patients, and more. – by Janel Miller

Question: What are the symptoms of concussions?

Jennifer M. Coughlin MD, assistant professor, department of psychiatry and behavioral sciences, Johns Hopkins Medicine:

Jennifer Coughlin
Jennifer M. Coughlin

Cognitive symptoms can include disorientation, confusion, impaired concentration, and sometimes loss of consciousness. Mood-related symptoms might include irritability, anxiety, mood lability, or altered sleep. Concussed athletes can also have physical pain such as headache, or onset of uncoordinated movements. While a physician can attribute readily the symptoms to the concussion if the onset is related temporally, it is not uncommon for players to have repeated hits, some even subconcussive, which may blur the temporal relationship between onset of symptoms and injury. In the case of mood-related symptoms, physicians can often gain clues to rule out independent psychiatric illness such as major depressive disorder by careful history taking and mental status exam. The symptoms usually abate within 7 to 10 days in adults, but can persist longer in children or adolescents.

Q: Could a concussion be mistaken for something else?

Maroon: The migraine, dizziness or unsteadiness that can occur following a traumatic episode such as a concussion may be confused with a middle ear or balance problem when actually it is an interference with function of the vestibular ocular system. To help distinguish between these conditions, note that a concussion is not usually associated with true vertigo or feelings of spinning around as one experiences with a middle ear disturbance or trauma. Other components of a concussion such as memory impairment and forgetfulness are not usually associated with an inner ear problem.

Q: How can a PCP ascertain if a patient has had a concussion?

Joseph D. Smucker, MD , orthopedic spine surgeon, Indiana Spine Group:

Joseph Smucker
Joseph D. Smucker

More often than not, the person with the concussion or sports-related injury will have problems with their short-term memory, despite being neurologically normal. Asking questions like ‘What field are we playing on?’, ‘What quarter is it?’, ‘How far along in the game are we?’, ‘Who participated in the last scoring play?’ seem to be most sensitive in identifying someone who’s involved in a concussion.

Q: How can PCPs bring up the subject of long-term consequences of concussions with the parents of young children who might want their child to play football ?

Jesse Mez, MD, MS, Alzheimer’s Disease and CTE Center, Boston University:

Jesse Mez
Jesse Mez

Parents should be told there is a relationship between tackle football, and neurodegenerative disease, including CTE, and this relationship does not appear contingent on having a symptomatic concussion while playing. We don’t yet have a good sense of how to quantify the amount of football needed to substantially increase risk, but we have observed CTE in those with as little as high school football. In light of the relationship between football and CTE , it’s important to advise caution to parents. There are benefits to playing football, such as better cardiovascular health and the relationships children will build through team sports, but there are other ways to achieve those same benefits without the child hitting their head repeatedly.

Q: How can PCP s broach the subject of concussions with current athletes?

Franks: Try and get them to see that it could impact their long-term health. Everyone has heard of CTE, and has heard of the long-term implications of concussions, so we worry about the long-term health of their brain. I personally tell my patients letting me know when the concussion first happens improved their chances for treatment, and likely significantly lessens the amount of time he or she is out of the game.

Q: What are treatment options?

Franks: It depends on the type of symptoms a patient is encountering. If it’s neck pain, we can do physical therapy. If it’s balance and coordination, we’ll use vestibular therapy. Vision problems can be treated with a specific kind of glasses or prisms to help with vision as well as vision therapy. With cognition, we put school accommodations in place to help with the learning or processing of information as well as use certain therapies. With sleep we can use melatonin to induce sleep and try to reset the sleep-wake cycle in part, by trying to keep the patient from sleeping during the day. Within 7 to 10 days, our patients are anxious about perhaps getting behind in school so we really try to treat the social and emotional symptoms right away because once the symptoms from stress start to show significantly, it’s much more difficult to get them symptom free.

Johnson: It is very important for those suffering with severe symptoms to know that many people benefit from available psychiatric or neurological treatments.

Q: How has the treatment of concussions evolved over time?

Franks: We’re transitioning away from is ‘rest is best.’ For so long, concussion treatment involved taking away the electronics, keeping the patient home from school, and preventing them from leaving home. Newer research shows that isn’t always best.. The most recent version of the Berlin Consensus Statement from the Concussion in Sport Group found if you can use a cell phone, that’s your gateway back into school because it’s part of the daily living process at this point. We are also finding that students with structure and accommodation in their normal routine are doing better than those who stay at home. We are finding that we are more successfully dealing with anxiety and depression by keeping them in their normal activity and that noncontact exercise has been proven beneficial to mitigate those stressors while they are in recovery. When considering treatment, creating a managed recovery program that deals with both academics as well as physicality is important in managing these patients.

Q: Can you explain what a PCP needs to consider when deciding if an athlete can return to play?

Maroon: There are three criteria for determining return to play: 1, the complete absence of all symptoms related to a concussion; 2, the ability to exercise fully under aerobic stress conditions; and 3, return to baseline on neurocognitive tests.

Franks: They must be symptom free and they cannot be on any medicines that control the symptoms. The patient must be able to do 2 to 3 days of school without any academic accommodation, and cognitive and neurological testing results must be at baseline. Then they must do five steps of challenging physical activity, which is meant to bring out concussion symptoms; they need to do that successfully without returning to concussion symptoms. The final step is a full practice. We call this the ‘Return to Play’ protocol. Policies regarding concussions in the player’s school and state must also be considered.

Q: What are some concussion assessment tools you can recommend to PCPs ?

Maroon: The ImPACT is used by the National Football League, National Hockey League, Major League Baseball and 12,000 high schools, and can also be used in pediatrics. This 25-minute online test is not a diagnostic tool and can be taken at both baseline and post-concussion to gauge working memory, attention span, nonverbal problem solving, reaction time, sustained and selective attention time. ImPACT also registers current severity of almost two dozen concussion symptoms by using a seven-point Likert scale and may be administered multiple times after a concussion diagnosis to assist in quantifying rehabilitation progress and whether an injured person can return to activity.

Smucker: One test that may be used by medical professionals, including PCPs, is the Sport Concussion Assessment Tool, currently in its 5th edition (SCAT5).

Franks: The CDC lists several tools on its website that a PCP can use.

Q: What should PCPs know when evaluating their older patients whose contact-sport playing days may be over, but who are having new cognitive complaints?

Mez: If PCPs have older patients who are experiencing cognitive difficulties, one of the things they should be assessing is their contact sports history and their traumatic brain injury history. If either of these two items is substantial, such as college football play, then CTE should be on the differential diagnosis, even though we don’t currently have clear clinical criteria for diagnosis. Our experience is that CTE can appear clinically very similar to Alzheimer’s disease. In this setting, additional work-up like a lumbar puncture or amyloid PET scan might be warranted to help distinguish the underlying pathology. We don’t know yet how Alzheimer’s drugs like donepezil and memantine impact people with CTE, so it might mean being a little more cautious in prescribing those medications.

Q: When should concussion care move beyond the primary care physicians’ office?
Franks: If a PCP is not certain where to go with a patient regarding treatment or are finding they are not getting any better, refer the patient as quickly as possible to a specialist so they can get into the appropriate treatment.

Disclosure: Maroon reports being a shareholder and founding member of ImPACT Applications. Neither Coughlin, Franks, Mez nor Smucker report any relevant financial disclosures.

Robert Franks
Robert Franks

A prompt diagnosis is critical when encountering a patient who might have a concussion, a sports medicine doctor who specializes in sports-related concussion management told Healio Family Medicine.

“Timing is everything,” Robert Franks, DO, FAOASM, director, Rothman Institute Concussion Program in Philadelphia said. “We need to get these patients into treatment as quickly as possible.”

“The most important thing in concussion management is the correct diagnosis and then proper early treatment,” agreed Joseph C. Maroon, MD, co-creator of the ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) used by many professional sports organizations, and professor of neurological surgery at the University of Pittsburgh Medical Center.

Joe Maroon
Joseph C. Maroon

The Brain Injury Research Institute estimates between 1.6 million and 3.8 million recreation- and sports-related concussions occur annually in the United States, but Franks said many more may occur.

“Not only are concussions underreported in primary care, they are underrecognized,” Franks said.

Healio Family Medicine recently spoke to several retired professional athletes whose careers were affected by concussions. A former previous NHL player, All-Star Keith Primeau suggested primary care physicians may need to educate themselves more on concussions as they affect more children and school-age athletes.

To help primary care physicians make accurate, timely diagnoses of concussions, Healio Family Medicine asked neurological, orthopedic, sports medicine and psychiatry experts to provide information on concussion symptoms, treatments, broaching the subject with patients, and more. – by Janel Miller

Question: What are the symptoms of concussions?

Jennifer M. Coughlin MD, assistant professor, department of psychiatry and behavioral sciences, Johns Hopkins Medicine:

Jennifer Coughlin
Jennifer M. Coughlin

Cognitive symptoms can include disorientation, confusion, impaired concentration, and sometimes loss of consciousness. Mood-related symptoms might include irritability, anxiety, mood lability, or altered sleep. Concussed athletes can also have physical pain such as headache, or onset of uncoordinated movements. While a physician can attribute readily the symptoms to the concussion if the onset is related temporally, it is not uncommon for players to have repeated hits, some even subconcussive, which may blur the temporal relationship between onset of symptoms and injury. In the case of mood-related symptoms, physicians can often gain clues to rule out independent psychiatric illness such as major depressive disorder by careful history taking and mental status exam. The symptoms usually abate within 7 to 10 days in adults, but can persist longer in children or adolescents.

PAGE BREAK

Q: Could a concussion be mistaken for something else?

Maroon: The migraine, dizziness or unsteadiness that can occur following a traumatic episode such as a concussion may be confused with a middle ear or balance problem when actually it is an interference with function of the vestibular ocular system. To help distinguish between these conditions, note that a concussion is not usually associated with true vertigo or feelings of spinning around as one experiences with a middle ear disturbance or trauma. Other components of a concussion such as memory impairment and forgetfulness are not usually associated with an inner ear problem.

Q: How can a PCP ascertain if a patient has had a concussion?

Joseph D. Smucker, MD , orthopedic spine surgeon, Indiana Spine Group:

Joseph Smucker
Joseph D. Smucker

More often than not, the person with the concussion or sports-related injury will have problems with their short-term memory, despite being neurologically normal. Asking questions like ‘What field are we playing on?’, ‘What quarter is it?’, ‘How far along in the game are we?’, ‘Who participated in the last scoring play?’ seem to be most sensitive in identifying someone who’s involved in a concussion.

Q: How can PCPs bring up the subject of long-term consequences of concussions with the parents of young children who might want their child to play football ?

Jesse Mez, MD, MS, Alzheimer’s Disease and CTE Center, Boston University:

Jesse Mez
Jesse Mez

Parents should be told there is a relationship between tackle football, and neurodegenerative disease, including CTE, and this relationship does not appear contingent on having a symptomatic concussion while playing. We don’t yet have a good sense of how to quantify the amount of football needed to substantially increase risk, but we have observed CTE in those with as little as high school football. In light of the relationship between football and CTE , it’s important to advise caution to parents. There are benefits to playing football, such as better cardiovascular health and the relationships children will build through team sports, but there are other ways to achieve those same benefits without the child hitting their head repeatedly.

Q: How can PCP s broach the subject of concussions with current athletes?

Franks: Try and get them to see that it could impact their long-term health. Everyone has heard of CTE, and has heard of the long-term implications of concussions, so we worry about the long-term health of their brain. I personally tell my patients letting me know when the concussion first happens improved their chances for treatment, and likely significantly lessens the amount of time he or she is out of the game.

PAGE BREAK

Q: What are treatment options?

Franks: It depends on the type of symptoms a patient is encountering. If it’s neck pain, we can do physical therapy. If it’s balance and coordination, we’ll use vestibular therapy. Vision problems can be treated with a specific kind of glasses or prisms to help with vision as well as vision therapy. With cognition, we put school accommodations in place to help with the learning or processing of information as well as use certain therapies. With sleep we can use melatonin to induce sleep and try to reset the sleep-wake cycle in part, by trying to keep the patient from sleeping during the day. Within 7 to 10 days, our patients are anxious about perhaps getting behind in school so we really try to treat the social and emotional symptoms right away because once the symptoms from stress start to show significantly, it’s much more difficult to get them symptom free.

Johnson: It is very important for those suffering with severe symptoms to know that many people benefit from available psychiatric or neurological treatments.

Q: How has the treatment of concussions evolved over time?

Franks: We’re transitioning away from is ‘rest is best.’ For so long, concussion treatment involved taking away the electronics, keeping the patient home from school, and preventing them from leaving home. Newer research shows that isn’t always best.. The most recent version of the Berlin Consensus Statement from the Concussion in Sport Group found if you can use a cell phone, that’s your gateway back into school because it’s part of the daily living process at this point. We are also finding that students with structure and accommodation in their normal routine are doing better than those who stay at home. We are finding that we are more successfully dealing with anxiety and depression by keeping them in their normal activity and that noncontact exercise has been proven beneficial to mitigate those stressors while they are in recovery. When considering treatment, creating a managed recovery program that deals with both academics as well as physicality is important in managing these patients.

Q: Can you explain what a PCP needs to consider when deciding if an athlete can return to play?

Maroon: There are three criteria for determining return to play: 1, the complete absence of all symptoms related to a concussion; 2, the ability to exercise fully under aerobic stress conditions; and 3, return to baseline on neurocognitive tests.

PAGE BREAK

Franks: They must be symptom free and they cannot be on any medicines that control the symptoms. The patient must be able to do 2 to 3 days of school without any academic accommodation, and cognitive and neurological testing results must be at baseline. Then they must do five steps of challenging physical activity, which is meant to bring out concussion symptoms; they need to do that successfully without returning to concussion symptoms. The final step is a full practice. We call this the ‘Return to Play’ protocol. Policies regarding concussions in the player’s school and state must also be considered.

Q: What are some concussion assessment tools you can recommend to PCPs ?

Maroon: The ImPACT is used by the National Football League, National Hockey League, Major League Baseball and 12,000 high schools, and can also be used in pediatrics. This 25-minute online test is not a diagnostic tool and can be taken at both baseline and post-concussion to gauge working memory, attention span, nonverbal problem solving, reaction time, sustained and selective attention time. ImPACT also registers current severity of almost two dozen concussion symptoms by using a seven-point Likert scale and may be administered multiple times after a concussion diagnosis to assist in quantifying rehabilitation progress and whether an injured person can return to activity.

Smucker: One test that may be used by medical professionals, including PCPs, is the Sport Concussion Assessment Tool, currently in its 5th edition (SCAT5).

Franks: The CDC lists several tools on its website that a PCP can use.

Q: What should PCPs know when evaluating their older patients whose contact-sport playing days may be over, but who are having new cognitive complaints?

Mez: If PCPs have older patients who are experiencing cognitive difficulties, one of the things they should be assessing is their contact sports history and their traumatic brain injury history. If either of these two items is substantial, such as college football play, then CTE should be on the differential diagnosis, even though we don’t currently have clear clinical criteria for diagnosis. Our experience is that CTE can appear clinically very similar to Alzheimer’s disease. In this setting, additional work-up like a lumbar puncture or amyloid PET scan might be warranted to help distinguish the underlying pathology. We don’t know yet how Alzheimer’s drugs like donepezil and memantine impact people with CTE, so it might mean being a little more cautious in prescribing those medications.

PAGE BREAK

Q: When should concussion care move beyond the primary care physicians’ office?
Franks: If a PCP is not certain where to go with a patient regarding treatment or are finding they are not getting any better, refer the patient as quickly as possible to a specialist so they can get into the appropriate treatment.

Disclosure: Maroon reports being a shareholder and founding member of ImPACT Applications. Neither Coughlin, Franks, Mez nor Smucker report any relevant financial disclosures.