January 31, 2020
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BLOG: Bad advice may hamper concussion recovery

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Anthony P. Kontos, PhD
Anthony P. Kontos

by Anthony P. Kontos, PhD

Patients often see a pediatrician or emergency department physician first after a concussion and are usually sent home with the following advice: take an immediate break from physical and cognitive activity (ie, rest completely) and/or gradually ease back into normal activity as symptoms tolerate and seek further care if symptoms persist or worsen.

Our recent findings suggest that this approach, which reflects current consensus, may need to also include advice to seek early care from a concussion specialty clinic. At the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program, we have spent the last 20 years developing and evolving an evidence-based model for concussion care. Our approach is predicated on a clinical profiles model based on a comprehensive assessment and clinical evaluation involving a multidisciplinary team and targeted, active treatments that provide precision care for each patient and each injury.

Immediate care is critical

We believe that people should seek specialty care from a licensed clinician who is trained to evaluate the injury and various domains of concussion symptoms and impairments (vestibular, ocular/vision, cognitive, anxiety/mood, migraine and other factors) as early as possible. Simple strategies like managing sleep and stress, proper hydration and nutrition, and physical activity can help accelerate the pathway to recovery for many patients. In addition, earlier appropriate therapies – such as vestibular or oculomotor therapy – that target specific symptoms and impairments can enhance a patient’s recovery from concussion.

My colleagues and I recently analyzed outcomes for 162 teen and young adult athletes (ages 12 to 22 years) who were diagnosed with a concussion and for whom we had documented full recovery. We found that athletes who sought care within the first week of injury recovered faster than those who sought care later (8 to 21 days) after the injury. Most of the difference between the early and late groups was due to the initial delay, not to injury severity, which was similar between the groups.

We also know that prescribed rest, which has been the predominant therapy for concussed patients, is not necessarily the best approach. In fact, the latest research has shown that patients who are active earlier in the recovery process actually recover sooner than those who rest for prolonged periods (Sufrinko et al., Leddy et al., Thomas et al.). Therefore, physical activity is one of the key components in our approach to treating patients.

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Gender and vision

Although some research suggests that girls and women have worse outcomes after concussion, we found no significant gender-based differences in recovery time in our study. Interestingly, Christina Master, MD, and colleagues recently reported that female athletes took longer to recover from a concussion than males, but also that the female athletes sought specialty medical treatment much later than their male counterparts (Desai et al.). However, the gender differences disappeared when controlling for time to presentation to specialty care, which is consistent with our findings.

Another factor in our study that was associated with longer recovery was an elevated visual motion sensitivity (VMS) score on the Vestibular Ocular Motor Screening (VOMS) tool. We developed and published this 5-minute screening tool that clinicians can use to assess vestibular and oculomotor function post-concussion (Mucha et al.). VOMS includes brief assessments of smooth pursuits, saccades, nearpoint convergence, VMS and vestibular-ocular reflex (VOR). In general, VOR and VMS tend to be strong predictors of longer recovery time.

A comprehensive assessment of a patient’s history and current injury that comes with seeking early specialty care can make a huge difference for patients after a concussion. The earlier patients are evaluated and receive appropriate targeted treatment — including vestibular and vision therapy as indicated — the better it is for their recovery.

References:

Desai N, et al. Clin J Sport Med. 2019;doi:10.1097/JSM.0000000000000646.

Kontos AP, et al. JAMA Neurol. 2020;doi:10.1001/jamaneurol.2019.4552.

Leddy JJ, et al. JAMA Pediatr. 2019;doi:10.1001/jamapediatrics.

Mucha A, et al. Am J Sports Med. 2014;doi:10.1177/0363546514543775.

Sufrinko AM, et al. J Pediatr. 2017;doi:10.1016/j.jpeds.2017.02.072.

Thomas DG, et al. Pediatrics. 2015;doi:10.1542/peds.2014-0966.

For more information:

Anthony P. Kontos, PhD, is research director of the Sports Medicine Concussion Program and

associate professor in the Department of Orthopaedic Surgery at the University of Pittsburgh Medical Center in Pittsburgh, Pa. Kontos’ research in sports-related concussion includes psychological issues, neurocognitive and neuro-motor effects, and concussion in youth and underrepresented groups. He has more than 300 professional publications, and his research is currently funded by the CDC, Department of Defense, National Collegiate Athletic Association, National Football League and NIH. He is also the lead author of the book, Concussion: A Clinical Profile Approach to Assessment and Treatment.

Disclosure: Kontos receives funding for research at the University of Pittsburgh from the National Football League.

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Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.