Medical Therapies in Concussion

Study Title: Medical Therapies for Concussion
Authors: W. Meehan
Journal: Clinics in Sports Medicine
Date: 2011

Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this "traumatic brain injury", particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an "invisible injury", Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan's first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline - his preferred treatment) as well as the potential negative effects ("rebound") of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan's academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.