Andrew Howard MD FRCPC (Psychiatry) (biography and disclosures), Tyler Schwaiger MSc (biography and disclosures), Noah Silverberg, PhD (R Psych) (biography and disclosures), Will Panenka MD FRCPC (Neurology and Psychiatry) (biography and disclosures). GF Strong; British Columbia Neuropsychiatry Program; UBC. Disclosures: The authors disclose no financial interest in the academic content of this article.
What care gaps or frequently asked questions I have noticed
Intro
Concussion or mild traumatic brain injury (mTBI) results in acute, transient neurometabolic dysfunction (Shaw, 2002) but typically no structural brain injury detectable with clinical neuroimaging (Barkhoudarian et al., 2016; Stillman et al, 2017). Clinical signs of concussion include a brief loss of consciousness and/or a period of post-traumatic amnesia or confusion. The history, physical exam, and imaging should exclude more concerning etiologies, and a thorough accounting of possible confounds such as substance use, anxiety, neck injury, and other factors should be performed (Holm et al., 2005). A complete clinical recovery within a few weeks to months is the most common outcome, but some patients develop persisting disabling symptoms (McCrea et al., 2009a; Cassidy et al., 2014).
Current management practices
The practice of prescribing complete rest after a concussion may have its origin in early observations that psychological stress, physical exertion, loud noise, and bright lights tended to aggravate the acute symptoms of concussion (Symonds, 1928). The “rest until asymptomatic” approach to concussion management may not have become widespread until it was incorporated into the agreement statement of the First International Conference on Concussion in Sport (Aubry et al., 2002). Rest gained traction as a therapeutic strategy to expedite concussion recovery despite conflictual data from randomized controlled trials (Relander et al., 1972, de Kruijk et al., 2002), and became conflated with the concept of restricting athletes from participation in contact sport to prevent repeat injury (Longhi et al., 2005). Cognitive rest, or restriction from mentally demanding activities, became emphasized as an important component of the rest prescription (McLeod & Gioia, 2010; Arbogast et al., 2013). Expert consensus statements and practice guidelines continued to advise rest after concussion until at least 2013 (McCrory et al., 2005; McCrory et al., 2009; McCrory et al., 2013; Harmon et al., 2013). This advice was echoed in patient education materials (Chrisman et al., 2011). The most current physician surveys available suggest that rest is the most commonly prescribed “treatment” for concussion (Zemek et al., 2015; Lebrun et al., 2013; Stoller et al., 2014).
Knowledge-practice gaps
Physicians since post-World War II have exhorted the negative outcomes of bed rest (Asher, 1947), and its potential inefficacy and harm in treating concussions (Meerloo, 1949; Voris, 1950). In the last 5 years, concussion in sport guidelines shifted away from rest as the “cornerstone of concussion management” (McCrory et al., 2005), and eventually replaced their recommendation of “rest until asymptomatic” in favour of recommending a maximum of 24-48 hours of rest, followed by a gradual and progressive return to cognitive and physical activity, so long as symptoms are not exacerbated. However, the Concussion in Sport Group’s most recently published recommendations concede that further studies are needed to determine “the exact amount and duration of rest” (McCrory et al., 2017). Other recent clinical practice guidelines have similarly moved to encourage early gradual return to activity as tolerated.
Data that answers these gaps
Rest might increase symptoms and recovery time following mTBI (Thomas et al., 2015; Buckley et al., 2015; Moor et al., 2015; Grool et al., 2016). Inactivity has been associated with physical deconditioning and exercise intolerance (Smorawinski et al., 2001; Kozlowski et al., 2013), social isolation, discouragement about recovery, and reactive anxiety and depression (Walters and Williamson, 1999; Craton and Leslie, 2014, Vanderploeg et al., 2014). Post-concussive symptoms can be reversed with graded exercise programs (Leddy et al., 2007; Baker et al., 2012). Early mobilization can reduce post-concussive symptoms (Andreassen et al., 1957), and recovery time (Relander et al., 1972). For patients with persistent symptoms after concussion, interventions that promote increased physical activity may be beneficial (Gagnon et al., 2009). Early cognitive (Brooks et al, 2016) or physical exertion (Leddy et al, 2017) does not seem to raise the risk of prolonged recovery. Wiebe and colleagues (2016) used accelerometers to obtain objective measurements of physical activity following concussion, and found that symptoms inversely correlated with level of physical activity. A secondary analysis of the Thomas et al. clinical trial (Silverberg et al., 2016) found that abrupt increases in mental activity (moreso than physical activity) provoked symptoms but this provocation was typically transient and did not impact cognitive function and balance outcomes.
What we recommend (practice tip)
- Diagnosis. Primary care physicians should consider a differential diagnosis of the sequelae of head and neck trauma (especially in the absence of definite loss of consciousness). Neck pain, headaches, and psychiatric symptoms (e.g. anxiety, depression, pain, and sleep disturbance) require prompt behavioural and pharmacological intervention.
- Education. Advise patients about the common self-resolving symptoms they may experience, and that mild symptom exacerbation is common, transient, and will not prolong recovery. Provide strategies for coping with (tolerating) specific symptoms and exacerbations, teach cognitive-behavioural strategies for attenuating anxiety, and address sleep hygiene. Avoidance of symptoms is not the goal in the short-term. Patients with residual symptoms should aim to gradually increase their participation in valued daily activities. Educating patients about this approach may expedite recovery by reducing or preventing reactive anxiety and depression, and by improving adherence to the established return to activity plan.
- Define rest, and establish a timeline. Vigorous physical activity should be avoided if a patient is experiencing intense acute symptoms but not for more than 48 hours. In the Emergency Department or at an acute clinic visit, individualize a reduction in intensity and frequency of daily activities (physical and cognitive) for a specific amount of time with immediate recommendations to slowly increase exposure/functioning (at the patient’s pace), so that an overwhelming symptom burden is not experienced. Complete rest (or symptom avoidance) for an indefinite amount of time, regardless of symptomatology, should be avoided.
- Negotiate a return to activity plan. Youth should have reintegrated into school before returning to sports. Counsel patients to return to activity in a progressive manner, in such a way that limits a significant exacerbation in symptoms (although some emergent symptoms with increases in functioning and activity should be expected). Those patients who have residual symptoms and are activity intolerant (or phobic) may require a detailed collaborative step-wise plan. Athletes should not resume activities with significant risk of re-injury (e.g. full contact practice) until all symptoms have resolved and they have been cleared by a medical professional.
- Monitor response and adherence to plan. Schedule regular follow-up during the key transition points in the return to activity plan. Assertively treat psychiatric symptoms. Counsel patients to stick to the plan and to maintain proper pacing through their recovery. Patients who do not attempt to return to activity should be evaluated for depression, anxiety, and vestibular dysfunction by specialists as soon as possible.
References:
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Useful article with sensible advice.
Interesting – as an ED physician, I can’t say that anyone in my department prescribes prolonged, strict bed rest – however most of us do still recommend some variation of “rest until asymptomatic”, followed by graduated return to full activity. Are there any studies which have compared, in a prospective fashion, patients who were encouraged to resume activity while still moderately or severely symptomatic, vs those who were required to wait until resting symptoms were minimal? Many of the studies cited above (e.g. Wiebe et al. 2016) did not even enroll patients until 5 or more days post concussion so these data provides no guidance for what to do in the first few days. Others (e.g. Thomas et al. 2015) prescribed at least 1-2 days rest for all enrolled patients, during which time most if not all of them probably became asymptomatic at rest so again no help there. Furthermore, in the Thomas paper the actual amount of activity reported by the subjects was in fact quite similar, with only a couple of days during the study period having a difference which could plausibly be called clinically significant.
Therefore, although there is a strong argument against prolonged bed rest, I don’t see any data which directly show that improved outcomes are achieved by NOT waiting until symptoms have largely abated before beginning to escalate activity intensity – unless I am missing something?
The last question which has not been considered is that many of the citations are from eras before the widespread adoption of smartphones. The effect of screen time on young people WITHOUT traumatic head injuries is dramatically different, and more deleterious, than it was in previous decades, let alone those with traumatize brains. We simply do not have enough information to determine what adverse effect screen time may have on the concussed brain of a young person, and it doesn’t seem unreasonable to err on the side of caution and giving more restrictive advice when it comes to mental rest (particularly from electronic devices) following a head injury.
Thankyou
As a GP
What advice should I give regarding contact sports like Ice Hockey and Rugby?
Dr. Krause:
These are most welcome points as is the opportunity for dialogue about the current epidemic of persistent post-concussive symptoms as we believe there are many reasons for this phenomenon that are not being addressed.
One of the contributors no doubt is misinterpreted advice given acutely although with the best intentions.
There are no studies we are aware of, as you propose, comparing individuals encouraged to resume activity with moderate-severe symptoms vs those advised to resume activity when symptoms are minimal. Many of us however have followed these individuals for months and years and have observed the negative impact of advice given to patients acutely. No harm comes from encouraging individuals with mTBI or closed head injuries to resume activity in a stepwise and gradual fashion (with an expectation that they will have to tolerate brief exacerbations in symptoms); however, we have seen individuals up to a decade after head injury who still avoid symptom exacerbation and remain symptomatic due to the initial advice of “rest until symptoms are minimal.” Perhaps the best approach as an emergency room physician, and only if the diagnosis of mTBI is conclusive, should be rest for the first 24 hours then slowly (and with the expectation of exacerbating symptoms) resume activity in a stepwise fashion (including use of screens) and keep increasing activity regardless of the temporary effect on symptoms. You can confidently assert that this approach does no harm (whereas telling individuals to rest until their symptoms are manageable may well do harm) and may rescue the subset of individuals for whom symptoms begin to dictate function and become chronic.
Dr. O’Brien:
Thanks for this.
Athletes should be encouraged to follow the return to play protocol of the 4th edition of the consensus statement on concussion in sport (if they have conclusive evidence of concussion) at http://bjsm.bmj.com/content/47/5/250.full
For individuals who remain symptomatic and for whom the protocol is having a substantially delayed impact (more than a few weeks), symptomatic exacerbations should be tolerated and increases in activity made in a stepwise fashion regardless of symptoms.
Well reasoned, well laid-out and well supported by the literature cited; in fact, a breath of fresh air for treating physicians in this guideline-rich and anxiety-provoking topic. The acute pain from soft tissue or other injuries, the emotional shock of an unexpected trauma might be expected to contribute to altered sleep, anxiety and stress acutely. Headache, dizziness and other non-specific symptoms such as poor concentration and forgetfulness are common consequences of anxiety and pain. Strong analgesics and muscle relaxants can contribute to early symptoms such as nausea, dizziness and sedation. My clinical experience supports the recommendation that primary care physicians and others seeing the patient acutely should consider the differential diagnosis for such symptoms before diagnosing concussion, especially where there has been no alteration in consciousness.
This approach represents a correction from the big swing from under-recognition of concussion, followed by excessive caution in over diagnosing and managing mild concussions, to a better-reasoned and supported approach, being a more reasoned diagnosis and evidence-supported management of the mild end of the concussion spectrum.
I think the jury is certainly still out on the definitive treatment strategy for this difficult condition. Due to the difficulty of enrolling patients at the earliest onset of symptoms in various studies creating selection variation/bias, variance of definition of severity of symptomology and treatment plans, it would be years before a large enough study could give us better informed answers. If one look far and deep enough, one could also find studies that would support one strategy or another. However, the strategy proposed by Mr. Schwaiger et al could be a practical and reasonable approach.
Dr. Howard: Thanks for your reply. It’s very interesting to hear your perspective on the “epidemic of persistent post-concussive symptoms”. Your comments are reminiscent of the psychological burden that a word such as “whiplash” can confer on a certain subset of patients. I now have a heightened awareness of the nihilism with which some patients may react in the wake of a concussion diagnosis.
Great article. Under your 1st point of diagnosis you mention “headaches, – – – require prompt behavioural and pharmacological intervention” . As a University health physician involved with care of varsity sports teams, the management of postconcussive headache and its impact on academics is a major issue. Two questions I would appreciate your advice on:
1) I sometimes end up using migraine prophylactics such as amitriptyline for postconcussive headache (usually with significant help), but based on dialogue with experts at concussion conferences, I have not initiated this in the 1st 2-3 months following injury. Do you have any advice on utilizing this sooner ?
2) Any opinion on using a pain reliever such as ibuprofen in the 1st couple weeks following injury ? My concern is that in this timeframe we are monitoring symptoms (such as headache) to guide the pace of return to cognitive activity, but then masking this key symptom by using pain relievers. Thanks
Dr. Hitchman:
Thanks for your points.
The Ontario Neurotrauma Foundation has good guidelines for treatment of post-traumatic headache.
However, the treatment really is tailored to the individual and most athletes as you know prefer to avoid medication.
However, one should be suggesting conventional non-narcotic analgesics with short-term benzodiazepine sedative-hypnotics for headache/sleep as reasonable measures if still symptomatic after several days. Triptans are useful for vascular/migraine-type headaches. Nortriptyline 10-25 mg is easier to tolerate than amitriptyline. If symptoms last longer than one week, screen for depression/anxiety, and if headache accompanies, consider venlafaxine + sedative-hypnotic, mirtazapine, fluvoxamine, etc.
As for masking symptoms, the guideline is not to treat headache in order to guide the pace of return. This is actually an unreasonable expectation as most clinicians in neurosciences will appreciate. If you wanted to be strictly adherent to sports concussion guidelines (and we would recommend you tailor treatment to the individual instead) you would treat with conventional analgesics after and not before exposure to the activity.
We will offer some suggestions on management of concussion in a separate issue.
More data from a Case-Control Study Dr. Silverberg ran showing that over 80% of individuals are still told to rest more than 48 hours and subjects were 150% more likely to return to partial or full time work if they were NOT advised to rest more than 48 hours.
https://www.frontiersin.org/articles/10.3389/fneur.2019.00362/full