Consensus statement on Concussion in Sport. Zurich 2012

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1 Post Concussion Syndrome, Pharmacotherapy and Neurocogni7ve evalua7on Subramani Seetharama MD, MS Medical Director Har>ord Hospital Rehabilita7on Network I have no relevant financial rela7onships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME ac7vity. I do not intend to discuss an unapproved/ inves7ga7ve use of a commercial product/ device in my presenta7on. Pharmacotherapy in sport concussions may be applied in 2 dis7nct situa7ons: Management of specific or prolonged symptoms (eg. sleep disturbance, anxiety, migraines) Modifying underlying pathophysiology with an aim to shorten the dura7on of symptoms Return to play: important considera7on is a) athletes should be symptom free; b) all pharmacological agents that may mask or modify symptoms should be discon7nued; c) special considera7on for an7depressants. Consensus statement on Concussion in Sport. Zurich

2 Concussion Clinical Trajectories Cognitive /Fatigue Post Traumatic Headaches Post Traumatic Migraine Concussion Ocular Anxiety/ Mood Sleep Dysfunction Vestibular 4 Factor Analysis Based on PCSS Post trauma*c headaches: Most commonly reported symptom May not develop immediately. OSen worse with cogni7ve or physical exer7on E*ology: Cervicogenic (occipital) Musculoskeletal (myofascial/tension) Fa7gue related Medica7on induced Post trauma7c headaches Analgesics An7- inflammatories Muscle relaxants Side Effects Acetominophen:High doses vomi7ng, liver and kidney failure ASA, NSAIDS: Gi upset, bleeding, nausea, vomi7ng, prolonged use can cause rebound headache Use in conjunc7on with other therapies. 2

3 Post Trauma7c Migraine Def: headache, nausea associated with sensi7vity to light or nausea (Intl headache Society Guidelines). 174 HS athletes, showed that PTM when compared to no headache, the chance of protracted recovery (>21 days) was 7 7mes higher and 2.5 7mes higher than when compared to headache only. PTM effects Visual memory and reac7on 7me on ImPact significantly more than no headache or headache group, peaking at 1-7 days post injury. Dr Michael Collins, UPMC 7 Post trauma7c Migraine Preven8onTreatment An*depressants: Amitriptyline: mg QHS 7trate upto 150mg max dose Venlafaxine, Escitalopram (Lexapro), Sertaline (ZoloS). Beta Blocker : Propranolol mg in divided doses Abd cramps, fa7gue, wheezing/sob, bradycardia, Low BP, avoid in athletes and pa7ents with asthma Drowsiness, dizziness, motor 7cs, Gi upset, blurred vision Post Trauma7c Migraine An*convulsants: Topiramate 15-25mg QHS, max 100mg BID Impaired memory and concentra7on, headache, motor 7c, GI upset, hair loss Valproic acid 250mg BID, Max dose 1500mg/ Drowsiness, dizziness,diarrhoea, mood day. swings, appe7te and weight changes Gabapen7n start 300mg/day and increase incrementally. Max 3600mg/day. Dizziness, headache, blurred vision, memory problems, motor 7cs 3

4 Post Trauma7c Migraine Abor*ve: Ergot prepara7ons: intranasal vs IM/SQ vs IV mg, max 2.0 mg/day Triptans: Sumatriptan (Imitrex) mg prn intranasal, 10-20mg po BID prn Zolmitriptan: Oral 5-10mg, Intranasal 5mg Rizatriptan (Maxalt) : 5-10mg po, can repeat second dose 2 hrs from first dose (max 30mg/day) Unusual taste with intranasal, dizziness, chest 7ghtness, flushing, 7ngling Post trauma7c Migraine Adolescents: Elavil, Neuron7n, Inderal Flexeril 5mg ½ to 1 tab qhs Rizatriptan, Phenargan: 25 mg 1/2 tab po prn repeat in 2 hours. Pre- adolescents: Periac7n mg/kg/day Sleep Dysregula7on Difficulty falling asleep. Sleeping less or more than usual Hypersomnia 4

5 Sleep Dysregula7on Behavioral strategies Melatonin 3mg and 5mg, XR An7depressants: Amitriptyline Trazodone 25-50mg QHS An7 Histamines: Vistaril mg start dose for kids. Adults mg Non- benzodiazepine hypno7cs: Ambien, Lunesta Klonopin Day7me sleepiness, sleepwalking, confusion Headache, Gi upset,confusion, nightmares,7nnitus Cogni7ve Dysfunc7on Fogginess Decreased alen7on Memory dysfunc7on Cogni7ve fa7gue Cogni7ve Dysfunc7on Cogni7ve fa7gue: Neuros*mulants: Enhancement of the dopaminergic transmission by neuros7mulants can improve long term func7onal outcomes. Methylphenidate (Ritalin) 5mg BID, Max 20 mg twice daily Dextroamphetamine (Adderall) 5mg daily, Max 40 mg/day Modafanil (Provigil): 100mg po QAM, 7trate, max 400mg/day Atomexi7ne (Stralera) 40mg daily in divided doses, max 100mg Insomnia, increased appe7te, motor 7cs, anxiety, irritability, tachycardia Anxiety, insomnia, Gi upset, euphoria, irritability Insomnia, hallucina7ons, headache, dizziness 5

6 Amantadine Retrospec7ve case controlled study 25 males, 14 females, adolescent subjects Dose : 100mg BID Outcome measure: ImPACT Results : Improvement in symptoms, verbal memory, and reac7on 7me. Amantadine: 100mg - 400mg daily. ( in kids start at 50mg once daily for 4-6 weeks.) Anxiety, insonia, blurred vision, dizziness Cogni7ve dysfunc7on Donepezil (Aricept): Acetylcholine esterase inhibitor. 5-10mg daily Nausea, vomi7ng, bradycardia, difficulty urina7ng,, worsening of asthma. More emo7onal Irritable Sad Nervous Anxious/Depressed PTSD Neuropsychiatric 6

7 Neuropsychiatric Depression: Tricyclics: Amitriptyline SSRI(Selec7ve serotonin reuptake inhibitors); Setraline (ZoloS), Fluoxe7ne (Prozac), Citalopram (Celexa), Escitalopram (lexapro) Neuropsychiatric Anxiety: Benzodiazepines: Clonazepam (Klonopin) mg up to twice daily. (helps with ves7bular dysfunc7on assoc with anxiety) Seda7on, dizziness, loss of orienta7on, respiratory depression A7van/Diazepam Short term use only, can develop panic alacks and insomnia References Pertaglia,Anthony et al. From Field to Play to Field of Combat: A Review of the Pharmacological management of Concussion Neurosurgery 70 (6), Reddy, Cara; Collins, Michael et al.efficacy of Amantadine treatment on symptoms and neurocogni7ve performance among adolescents following sports- related Concussion. J of Head Trauma Rehab 2012 Kinnaman, Karen et al. Management startegies and medica7on use for trea7ng Pediatric pa7ents with Concussions. Acta Pediatrica, 2013,102 :e424- e428 7

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