PROLONGED CONCUSSIONS

Transcription

1 PROLONGED CONCUSSIONS The Problem that Won t Go Away. Suzanne Hecht, MD, FACSM, CAQ University of Minnesota Team Physician: UM Athletics

2 DISCLOSURES DJ Global: Primary Care Sports Medicine Advisory Board NFL Charities Research Grants Multiple Concussions & Cerebral Vascular Reactivity Chair: Big Ten-Ivy League TBI Research Com Off label use All medications discussed in this lecture. No meds approved by FDA for concussion rx

3 OBJECTIVES Review medications that may be beneficial for patients w/ prolonged concussions Know the 4 symptom domains of prolonged concussions cognitive, somatic, emotional, & sleep Understand the importance of neurovestibular therapy

4 Define Prolonged Interventions Medications Neurovestibular therapy Behavioral Optometrist Psychologist Exercise

5 ENERGY CRISIS Lasts: 3-7d in animals 10-14d in humans Calcium % of normal Glutamate K+ Glucose minutes hours days Cerebral Blood Flow Giza, JATA 2003

6 PROLONGED? When does this start? Mixed definitions in literature 6 wks-6 mo DSM & WHO Definitions Hecht: 80-90% of adults resolved in 7-10 days & kids in 3 wks Prolonged adults: 3-4 wks Prolonged kids: 4-6 wks

7 MEDICATIONS Why? Who should be treated? What should they be treated with? When should medications be considered? What is the evidence?

8 EVIDENCE Very limited studies w/ methodological issues Data usually from more severe TBI NO studies to date that show meds can speed the recovery of TBI. No standard protocols exist Meehan Clin Sports Med Jan 2011; Petraglia; Neurosurg 2012; Makdissi; BJSM April 2013

9 WHY? People with prolonged concussion symptoms feel bad most if not all days! Out of sports Out of many activities Struggling at school/work Disturbed sleep

10 WHO? Athletes with a prolonged recovery Significant symptoms Risk vs benefit Able to accept lack of evidence Parents & athlete

11 Concussion Treatment Somatic Headaches Visual problems Dizziness Noise/Light Sensitivity Nausea Balance Emotional Nervousness Irritability Sadness More emotional Sleep Sleeping more Sleeping less Difficulty falling asleep Non-restorative sleep Cognitive Attention problems Memory dysfunction Fogginess Fatigue Cognitive slowing

12 SLEEP & THE BRAIN Sleep deprivation is a form of torture Rats deprived off all sleep die in 3 wks Deprived of REM sleep: 5 wks Lack of sleep Poor physical & mental performance Impaired memory Hallicunations & mood swings Neuronal repair

13 SLEEP Sleep Hygiene Natural sleep is preferred to medicated Melatonin Pineal gland hormone made from serotonin Secreted when less light/dark; sunset Wide range of effective dosing Bendryl, Ambien, low dose TCAs, Trazodone Avoid benzos

14 SLEEP Low dose Tricyclic antidepressants Also for HA rx & chronic pain management Amitriptylline Nortriptylline TCA side effects Dry mouth, urinary retention

15 COGNITIVE Methylphenidate Used to treat ADHD Studies mixed for TBI Increases dopamine & NE Amantadine My preference.

16 AMANTADINE Not FDA approved for concussion rx Approved for influenza & Parkinson s Dopamine agonist Partial NMDA glutamate blocker Sparse evidence Some anecdotal success in concussion rx Better evidence for moderate/severe TBI Meehan; Clin Sports Med 2011 Kraus; Brain Injury 2005

17 AMANTADINE Safe in pediatric patients Dosing: 100mg bid (breakfast & dinner) Start 100mg q am for 5-7 days & then increase Side effects: Abrupt visual change Suicidality Tends to be activating

18 SOMATIC: HA Using doing too much Reassess activities Visual complications Convergence insufficiency Gaze stabilization Tylenol/NSAIDS Watch out for rebound HAs

19 SOMATIC: HA Migraine medications Imitrex, Maxalt TCA (amitriptylline, nortriptylline) Topamax Avoid beta blockers +/- Calcium channel blockers Tension HAs Address myofascial issues in addition to meds

20 Neurovestibular Tx Gaze stabilization, convergence insufficiency & balance Neurovestibular Therapist Behavioral Optometrist Eye evaluation/prescription RCT cervicovestibular rehab vs controls w/ prolonged symptoms Tx group 73% vs 7% cleared w/in 8 wks Scheider; BJSM Sept 2014

21 NAUSEA May feel motion sick if neurovestibular dysfunction is present HA can cause nausea GERD secondary to NSAID use Target cause if you can figure it out Zofran is my first choice Avoid motion sickness meds, unless traveling

22 VERTIGO Assess for BPPV Debris usually in posterior semicircular canal Dix-Hallpike RX Epley Little downside to trying Epely if +Hallpike

23 EMOTIONAL Address psychological issues Anxiety Depression SSRIs, benzo (low dose) Counseling

24 EXERCISE Subsymptom exercise has been shown to help recovery in PCS Exercise is good for the brain Graded exercise program Makdissi; BJSM 2013; Leddy; Sports Health 2013

25 SUMMARY Med trial for prolonged symptoms Manage sleep disturbance early Look for neurovestibular dysfunction Remember to address the neck Exercise can help Listen carefully to the patients Treat their symptoms!!

26 THANK YOU!!