Non-operative Concussion Treatment

A complete history and physical examination should be performed. History should include number of concussions, complete cluster of symptoms, presence or absence of loss of consciousness and/or amnesia, how much sports patients missed during previous concussions, and how long did it take for complete recovery.  The physical examination should include vital signs, speech and gait analysis, a full musculoskeletal and neurological examination, cranial nerve evaluation, Romberg and Pronator Drift Tests, Point to Point Discrimination Testing, and Vestibular and Balance Testing, with special consideration given to performing a BESS (Balance Error Scoring System) test.  

     Patients should also have computerized neuropsychological testing performed – ideally comparing to baseline – to check the cognitive function of the athlete’s brain.  The Rothman Institute, as do many professional, collegiate, and high school teams, uses the ImPACT  (Immediate Post-Concussion and Cognitive Testing) program to monitor their athletes as they recover from a concussion.

     If the scores are significant enough or do not improve, formal neuropsychological testing is still the gold standard for cognitively testing the athlete.  Other considerations to check within the office setting include computerized testing for ophthalmological symptoms and/or referral for these symptoms.  Diagnostically, CT scan or MRI is ordered by physicians to rule out organic brain pathology such as cerebral bleeding or skull fracture. 

     Concussion is treated symptomatically.  Only when an athlete is symptom free, not taking any medicines for symptom control, and has normal mentation proved by computer neurocognitive testing returning to baseline can the athlete be placed on a return to sport protocol to attempt to return to sport.  The goals of treatment are to control symptoms, prevent the cumulative effects of concussion, prevent Second Impact Syndrome, and prevent Post-Concussion Syndrome.  First line treatment is always complete mental and physical rest that includes refraining from things that can challenge the vestibular and cognitive system such as texting, video games or long periods of reading. 

     Pharmacological treatment of concussion varies from patient to patient and is targeted at the particular symptomatology of the concussive episode.  There is no one medication that specifically treats concussion and many have associated side effects.  A combination of Vitamin B2, Magnesium, and fish oil can also be used before beginning true pharmacological drugs as this has been successful in alleviating headache in the migraine patient. 

     Besides medications, there are often other therapies used in the treatment of the concussed patient.  Vestibular and physical rehabilitation can be used for patients with vestibular components of concussion such as those with balance and coordination issues.  Ophthalmologic retraining either via formal programs or computer can be used for those patients with visual dysfunctions.  Cognitive rehabilitation can be used for those patients with severe cognitive dysfunction discovered using formal neuropsychological testing.  Finally, patients who admit to beginning symptoms of a co-morbid mood disorder, such as depression, benefit from immediate psychological intervention.

     Once the patient has become symptom free for 24-48 hours, is taking no medications to control symptoms and has a computerized neurocognitive test that has approached baseline, the patient may be begin a return to play protocol.  This protocol was first proposed by the Concussion in Sport Group and has been approved by many sports medicine bodies over the last several years.  The first step is complete rest for 24 hours.  Step two is light aerobic exercise such as cycling or walking to increase heart rate to 70 % of maximum predicted heart rate.  Step three is sport specific training which adds movement to the treatment paradigm.  Step four is non-contact training drills that add exercise, coordination and cognitive load to the treatment paradigm.  Finally, if there are no issues with symptomatology, the patient can begin full contact training to restore confidence and assess functional skills.  If the patient becomes symptomatic at any time, he or she is dropped to the step previous and progression is again attempted after 24 hours.