Getting Ahead of PostConcussive Syndrome
Jaime M. Levine, D.O.
Brian S. Im, M.D.
Heidi N. Fusco, M.D.
Emilia Ravski, D.O.
Agenda
•Course is geared towards the difficult concussion patient in
the office setting
•Segments
1.
2.
3.
4.
5.
6.
In-office assessment, Dr. Fusco
Rehabilitation Interventions, Dr. Im
Pharmacology, Dr. Levine
Research on the horizon, Dr. Ravski
Cases Studies
Q&A
•Faculty
Board-Certified in Brain Injury Medicine
At Rusk  /321
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(Summer, 2015)
What Is Post-Concussive Syndrome?
•Persistence of symptoms following
concussion over a prolonged period of time
•Incorporates somatic, psychological,
behavioral, sleep, and cognitive difficulties
•Physiologic effects result in more effort
required to perform cognitive and physical
tasks leading to fatigue
•No structural injury
The Office Assessment of
Post-Concussive Syndrome
Heidi N. Fusco M.D.
Clinical Instructor
Rusk Rehabilitation
NYU School of Medicine
Patient History
•Before entering office patient fills out SCAT 3 Symptom
Inventory
22 items self-rated on 7-point Likert scale
Can be used serially
Reliable and valid
•Fill out each visit
•Also ask about seizure, falls, bowel/bladder changes,
tinnitis, neck pain
Graded Symptom Checklist (GSC)
•Headache
•Pressure in head
•Neck pain
•Nausea/vomiting
•Dizziness
•Blurred vision
•Balance problems
•Sensitivity to light
•Sensitivity to noise
•Feeling slowed down
•Feeling like in a fog
•Don't feel right
•Difficulty concentrating
•Difficulty remembering
•Fatigue or low energy
•Confusion
•Drowsiness
•Trouble falling asleep
•More emotional
•Irritability
•Sadness
•Nervous or anxious
Patient history
•Date of injury
•Work, non-work related
•Mechanism of injury
•Loss of consciousness
•Symptoms after concussion
•ED / Urgent care evaluation
•Imaging
•Treatment: clinicians, medications, therapies
•How have symptoms progressed
•Most problematic symptom
•Hx of disability, ADHD, or other developmental disorder.
•Hx of anxiety or depression, or other psychiatric problems
•Litigation
Rest of History
•History of prior head injury
•PMH
•PSH
•FH
•SH
•Meds
•Allergies
Focused exam pending patient presentation
•Neurological exam
•Physical exam to focus on system that could explain
prolonged symptoms.
weakness/hair loss/cold skin ~ hypothyroidism
distended abdomen ~ gi problem
•Cervical ROM, Tenderness
Concussion-Specific tests and limitations
•Standardized Assessment of Concussion (SAC)
Sensitivity in first 48 hours
•King-Devick Test
•Modified Balance Error Scoring System (M-BESS)
Full BESS has better sensitivity
•Military Acute Concussion Evaluation (MACE)
Not valid if more than 12 hours after injury
•Vestibular/Ocular Motor Screening (VOMS)
Cognitive Assessment/Standardized Assessment of
Concussion (SAC)
Orientation- 5 pts
Immediate memory of 5 words practiced 3 times- 15 pts
Concentration- 5 pts
Delayed recall of 5 words- 5pts
King-Devick Test
•1-minute test
•Measures speed and accuracy of reading aloud single digit
numbers from 3 test cards.
•Tests for impairments of eye movements, attention,
language, and other correlates of suboptimal brain function.
•Found to be accurate and reliable in identifying athletes with
head trauma on sideline and in office
Modified Balance Error Scoring System (M-BESS)
•Evaluation of 3 stances on firm surface only
1. Feet together, hands on hips and eyes closed x 20
seconds
2. Feet in tandem, hands on hips and eyes closed x 20
seconds
3. 1 foot lifted, hands on hips and eyes closed x 20
seconds
•Score: errors out of 30, higher score worse
• http://www.knowconcussion.org/concussion-management/balance-error-scoring-system-bess/
Vestibular/Ocular Motor Screening (VOMS)
•Assesses vestibular and ocular motor impairments with
patient reported symptoms provoked in 5 assessments:
1.
2.
3.
4.
5.
Smooth pursuit
Horizontal and vertical saccades
Convergence
Horizontal vestibular ocular reflex
Visual motion sensitivity
•Found to be sensitive in identifying concussed patients
•Correlated with PCSS (GSC)
Clinical Pearls
•Pre-office questionaires can focus complicated history
•Set questions in office, standardized
•Focus treatment plan on most bothersome symptoms
•SCAT 3, King-Devick test, M-BESS, and VOMS can pick up
subtle deficits in attention, concentration, processing speed,
orientation, memory, language, balance, vestibular and
ocular function.
Rehabilitation Management
of Concussion
Brian S. Im M.D.
Assistant Professor
Rusk Rehabilitation
NYU School of Medicine
Learning Objectives
•The Learner will be able to identify postconcussive syndrome
•The Learner will be able to recognize the role
of rest and exercise in concussion and postconcussive syndrome
•The Learner will understand the different
rehabilitation treatment options available for
management of persistent concussion
symptoms
What Are Some Common Concussion Symptoms?
•Fatigue
•Pain
•Dizziness
•Blurry or Double Vision
•Balance Difficulties
•Hypersensitivity
•Memory Problems
•Concentration Difficulties
•Irritability
•Sleep Disturbance
How Long Should I Rest?
•Unclear what the optimal time for
cognitive and physical rest should be
but most agree rest is beneficial
early on in recovery course
•Recent studies show a graded subsymptomatic exercise program is
beneficial for those with prolonged
symptoms
What Is The Current Recommendation For Return To
Activity After Resolution Of Concussion Symptoms?
•Return to full cognitive activities should
precede return to physical activities
•In regards to sports, follow a gradual step by
step regimen for safe return to play after full
cognitive recovery
•Student athletes should return to full
classes/academic work prior to return to play
Step-by-Step Regimen for a Safe RTP
•Athletes should spend 24-48 hours at each level before
progressing to the next
•If symptoms return at any point, the athlete should drop
down a step for 24 hours then proceed with the
progression as tolerated
•Stages:
1.
2.
3.
4.
5.
6.
Rest (physical and cognitive)
Light aerobic exercise
Moderate to intense aerobic exercise
Sport-specific activities/noncontact training drills
Full contact activities
Game play
What Are Common Treatment Options In A
Concussion Rehab Program?
•Vestibular Therapy
•Vision Therapy
•Physical Therapy
•Cognitive Retraining
•Psychotherapy and Counseling/Support
•Behavioral Management
•Vocational Counseling and School Support
•Concussion Education
•Home Exercise Program
What Is Vestibular Therapy?
•Balance retraining
•Dizziness management
•Reset inner ear equilibrium
What Is Vision Therapy?
•Often done in conjunction or part of a
vestibular therapy program
Convergence retraining
Eye movement and tracking retraining
Adaptations for photosensitivity
What Can Physical Therapy Offer for Concussion
Management?
•Neck dysfunction can often exacerbate
concussion symptoms such as headache
Pain management modalities
Stretching
Manual techniques
What Is The Role of Cognitive Therapy?
•Cognitive dysfunction usually manifests in
executive function difficulties
Compensatory strategy training
Cognitive retraining exercises
Is There A Role For Psychological Counseling?
•Psychological problems such as anxiety and
depression can exacerbate and prolong
concussion symptoms
•Cognitive behavioral therapy
Individual psychotherapy
Support groups
How About Treatment For Behavioral Issues?
•As with other forms of trauma to the brain,
emotional control and behavioral difficulties
can be seen after a concussion
•Often done in conjunction with psychological
treatment
Behavioral management strategies
Social re-integration strategies
Counseling and support
Any Further Rehabilitation Services That May Be
Helpful?
•Home Exercise Program
To carry over gains learned in therapy
•Concussion Education
Normalization of concussion symptoms
Facilitate understanding of complexity of
issues
•School Services
Assist with return to learn and school plan
Liaison with school administration
Resource for feedback and support
Summary
•Persistent concussion symptoms are often rooted
in a complex interaction between
physical/physiologic and psychological factors
and neither aspect should be ignored
•A comprehensive rehabilitation and medical
management program can aide in recovery for
patients with persistent symptoms following a
concussion
•There is a role for both cognitive rest and physical
activity in the recovery from concussion. Current
evidence suggests treatment for concussion
symptoms that persist after an initial period of rest
is to consider a sub symptomatic graded exercise
program.
The Role of Pharmacology in
Management of PostConcussive Syndrome
Jaime M. Levine, D.O.
Clinical Assistant Professor
Rusk Rehabilitation
NYU School of Medicine
Why Use Pharmacology in PCS?
•How do we recover from a brain injury?
1. Spontaneous recovery
2. Rehabilitation strategies
3. Secondary prevention
4. Pharmacology
Neuropharmacology Rules of Thumb
•Limit polypharmacy
•Start low and go slow
•Informed consent essential
•Seek feedback from interdisciplinary team
•Reevaluate often
•Strive for one prescriber
•If past psychiatric history or significant headache history,
consider referring back for continued management
•Withdrawal of an agent  to see if spontaneous recovery
has caught up
Agents to Support Better Sleep
Melatonin: What We Know
• Melatonin has value for sleep disorders following head injury.
•Consensus is that about 30% of patients following head injury have
insomnia.
•Little published on its use in TBI
•One case report of a 15-year old girl with head trauma who developed
a delayed sleep phase syndrome. (Nagtegaal, J.E. 1997)
Physiological markers monitored:
Sleep-wake rhythm, plasma melatonin, body temp, wrist activity
All markers returned to normal after treatment with 5mg melatonin
•A few studies on melatonin in neurologically impaired children with
neutral to favorable results.
•Ramelteon is a pharmaceutical grade analogue of melatonin
Melatonin and Amitriptyline: What We Know
• Melatonin and Amitriptyline have value for sleep disorders following head injury.
• Kemp et al (2004) did a randomized double-blind controlled cross-over trial with
melatonin (5mg) or amitriptyline (25mg).
Minimum 6 months post-TBI
16-65 y/o
Sleep variables measured:
1. Alertness
2. Duration
3. Quality
4. Latency
Also measured neuropsychological functioning and mood
Results:
 Melatonin: improved daytime alertness
 Amitriptyline: improved sleep duration and shortened latency
 Most patients were unimpaired on neuropsychological tests of
attention and speed of processing
 No changes in cognitive performance or mood
 No adverse drug effects
Trazodone: What We Think We Know
•Trazodone is a multifunctional drug that helps patients
with TBI sleep.
•Mechanism of action is unique: has dose-dependent actions
Hypnotic actions at low doses due to blockade of:
5-HT2A receptors
H1 histamine receptors
Alpha1 adrenergic receptors
Higher doses block the serotonin transporter (SERT) and have
antidepressant properties
Agents to Support Healthy Sleep
Take Home Points From the Literature:
•Melatonin and amitriptyline have value for sleep disorders
following head injury.
•Ramelteon is a pharmaceutical grade analogue of
melatonin
•Trazodone is a multifunctional drug that helps patients with
TBI sleep.
Agents to Support Healthy Sleep
Anecdotes from My Practice:
• Ramelteon at 4mg dosing is
great to have onboard.
Few to no contraindications
Viewed as a “supplement”
not drug to some
• Trazodone 50-200mg QHS
Caution in young men
Avoid with other
serotonergics, especially at
higher doses
Antidepressant effect at
higher doses
• Neurontin
Back-load dosing
•Instead of 300mg Q8, can
give 300mg QAM and
600mg QHS
•Mirtazapine 7.5mg, may
increase to 15mg
Antidepressant effects
Can increase appetite
Headache Management
Post-Traumatic Headaches
•
Definition
Onset usually within 7 days,
but within 3 months usually
accepted as post-traumatic
An underlying primary HA
disorder exacerbated by TBI
• Treatment Goals
Abort attack
Decrease
frequency/duration
Decrease severity/disability
Prevent chronicity
• Before Medications
Avoid triggers
Emphasize healthy diet,
sleep, exercise (if
appropriate) and stress
management
Identify comorbidities in
preparation for drug selection
 Mood disorder
 Seizures
 Poor sleep
 Other types of pain
Post-Traumatic Headaches: Treatment
Considerations
•Considered chronic if persist > 3 months
•If persist > 6 months, likely to continue for many more
months
•If persist beyond 2 months, consider prophylactic therapy
If multiple stressors or co-morbidities, consider earlier
•Prophylactic Rx may take up to 4 weeks to take full effect
Post-Traumatic Headache Pharmacotherapy by HA Type
Tension
Migraine
Abortive Tx
NSAIDs
NSAIDs or Triptans (<3X/week).
Avoid opioids
When to
Prophylax
If >10 HA/month and
significant disability
If >2 HA/week not relieved by
abortive therapy
Prophylactic Tx Amitriptyline
Nortriptyline
Topiramate
Amitriptyline or nortriptyline
Propranolol LA
Valproate
Gabapentin
Onabotulinum toxin A
Post-Traumatic Headache Pharmacotherapy by HA Type
Cervicogenic
Occipital Neuralgia
Workup
Imaging
Intervention
Trigger Point Injections
Occipital Nerve Block
Adjuvant
Therapy
Physical Therapy
Trileptal
Gabapentin
Gabapentin
Nortriptyline/Amitriptyline
NSAIDs
NSAIDs
Mood Changes
When Mood is Affected
• Combination of post-traumatic headache, poor sleep and depressed
mood  amitriptyline or nortriptyline
• Depression or anxiety alone  vast sea of medications to choose
among
• Premorbid history of depression or anxiety 
Adjust dose of current regimen
Simply add non-pharmacological strategies to treat exacerbation
Refer back to original treater
A Word on Fatigue
•Fatigue is one of the most troubling and disabling
symptoms following any type of brain injury.
•Secondary versus primary fatigue/physical versus mental
fatigue
•Compounded secondary fatigue in PCS is multifactorial:
Rest
Medications
Pain
Mental fogginess
•How to treat?
Exercise
Streamlining fatiguing activities
Allow time and spontaneous recovery to help
New Research in Post-Concussive Syndrome
Emilia Ravski, D.O.
Primary Care Sports Medicine Fellow
University of Pittsburgh Medical Center
Physical Medicine and Rehabilitation Resident, Class of 2015
NYU-Langone Medical Center
Rusk Rehabilitation
•
Prospective cohort study
•
Examined the concentration of plasma T-tau and serum S-100B and NSE
•
Included 88 professional Ice Hockey players from the Swedish Hockey
League
•
Baseline levels collected from players
•
28 concussed players
– Blood levels collected at:
• 1, 12, 36, 48 and 144 hours after injury
•
T-tau levels were significantly higher in all samples after concussion compared to
pre-season
•
T-tau and S-100B at 1hr
–
–
•
T-tau level at 1hr
–
•
Predicted the duration of symptoms and time to return to play
T-tau level at 144hrs
–
•
Highest levels
Correlated with the number of days it took for concussion symptoms to resolve
Significantly elevated in players with PCS for more than 6 days vs players with PCS for less than 6
days
No significant difference in NSE levels
Serum tau Fragments Predict Return to Play in
Concussed Professional Ice Hockey Players
Shahim P, Linemann T, Inekci D, Karsdal MA, Blennow K, Tegner Y, Zetterberg H,
Henriksen K. J. Neurotrauma. 2015 Jan 26.
• Fragmented Total-tau into tau-A and tau-C
• Serum tau-A concentrations
– Were higher in those with PCS vs short term symptoms
– Potentially can be utilized as a predictive factor for RTP
J Neurosurg Pediatr. 15:589-598, 2015
•
Retrospective, case-control study
•
Used the Vanderbilt Concussion Clinic Database to identify athletes who sustained a
concussion while playing sports
–
–
•
Study group
• 40 athletes (9-18yo) who reported PCS (> 3months)
Control group
• 1:2 matched controls who reported resolution of
symptoms by 3 weeks
Variables evaluated
–
–
–
–
Demographics
Medical, psychiatric and family history
Acute post injury symptoms (0-24hrs)
Subacute post injury symptoms (0-3wks)
J Neurosurg Pediatr. 15:589-598, 2015
•
Risk for development of PCS
–
–
Personal history
• Mood disorders
• Psychiatric illness
• Significant stressors
Family History
• Mood disorders
• Psychiatric illness
• Migraine
–
Delayed symptom onset (≥3 hrs post injury)
• 10 times more prevalent among athletes with PCS compared to control group
–
No association found between initial symptoms (0-24hr) or delayed symptoms (0-3weeks) and
development of PCS
•
Data gathered from a randomized controlled trial that examined the
efficacy of a web-based psychoeducational intervention on PCS
(Belanger et al. Milt Med. 2015)
•
158 participants with a self-reported mTBI
within 2 yrs and symptomatic at time of enrollment
– Civilian and military
– 18-55 years of age
•
•
Web based questionnaire used to evaluate:
Sleep quality
– Psychologic Distress
– Postconcussion symptoms
Copyright © Cedric Hohnstadt 2011. All rights reserved.
• Higher distress level and worse sleep
quality were associated with greater
severity of postconcussion symptoms
– Psychological distress was a more significant factor
– Difficulty falling asleep was the main quality of sleep complaint
Hyperbaric Oxygen
Postconcussion Syndrome
JAMA Intern Med.2015;175(1):43-52
•
Multicenter, double blind, sham-controlled clinical trial
•
72 military service members with ongoing symptoms at least 4 months after mTBI
–
–
•
Primary outcome measure
–
•
All participants received routine PCS care
Randomized into 3 groups
• 40 HBO sessions administered at 1.5 atmospheres absolute (ATA)
• 40 sham sessions consisting of room air at 1.2 ATA
• No supplemental chamber procedures
The Rivermead Post-Concussion Symptoms Questionnaire (RPQ)
Secondary outcome measure
–
Neurobehavioral Symptom Inventory
JAMA Intern Med.2015;175(1):43-52
• HBO showed no benefit over an air sham compression procedure
• Symptoms in both HBO and sham
groups improved compared to those
without supplemental chamber treatment
– Improvement likely due to placebo effect
Thank you!
Cases
The Unhappy Bus Driver
• 52 yo male presents with his wife 3 years after he lost control of an empty
school bus and drove into a telephone pole
• + LOC “doesn’t know”
• Went to ED via ambulance CT neck and head negative. Discharged home
• Since injury has been unable to work, has had severe deficits in ability to
function and perceived cognition, has had vision changes, headache, neck pain,
nausea, photo/phono sensitivity, weakness, complains of falling 3 times per
week.
• Has seen >10 physicians and done PT. Would also like scripts for Xanax,
oxycodone, oxycontin.
• MRI of head WNL, neck with mild DJD
• Symptom inventory on SCAT3 is 6/6 on all 22 questions
• On exam, medical exam normal, tender back muscles diffusely, +crying during
SCAT 3 questions, King Devick test elicits crying and unable to stand without
his cane.
• There is pending litigation
The Cabinet Injury
• 46 year old female ER RN stood up quickly and hit head on open
cabinet. No LOC. + Subgaleal hematoma on inspection. No CT
imaging.
• Went to occupational health, told to go home, reported to ED after 24
hours with worsening HA, photo and phono-sensitivity. Exam normal,
No CT imaging
• Presents after 3 weeks with ongoing symptoms of 10/10 headache,
neck pain, photosensitivity, dizziness, and reported deficits in speech,
language, and attention.
• On exam, WNL medical exam, TTP of cervical paraspinals diffusely and
normal ROM of neck with guarding, + horizontal nystagmus with EOM,
BESS Normal, and good performance on King Devick. On SCAT 3
questions everything normal except 0/5 on delayed recall.
Prescribed Treatment
•Taken out of work for 6 weeks
•Rx for vestibular rehabilitation
•Neuroophthalmology referral
The Childcare Worker
•22 year old female presents 2 days after being hit in head
with a wooden block thrown by a 3 year-old.
•Has been working, but is very irritable and fatigued. Unable
to tolerate reading or computer use. + HA, Dizziness, and
reports vertigo, photo and phono sensitivity
•Only taking homeopathic agents and will not take
medications
•She went to the gym this morning but had to stop her
workout on the elliptical after 3 minutes for dizziness,
fatigue and headache.
•4-5/6 on SCAT 3 symptom inventory
•On exam everything within normal range.
High School Interrupted
• 15 y/o healthy male with no
significant past medical history is
brought in by his parents with
reports of multiple concussions
over past several years.
• Major symptoms include:
headache, photo- and
phonosensitivity, dizziness
• He has been out of high school for
the past two years because his
concussion symptoms have been
too severe to tolerate an academic
or structured setting.
• Has had numerous neuroimaging
tests.
• Has tried many types of therapies,
including conventional
rehabilitation (vestibular, vision) as
well as hyperbaric O2 and
acupuncture.
• Can’t participate in any cognitive,
physical, or structured task for
longer than 15 minutes prior to
needing to lie down for an hour in
a dark, quiet room.
• Neuro exam normal
The Roller Dancer
• 58 y/o female with history of
• Has noticed a reduction in her
multiple episodes of hitting head
ability to perform during her roller
on obstacles in her path. The first dancing practice sessions, and an
instance was due to a
inability to write calligraphy as was
“claustrophobic crisis” as she felt
her hobby.
confined in a small crowded area, • Saw her primary care physician
and ran out of there in a rush to
who suggested she follow-up with
find more space. The second was her psychiatrist for exacerbation of
also when she was in a rush,
underlying psychiatric illness,
because she ran into an open door including claustrophobia and mild
on her right side.
OCD.
• She reports several other similar
stories, none involving LOC.
The Roller Dancer (Continued)
• On Exam: Neuro exam is non-focal except for a dense
right homonymous hemianopsia.
The Roller Dancer (Continued)
• Sent for ED where CT of her head which revealed a
hemorrhagic mass.
• Admitted for workup. MRI revealed a large hemorrhagic
mass in her left parieto-occipital junction.
• Went to the OR for removal the next day and is currently
undergoing adjuvant treatment for a high grade glioma.
The Roller Dancer
Questions?
Jaime.Levine@nyumc.org
Brian.im@nyumc.org
Heidi.fusco@mountsinai.org
Ravskie@upmc.edu
References
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