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Emerging Frontiers in Concussion - Session 7: Targeted Evaluation and Active Treatment and Rehabilitation Approaches for Concussion – Part 1
Doctors Kelley Anderson and Anne Mucha discuss various topics related to targeted evaluation and active treatment and rehabilitation approaches for concussion.
Upon completion of this activity, participants should be able to:
- Identify and use conservative behavioral strategies for concussion management.
- Identify and understand presentation of post traumatic headaches.
- Describe the vestibular system and its relationship to recovery following mTBI
- Describe common vestibular system abnormalities following mTBI
- Identify methods for screening for vestibular and ocular motor dysfunction following mTBI
- Collins MW, Kontos AP, Reynolds E, Murawski, CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following concussion. Knee Surgery, Sports Traumatology, Arthroscopy, Feb. 2014; 22(2):235-46. Epub ahead of print.
- Camiolo Reddy C, Collins MW, Lovell M, Kontos AP. Efficacy of Amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. Journal of Head Trauma Rehabilitation, July-Aug. 2013; 28(4), 260-65.
- Sabini RC, Reddy CC. Concussion management and treatment considerations in the adolescent population.
- The Physician and Sports Medicine 2010 Apr;38(1):139-46.
- Marmura MJ1, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015 Jan;55(1):3-20. doi: 10.1111/head.12499.
- Garza, Ivan, MD. Todd Schwedt, MD, MSCI. Chronic migraine. Uptodate.com
- Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Am J Sports Med. 2014.
- Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sports Med. 2015;34(2):213-231.
- Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med. 2011.
Dr. Anderson has reported no relevant relationships with proprietary entities producing health care goods or services/
Dr. Mucha has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- CE Speakers’ Bureau: ImPact Applications, Medbridge, APTA
All presenters disclosure of relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients is listed above. No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose.
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The University of Pittsburgh School of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.1) continuing education units (CEU) which are equivalent to 1.0 contact hour.
For your credit transcript, please access our website 4 weeks post-completion at http://ccehs.upmc.edu and follow the link to the Credit Transcript page. If you do not provide the last 5 digits of your SSN on the next page you will not be able to access a CME credit transcript. Providing your SSN is voluntary.
Release Date: 1/10/2017 | Last Modified On: 1/10/2017 | Expires: 1/10/2018
Well thanks, it's a pleasure to be here. You know I probably need to acknowledge that you know even though I am kind of the coordinator of all of our vestibular rehab in our group there is probably about 20 other clinicians that do what I do in my group and I'm so fortunate to have them, and many of them are here today. And you know so if I start to fade I'm just going to have one of them come up and finish the lecture because they could probably do just as good of a job or better job than me.
So learning objectives I think you have. So I don't know if we actually showed this graph earlier on today but this is typical recovery from concussion and most of you know that you know within the first few weeks we see a lot of spontaneous recovery of this injury. But I think that most of us are here to understand you know what is the issues behind the people that won't recover spontaneously, because I think the argument can be made that if we really just don't mess up the group that's going to recover spontaneously, if we just don't allow them to get reinjured there is not a lot we need to do other than you know just do some conservative management. But it's these 1 in 5 cases, these you know 20 to 30% of patients that really create a lot of our problems and create a lot of the morbidity associated with this problem.
So as you know I'm the vestibular lecture so the bias that I'm going to come at is that you know a lot of these patients that we see in this 1 out of 5 have vestibular problems, or at least a good portion do. So let's talk about this trajectory. And as I think a lot of the speakers yesterday really prefaced this lecture nicely and illustrated how vestibular problems do seem to come in part and parcel with a lot of these protracted recovery cases. So vestibular problems are common after concussion and I'll show you that. They are often part of that delayed recovery process and you know so what that implies is that we have to have good assessment tools for understanding the vestibular system and also more importantly is we need to do some things to intervene to make it improve.
So many of you may be familiar with this study, it was done a few years ago but it was something that was actually enlightening for us. If you look at all of these on field signs or symptoms that were tracked in high school athletes looking at well are there any things that we can identify early on after the injury at the time of the injury that help us elucidate whether this is going to be a protracted recovery case. If you look at all of those signs and symptoms, amnesia, loss of consciousness, confusion, vomiting, you know light and noise sensitivity all of these things that you think potentially to be issues really only one factor stood out in predicting whether somebody was going to take - be in that protracted recovery group and that was dizziness. In fact vomiting and loss of consciousness which you know many people thought were probably going to be strong indicators were not. They predicted actually quick recovery. But patients who had or athletes who had on field dizziness were more than 6 times more likely to fall in that protracted recovery group, meaning that it took them more than 3 weeks to get better. So what is it? Is dizziness telling us about vestibular problems? We probably, at least in some cases it is.
Now since that study there have some additional literature that supports this even further, and these are not on field indicators but these are post-injury you know in office indicators. But two studies published last year also echoed these findings. When these vestibular and sometimes vestibular and ocular findings are present, especially in our young patients it means that they are going to take longer to recover, they are going to have more PCS. And so this is something we have to look at more thoroughly.
So how do you figure out if perhaps your patient is in that vestibular/ocular subtype, particularly the vestibular subtype? Well of course we spent some time yesterday talking about family history and subjective history, and that's extremely important. Looking at those symptom lists, looking at whether vestibular and dizziness and balance problems are part of the tool, or part of the profile. I think most of us are familiar with balance testing as a way of assessing the vestibular system, right. Everybody knows about the BESS test, that's been the thing that's been out there, the earliest in the literature. But the problem with balance testing is it really only tells part of the picture when it comes to the vestibular system so it really wasn't sufficient.
And that's where the VOMS came from. And how many of you are familiar with the VOMS here as far as do you use it clinically? So I'm preaching to the choir on this side, and this side you guys aren't as familiar and that's fine. But that is the premise behind developing the VOMS is we needed something clinical that we could look at these other aspects of the vestibular system that were not balance. And then once those additional issues are identified through screening then more detailed clinical assessment of the vestibular and oculomotor systems is necessary.
So from a subjective standpoint what are the things that you are going to see or at least start putting you in that framework of understanding, or thinking that perhaps this patient has vestibular deficits? And you heard this from Mickey yesterday as well but these are the patients that typically will have dizziness as one of their prevalent symptoms. But there may be also some other things that are going along with that besides dizziness. They may have impaired balance, especially in the dark or in visually conflicting environments. They may have trouble with focusing their vision, they may feel like their vision doesn't catch up with their eyes. You know their eyes, they move and their visual field doesn't stay with their vision, or with their head movement.
They may have increased motion sensitivity, motion discomfort or even height problems. So with a patient that comes in and says you know I feel very uncomfortable at the top of my stairs and I never did that before, or I never had that before. That's an indicator. And then the big one is difficult in busy visual environments, and this is where you see kids have trouble in their school hallways whenever they area changing classes. You'll see patients be very uncomfortable in Target or Wall-Mart or at the grocery store, places like that. And those are those subjective factors and things in your clinical interview that start pointing you in the vestibular direction even before you do any physical exam.
And I believe Anthony spoke about the VOMS yesterday so I won't go into it much. For those of you that are familiar with it great, for those of you that aren't it's just a brief screening tool. So this is a very watered down version of the vestibular assessment that a vestibular physical therapist would do, but it's a way to start elucidating whether the vestibular system is creating some noise as well as some ocular issues as well. So if you use this in conjunction with your balance measures, with your subjective reports, with your past medical history you are going to have a more complete picture of what kind of clinical profile your patient is experiencing.
And I believe we showed these yesterday but it just goes to show that how these vestibular issues and oculomotor issues as well are very prevalent following a concussion. You see that the two items that are pointing to the vestibular assessment of the - in the VOMS are the last two items, the VOR and the Visual Motion Sensitivity items. And in our sample approximately 50% or more patients acutely or subacutely after concussion are experiencing these types of complaints so we know it's highly prevalent. And as Anthony spoke about yesterday in controls we just don't see problems in these areas. So the blue are the patients and the controls are the orange and you just see that there is a huge difference. And we heard from Alicia yesterday also who explained that those patients who probably are controls who are symptomatic are more likely those patients that are motion sensitive or have some of those profiles that are you know underlying on the vestibular system normally.
So again anybody that's familiar with the vestibular system so all my colleagues that know about the vestibular system you can ignore this part, this is for those of you that kind of think about this word. And I always laugh because every month or so I have a patient that comes in and says to me so can you explain a little bit more about this vesticular system to me? And I realize how much of an enigma it is. So this is for the basic of the vestibular system. So what it is it's two parts. One is the peripheral system which includes the peripheral system which is the inner ear, so it's that bony labyrinth in which you know your hearing apparatus as well as your motion detector apparatus is housed. So that's where you halve your semicircular canals, your otolith organs, the things that detect movement and then the vestibular nerve and ganglia that are associated with that. And then just importantly if not importantly where that peripheral system projects to centrally is the central part of the vestibular system, so that's the vestibular nuclei, the cerebellum. There is a lot of autonomic and thalamic interplay with the vestibular system, that's why you get a lot of motion sensitivity, cerebral cortex issues. So the vestibular system, and we'll talk about can be impaired both peripherally and centrally or one or the other after a concussion.
So from a functional standpoint it's pretty simple, there are two main functions. One is to stabilize your vision, so as I'm standing here talking with you all the reason that I am not losing my balance is because my vestibular system allows my gaze to be stabilized as I move my head. And then the second part is balance control, and the vestibular system contributes to balance control by creating those sensory inputs. But it's also combined and duplicated by other sensory systems like your vision and your somatosensation. So there is a overlap in balance control where the vestibular system works part and parcel with those other two systems.
So I don't want to sound too simplistic because again my vestibular colleagues will understand that vestibular rehabilitation is incredibly complex and there is a lot of things that go into it. But when we talk about concussion and concussion only there are four basic things that we see. And 99.99% of the time, although we did have a case last week where they fell outside of this 99.99%. But 99.99% of cases you are going to see one of these four or more than one of these four issues emerge: benign positional vertigo, VOR impairment so problems with that gait stability mechanism, balance impairment and visual motion sensitivity. And those are the things that need to be screened and need to evaluated and then if they are present that's what vestibular therapists need to address.
A word about vestibular therapy because some people are really not believers. There is emerging literature about vestibular therapy. Now for those of us that have been doing it for a while we know that there is a lot of great evidence, excellent evidence about vestibular rehab in non-concussed populations. We know that it has, it's very evidence based. But in concussion it's of course slower to emerge, but there are 3 studies that have been published and probably more to come soon about how the efficacy of vestibular rehab after concussion, one is in a military subset, one we did here in Pittsburgh in a retrospective chart review a few years back and then there was a randomized controlled trial done in Canada looking at the implementation of vestibular, vestibular/cervical therapy in patients and actually influenced return to play and helped to enhance outcomes and recovery.
So let me go back to those 4 issues that you see after concussion that affect the vestibular system. So Benign Paroxysmal Positional Vertigo, BPPV, now this is something that many people are familiar with. So actually how many of you guys in here are familiar with the concept of BPPV? Okay, so at least a good bit. Perfect. All right so and then let me just ask one other question, so how many of you only deal with young athletes in this room? So many of you. but how many of you see a mixed population of patients that are both young and old, older? Okay. So for those of you that only deal with young athletes you are probably never going to have a problem with BPPV, but all of you that raised your hand about dealing with a mixed population, patients that are 40 and above you are going to see this. And this is a peripheral problem, so this is one of the few of those problem areas on my list where the problem is in the inner ear itself and there is little crystal, otoconia that get dislodged when you halve the concussion forces. So it's a very mechanical problem. These patients will have typically have vertigo when they move their head in certain directions and that's really the hallmark is that if somebody comes in and complains that they are dizzy just sitting there in your office that's not BPPV, but if they are having dizziness that's related to changing their head position, like lying down in bed, turning over in bed, getting out of bed then BPPV needs to be screened for.
And the other thing about BPPV after concussion as with all types of traumatic brain injury this is one that I would probably suggest that you send to somebody that knows what they are doing as far as vestibular therapy because it is often not the typical easy case of BPPV after concussion. We see it much more often bilaterally, we see it more often in multi-canals and that's trickier to treat and you probably need things like video infrared goggles to treat it appropriately. So just know that if you do suspect BPPV you might just not want to send it after concussion to you know somebody that dabbles in vestibular therapy, you may want to make sure you send it to somebody that can really assess it. And the way that you manage it is through canalith repositioning maneuvers, or particle repositioning maneuvers, which basically try to reposition those crystals back to where they belong.
Okay, so VOR impairment, and this is again that ability to stabilize your gaze when your head is moving. And it's extremely important. And what we see after concussion is that, and this may be because of central or peripheral problems but we see that that problem with keeping your gaze stable becomes disrupted so that patients complain of blurry vision or that complaint that I spoke of earlier where people feel like their eyes and head aren't matched together starts to crop up. And what you'll see is this emerges more with faster movement. So patients that basically are sedentary won't really notice much trouble until they start moving faster and then they start to see these kinds of symptoms occurring.
So most people don't understand how the VOR is responsible for functions in life, and again if you are moving at just normal everyday speeds and you are very sedentary and not really getting outside of your home you may not notice a VOR problem because head velocity speeds that are slower don't necessarily require much robust activity of the VOR. However as soon as you get into more aggressive activity, things even as simple as you know cleaning your house, those normal activities of daily living, then you start to elicit that response and that's what we see often is that patients initially don't feel much but as they start trying to engage in their normal life then if they have a VOR problem it will come out. And then when you get into things like sports of course you need that, you need that system because these high frequency or high speed head movements really your visual system can't do the job. Your vestibular system has to be active. And the reason for that is that your visual system actually acts much slower than your vestibular system.
So let me illustrate that for you. All right so everybody take something out that they can read, so take either your program or something that you can focus on. All right, and what I'd like you to do is to - I want you to oscillate that back and forth okay at fast speeds, so really fast back and forth, back and forth and try to focus on something as you are doing that, okay. How many of you are having difficulty still reading what you are trying to see? Right, okay, so it's very, very difficult to do that. Now I want you to do the opposite, so you are going to hold that steady and now this time I want you to oscillate your head back and forth at that same speed. Okay, see how much better that works. Okay, that's your VOR, that's your VOR in a nutshell. So what happens is you have to use your visual system along with your VOR system for things to stay stable in your world, otherwise things just don't work.
So what do we do about VOR problems? Well the nice thing is that they are incredible amenable to treatment. There is fabulous literature that shows how adaptable the VOR response is, which is good for us. So vestibular therapists are going to do a host of things that are related to you know moving your head. So it might be as simple as you know just focusing on a target, I don't know if this one will work. Just focusing on a target much like what we just did here and moving your head but it doesn't stop there. Then you need to do things that make it much more dynamic and active. So basically then as you deal with somebody that's an athlete you have to work on things like changing posture, changing position, changing environment, changing demands of the task, so things of that nature will absolutely help the VOR system to respond the way it's supposed to.
Okay. So visual motion sensitivity, this is I can't stress enough how much - this is probably the thing that you are going to spend the most time on in vestibular rehab. The VOR issues will come along, BPPV can be treated very fast, visual motion sensitivity is something that absolutely takes longer and is more complicated to treat but it's incredibly important to work on. So these are the patients that have kind of a heightened awareness of visual motion. They have this hypersensitivity of their optokinetic system and what happens is that normal visual stimulus that doesn’t really influence most people becomes hyper-perceived. There is a lot of terms out there in the literature, we call it visual motion sensitivity because again we deal with a population where we need to have some terms that are understandable but there are other terms that have been you know put out there like space and motion discomfort, or visual vertigo, things of that nature that pretty much mean the same thing. But these patients are really the ones that really can't walk in supermarkets, they can't be in crowds, they can't be at PNC Park last night, they can't be at heights. In Pittsburgh we have tons of bridges and tunnels, patients will avoid tunnels and they will drive you know 10 miles around to try to not go through the Squirrel Hill Tunnels, things of that nature. And certainly it's something we need to address.
So I put this up here just because some people have - want to understand you know what does visual motion sensitivity mean to your patient? Well if you stare at something like this it's a pretty uncomfortable picture, right. It's a little unsettling, you kind of feel like things are moving when they are not really moving. As soon as you look at something that you think is moving it's no longer moving. And that's a very unsettling feeling and if you look at this for some people in the room you might even feel like it starts to bring on a feeling of discomfort, even slight anxiety you know when you look at that it makes you very uncomfortable. Well patients that have visual motion sensitivity feel this way all the time and this feeling is amplified in any environment where there is things going on around them.
Now the reason why visual motion sensitivity is hard to treat also and requires a bit of time is that it usually isn't - it's usually an indicator that there is more going on with this patient than just a vestibular system problem. It usually means that there is some other coexisting pathology and so we often see it kind of traveling along with the migraine traits and the anxiety component. So often in these patients that have this vestibular presentation we are treating posttraumatic migraine and/or anxiety mood issues. And I always say to the people that I work with and my students is if you see patients have this heightened visual motion sensitivity you need to look and dig for anxiety and migraine issues because more often than not you are going to see them traveling together. And then you need to address all three. So again these folks need to be in vestibular therapy, they often will need some type of medication, they may often need behavioral or psychotherapy to go along with their problem.
So what do we do for it? Well we actually again this is a system that can be adapted or habituated because if you think about it it's a hypersensitive system, so we need to do things that dampen that sensory response. So we gradually expose patients to provocative stimuli. Now I can't say enough how that has to be done in a very skilled way because if you can imagine and probably many of you have had experience with patients like this, you can trigger a whole host of negative responses if you are too aggressive with this. And then on the flip side you can completely allow somebody to become agoraphobic if you don't address it. So it's kind of finding that right dosage of what you can have them practice and handle, it's the skill of treating this. The big thing you have to manage is their anxiety responses and you also have to be wary of provoking migraine when you do this.
So this is a picture of our virtual reality grocery store. We have a virtual reality cave we call it at our Eye and Ear Institute here in Pittsburgh, and this is a research based paradigm, but this is you kind of take somebody - so that's a treadmill that they are standing on and they have this grocery cart handle. And then the rest of it is just is a projected screen and you can make the grocery store busy or you can make them search and scan for things. But the idea is that this is a way of dosing and progressing treatment. Now we don't all have access to something like this so we figure out ways in real life to have patients practice things of that nature using - you know we use a lot of videos, we use a lot of backgrounds, we use a lot of environmental stimuli. But it's incredibly important to be able to kind of train and desensitize that system.
So I put balance last because I think this is the thing that most people are aware of is the balance problems that you see after concussion. So we know that balance problems present very commonly acutely and subacutely after the injury. And what it's related to often is problems with the sensory organization, using three sensory inputs, and balancing the inputs of your vision, your somatosensation and your vestibular system. So the ability to use, especially the ability to use the vestibular sensation seems to be impaired, especially early after concussion. And measuring that of course the gold standard is using computerized dynamic posturography which is fabulous. We have you know in some of my clinics we have this, in some we don't. The other clinical measures that actually do correlate well to computerized dynamic posturography is the CTSIB, The Clinical Test for Sensory Interaction and Balance and then the BESS test as most of you are aware of for athletes. Again those are good substitutes when you don't have computerized dynamic posturography available to you.
But as we said and I believe Anthony showed this slide yesterday is that you can't rely on balance to be the end all, be all of the vestibular system evaluation because it just doesn't correlate to all of those other factors which I spoke of. It doesn't correlate to BPPV and VOR issues and VMS, and this is what we showed yesterday of how it doesn't relate at all to the items on the VOMS. So it's certainly a piece of the puzzle but needs to be tempered with the other measures.
So the other thing is that balance testing is incredibly important after a concussion is that we know that patients early on and actually sometimes it's one of the most powerful ways of demonstrating to an athlete that they actually are concussed right. You have them stand, have them stand on a piece of foam and close their eyes and they cannot maintain their balance. Well that freaks them out, sometimes even more than some of the symptoms. So that's really a great measure. But the problem is that recovery from these balance deficits, these sensory organization deficits really occurs more quickly than many of the other issues and symptoms after a concussion, so even though it's an important component it's not the only component for vestibular system recovery. So you need to dig further beyond the balance improvement.
And for training balance the big - the key components are that you have to make patients use their vestibular system to balance, so you have to change the surface. You have to change the visual environment, reducing their vision or changing the visual complexity. But it doesn't stop there, then balance is dynamic, it's more than standing on one foot. It's about putting you in environments and having to multitask and to have cognitive distraction. So again kind of only training balance in a very uni-dimensional way is probably not sufficient for training.
So I think I'm hopefully on time. Vestibular problems we know happen very frequently after concussion, are probably important to recognize because they are probably part and parcel with a lot of those patients that are going to take longer to recover. Hopefully if we intervene earlier we can help affect that recovery trajectory. That's at least our premise is that if we know that this is an important finding and we begin treatment a little earlier we can sometimes negate some of these negative consequences that cause patients to take longer to get better.
It's fun for me to talk about this, I mean this is my job day in and day out. I can get frustrated with this injury but so are the patients, so I feel like we are on a joint - the same page there. So it's a fun mystery of concussion and medication. I don't have any disclosures, that's my easiest slide.
So the objectives today we want to talk about the treatment goals, the treatment timeline, symptom cluster approach to pharmacologic treatment and the treatments themselves. And so this is a medication talk so those that don't prescribe medicine don't zone out because your athletes may be on these meds and it's better to know about them and have a good understanding so that you can help them understand why they need to be on these treatments if they are.
So early diagnosis is key, and we talk about this time and time again. And the main thing that I like to say about early diagnosis is that it allows you to provide that education early to help them understand their injury, to help them understand what they are going to be going through during their recovery phase and it just gives them a sense of ease when they have that education. I find that a lot of the patients that come to see us that don't understand concussion they feel so much better leaving at the end of the day because they start to get it, they are like okay, this is what my injury is and that helps them to recovery faster. Education is key as we know.
We want to determine a treatment trajectory and really that's for your sake. It helps you to organize your thoughts, to organize the symptoms and to allow yourself to kind of make focused treatment plans for the patient. And then initiate appropriate treatments when needed whether that's conservative through therapy versus medications. We want to limit the medications. I always say when they come in because they are going to say we don't like meds, and like okay well I don't either so we are on the same page. And I say you know meds are a part of your treatment in some cases but we are going to try to limit them. I understand that they are scary but once again once they are educated on that medication they feel a little bit better. And if they need it and they respond well to it they'll appreciate it in the long term.
So when do we start to think about medications with concussion? My slide is a little covered there, sorry about that. But when the current symptoms are severe enough to really impede their recovery. So if their symptoms are just limiting you now day to day activities you know you need to start thinking about that, and if the symptoms aren't getting better within a reasonable time. If the symptoms are interfering with their rehab program, so if they are not able to do their vestibular therapies or they are getting headaches with their exertional therapy and it's been going on long enough we have to start thinking about treating the symptoms because we know that if we don't rehab some of these systems that are injured these symptoms are going to go on for a long time and you are going to be seeing them for a longer time and other things are going to develop so it's really important to address those severe symptoms.
I also treat if the current symptoms are keeping them from work or school because we know now that if we take them out of social centers or their work environment or their school related environment they start to kind of fall downhill, you know they start to get secluded, they start to get anxious and then they get frustrated because they are getting so behind. Sp if they are not able to go to school because of these that's a real reason I start to think about meds. And if the - sorry this is totally in the wind. But if the symptoms are severe enough that they are rehabbing and they are still not getting better I'm thinking meds.
So some of the risk factors that we look at, and you've heard these time and time again, they are very important from a medication standpoint because this is what I'm assessing when they are coming in. Do they have a family or a personal history of migraines? That makes me think okay if they do I might be heading down the med pathway at some point. Do they have a history of anxiety of depression or a family history? Now is there a genetic component that maybe this injury might bring that anxiety out of them. Do they have a history of sleep disturbance? You'll hear this is the main thing I focus on because if they are not sleeping it's really hard to get better. That's when we do recover from not just concussion but just any activity to be honest. That's where our muscles recover, that's where our rest comes from. And a lot of the time if you don’t know that they are coming in with a preexisting sleep issue you are going to struggle, so make sure you ask is this a problem for you beforehand so that you can know all right well they are already baseline at a lower sleep number so that will help you in the long run. Do they have a history of ADD or ADHD because that sometimes becomes a little exacerbated or really what I use is deconditioned. And then history of vision abnormalities and then car sickness and dizziness. That helps me to know okay what are these risk factors that they might have that I may need to address with medications?
And of course, yes, I am probably one of the most conservative people and so I like to start with conservative therapy, but again I become the aggressive part of the treatment and so letting patients know that hey I want to be conservative too but we may need to get a little bit more aggressive with this helps them to understand you are on their side, you want to do what you can without meds but you will use them if needed. And you can see our conservative and we have the cognitive rest, the sleep hygiene, the physical rest and accommodations. Now when you - whenever you see cognitive rest and physical rest remember that is not in a dark room, that's relative rest is what I like to use. I use that for my musculoskeletal athletes too. Don’t worry I try not to shut you down, but relatively we are going to change some things in your daily routine so that you don't get hurt further.
And then we start to advance. Do they need therapies, the cognitive, the psychotherapy, over the counter meds I consider a little bit more moderate, vestibular or vision therapy and then physical. And then we get to the aggressive and you can see that whole line says meds, meds, meds, meds. And so we are trying not to hit that place but there is a role for it, there really is and we'll talk about that.
As you've seen before you can tell we are a team. I mean I think we function as a unit because we all have these slides that talk about the clinical trajectories and that's because it's important. Again for the education of the patient but to get your mind organized. This really helps me, I look at this and I go through it with the patient as well and I say all right which category or categories do you fall in? We are going to address this sometimes together, sometimes individually but I think again it's about organization in your mind, otherwise you are going to be a jumbled mess in there.
But first before we go into those trajectories again let's address sleep, it's all about sleep. I mean I love it, you love it, we probably don't get enough of it. But what could be causing it? Oftentimes preexisting sleep disorders and that's again a big one I talk about, just issues from a neurophysiologic effect from the injury itself you know that neurometabolic imbalance can create a sleep disturbance. Pain, a lot of people neck pain, headaches, there is a lot of issues keeping them up at night. Environmental stimuli especially in our younger population, TV, phone, music, etc, especially that phone, that buzz, buzz. I mean we all know what it is, it's right next to their bed. And you've got to say you know I'm not trying to be mean, I'm not trying to be the parent at this point but this is the best thing for you, shut that phone off at night. You know we focus on texting a little bit less because they get those text messages at night and you say this is your private time, this is when you are sleeping. You know you can talk to those friends in the morning. And again if you address ti saying I'm not being the mean one I'm just trying to get you better faster so you can get out there sooner. It's all about the way that you talk with them. It's a better understanding of their injury, a better understanding of why you are telling them no.
Pharmacologic effects, I could be keeping them up. What if I gave them something from a medicine standpoint that now you know you think you are giving them an antihistamine and they are that population that is hyper and alert as a result of it. So make sure you are not the cause of it.
And then anxiety and depression, such a real issue with sleep. Folks are thinking about what they missed the day before, what they need to the next day, just depression and anxiety itself keeps you up at night. I'm sure many of us are type A personalities so we all have a little anxiety, that's how we succeed in our jobs. And so you know that there are struggles at night sometimes with sleeping.
But do we do about it? Conservative, proper sleep hygiene, we've talked about this a lot. I stress to them you get 7 to 9 hours, no more, no less, and no naps. As soon as you hit that no haps you know they are like oh darn, that's what I'm doing every day for 2 hours. So you want to restrict them. And again the way that you say it is this is what's going to help you get better faster. That's what they want to hear, you know they want to get better faster and you are giving them tools and really you are giving them a little bit of the authority in this. Hey, you create your schedule, you are going to get yourself better. It's all about motiving as well.
And then relaxation therapies. Turn on that nice waterfall, turn on some white noise even, a fan, I say put it on the floor and face it away from you so you don't freeze. Let that hum go so that your mind is hearing that instead of its thoughts. And then I also think of little things, this always sounds silly when I'm describing it but you lay there in your bed and you start at your hair and you think hair relax, scalp relax, forehead relax, eyebrows relax and you go down and then you bore yourself by the time you are midway you are falling asleep. So just little tools to take their mind off of their thoughts.
But when all else fails yes we may be going to pharmacology. I use some of the over the counter medicines first. I've got non-concussed patients on Melatonin you know because our body has that hormone we need to enhance it a little bit. Just be careful because people will go high up in their dosages and really our body just needs a small amount, really 1 mg should work for a lot of us but I usually say about 3 to 5, that seems to be the one that works. And there is a regular versus extended release so if they are waking up in the middle of the night they can try that extended release. If they are having trouble falling asleep initially the regular.
Antihistamines I use just minimally but I do tend to try to reset their sleep cycle with a simple med like Benadryl or Vistaril is helpful because it's also helpful for that anxiety component so I'll do that short term, I don't want them using you now Z-Quill for the rest of their life but sometimes we just need to reset that sleep cycle. We do some more specific and prescription medications because again I've got to get them sleeping.
So in some cases I am using Amitriptyline and that is becoming more readily used I think because I use low doses of that medicine and it also helps migraine headaches, so I try to kill a couple of birds, even though I love the birds, with 2 stones, or with 1 stone. And I find that Amitriptyline if you titrate up slowly will really get that drowsing side effect, but you want to make sure that you are not just titrating up too fast because they'll really be groggy during the day and then what are you accomplishing, they want to do those naps that you are asking them not to. So I'll start at 10 mg, titrate up to 30 and then sometimes I'm up to 50 with that;, but it depends on the patient. You can use this in the younger population but again you want to be conservative with the children I mean as you are with anyone, but they can have more side effects that you've got to watch for. And again you are only using these if necessary.
Trazodone is a good sleeping pill. At baseline it's an antidepressant antianxiety but we use it as a sleeping pill. You just have to watch some of the side effects but to be honest I have good toleration for my patients and I'm usually about 50 to 100 mg of that, and again it's short term. This is what you are telling them, this isn't for the long haul, let's get your sleep better and let's get you off the med. They feel a little bit more comfortable that way.
I rarely use Ambien but on those that I've tried everything I just knock them out with Ambien. And you have to give them the side effects, you may wake up in the middle of the night, go to the refrigerator and eat something, but hey, at lease you are eating something. But those are some crazy side effects, so I limit the use of that. Low dose for that too, 5 mg.
But let's talk about some of the factors that may affect using pharmacologics and the thing that I look at when I'm starting to treat a patient is you know have we given them enough time to heal? And to be honest I've got the best team in the world so I know that they are sending them to me at the point where they need something, you know. And so we've let that brain rest, we let that brain heal on its own for a period of time. And so at that point you know usually about 3 weeks in if they are still struggling we are really talking the meds. Oftentimes though the majority of my patients are months into their recovery and I'm really trying to get them back on track.
Would earlier treatment speed recovery? That's kind of what we are trying to figure out, and again remember I don't love using meds so if I don't have to use them I'm going to try not to. But if I see that their symptoms are severe enough or feel like they truly would benefit from a medicine a little bit earlier I will try to get that started if possible.
What age is too young to give medications? Well that's really what you are comfortable with as a prescribing physician. I've got some kids that are 8 years old and they need headache medicines for their migraines. You try not to do that but again when the time is right you use it. But it's a comfort thing and what you've been trained to do. There is other issues, for older adults my age and above they may be on other medications and they have other comorbidities so if they are coming in on multiple meds I'm probably not going to try to add another medication except for maybe a little Melatonin. But you've got to watch what they are already on, the interactions you know that can be a big issue. And then again the past medical history is what's going to guide me. That anxiety, depression, migraine, car sickness, learning disabilities or ADD, ADHD those things may say okay Dr. Anderson, start thinking about you know the medicine trajectory that you might be heading to here.
So we are going to kind of go through this circle and talk about how we use medicines in these treatment trajectories. Dizziness as we've talked about time and time again is very important to identify and treat. On field dizziness we know is our best predictor of recovery, and I utilize that quite a bit. In the notes from my neuropsychologist I'll see one of their initial symptoms was dizziness and like okay how far out are we? A couple of weeks in we are in vestibular therapies, we are struggling, okay I'm pulling out my meds from my pockets, not literally. And I'm trying to figure out along with them, gosh we are talking, I think Anne comes down to my side of the treatment place several times throughout the week and we talk about is this a migraine variant, is this central, is this peripheral, is it from the ocular system? Is it a cervicogenic type dizziness or is it psychologic? You know so again there is not one medicine to treat all dizziness. I wish I had that. And we know that vestibular therapy is the first line in treatment of this, however there is a medicine that we can use and there are medicines that we can use to help treat the symptoms and really suppress them so that they can get through their therapies.
I usually start to think this when they have increased sensitivity to crowded environments, travel or moderate to severe dizziness. So if they are coming in and they are - they are not able to go out to the grocery store, to the mall, they are avoiding social situations because their symptoms are all stirred up they start to avoid, and that's the worst is avoiding those situations because then again the words that I like to use with them, you are becoming deconditioned. Just your muscles get weak when you stop exercising your body, your mind, your brain gets deconditioned to those places and that's where we start to again lead to some anxiety, some depression because they are withdrawing. And so those are the times where I will use a medication if needed.
So I use Klonopin, use it as a vestibular suppressant. The mechanism of action is unknown but it does, it has been studied to suppress that vestibular response. .25 to .5 mg, so I'm usually saying don't worry, I don't like this med either because ti come with a you know a bad label on it of addiction but I use it at very small doses and for a short period of time. So .25 mg is usually half a tab twice a day. In my very severe or moderate to severe vestibular patients I'll do .25 in the morning, l25 in the afternoon, on occasion I'll do .25 in the morning, l25 in the evening because let's remember this is actually an antianxiety medicine so if they are not sleeping I can calm that brain just a little bit at night as well. And the goals are to suppress those vestibular symptoms so they can get through their rehab, so they can get through their day, so that they are not starting to avoid. It also improves the vestibular related anxieties and I supplement this with vestibular therapy. So most often they are still in their therapies and as those therapies conclude so does their use of the Klonopin. And you have to set the stage, this is what we are going to be using it for and then we are coming off. My goal is to come off all of their meds at the end of their recovery. Again education, you know talking to them about the medicines and why they are using it and what it's used for and how long they are going to, they are hopefully going to be on it is so key for them.
So we've covered two of them, let's go to the next one, the posttraumatic headaches. Notice this is posttraumatic headaches and there is a list of different things that this could be coming from. So again this is why I went into medicine, I like mystery, I like figuring things out. So the goal is to figure out are they having a posttraumatic migraine? Is it musculoskeletal in origin? Do they have trigger points, muscle spasms, facet or disc related issues? A lot of this is whiplash so we are stirring up the cervical spine. Are they get rebound headaches from the medicines that they are on? We'll talk about that in a little bit. Do they have nerve injury from impact you know or irritation or spasm that's causing unacceptable neuralgia, you can see the nerves just fan out behind the head so I start to think okay if we are getting this headache that just kind of goes like a seashell I like to say up over your head is that a source of headache? Are they fatigue related which we'll talk about. Are they vestibular/ocular? So again it's a team approach to figuring out where this is coming from.
Musculoskeletal headaches we try physical therapy. We do sometimes muscle relaxants or analgesics, I limit those meds if possible because either I have them on some other or that makes them drowsy and I don't want that. I use a lot of TENS units, I love this, let's trick the mind, let's have the mind thing about that stimulation instead of feeling the pain that the brain is getting from the body. Thoracolumbar support bracing, a lot of my patients come in like this and I'm like guys the next visit I better see you like this. I have better posture now because of my patients I think. But I'll use braces that help to pull those shoulders back and it's training braces, it's to help them remember this is where we need to be to take the pressure off of our traps and our cervical muscles. Manipulation whether that's in PT or with an osteopathic or chiropractice manipulation, we do utilize that at times. And then if they have no relief with conservative we are going into the x-rays, we are looking at the MRIs. There may be referrals for injections and again we are sort of taking that scale from conservative to more aggressive.
And we limit the over the counter use you know of medications. It is not forbidden to use them but we want to limit them, and I'll talk about that. Hydration is key. At baseline we all should be having 80 oz of water a day, my goodness it makes me want to go to the bathroom now. But think about we are getting them active again too and a lot of them are athletes and so they are working off and burning off more fluids, so they need to be replacing what they are burning off in those exertion therapies that they are going through. Making sure that they are getting 3 regular meals a day or 5 small a day. I mean this is just general good health and that's what I'm telling them, we are going to make you better at the end of this concussion than you were before it. Cold compresses to the forehead or the back of the head. And the other things are it's covered up here but you know what else is going on? It's allergy season right now, I know mine are acting up. You know are they getting sinus congestion, that's the cause of their headaches. So ask questions.
Acute relief, again do you use over the counter meds, Tylenol, Ibuprofen, Naproxen, these are not - this is not poison, they can have it now and then. It's just we want to make sure that they realize that you can get a rebound headache because they do not write that on the bottle and everybody comes in, oh I'm taking you know Aleve twice a day every day. Okay, well how long have you been doing that for? Ever since my injury which was back in January. Oh, you know I have the joy of having a team that assesses that as well but some sneak through. And I'll be like okay, we've got to jump on that.
The tension headache medicine I like for my younger population because it doesn’t have the aspirin component in it, and so they can get it over the counter and use it for those acute migraines, again limit use. And then Excedrin, I love that one, that works for my migraines. And so they've got to do a little trial and error process there. And then we go secondary to the prescription meds like the triptans which Maxalt, Imitrex that help to break that acute migraine that comes in. Side effects though can be nausea, dizziness, drowsiness and muscle weakness so make them aware of that.
And so there is medication overuse headaches, they mimic our regular headaches, they occur daily, they can wake you in the morning, they improve with simple medications. They return as the medication wears off and it increases with physical or mental exertion. Every headache does that right. And so you really have to ask what meds they are on.
Vitamin supplementation comes in with migraine treatment and these are folks that really truly have a history of migraines. People like to take medications sometimes because they feel like it's doing something, well hey hit them with a vitamin. It really does take 3 to 6 months to take effect if they take it daily so don't expect immediate treatment or relief with this but it's a good tool to add on, especially in that history of migraines.
And then sometimes like I said we are really going onto the preventative treatment with some antidepressants, anticonvulsants and even those oldies but goodies the beta blockers. The Amitriptyline I like because it helps the sleep, it helps the headache component. SSRIs are used in the times when there is anxiety, depression involved, that's the stress related headaches. And again I try not to use this, but it's common in my practice these days because we've seen what concussion can do to the anxiety and depression side.
And then cognitive symptoms, headaches that worsen as the day progresses is called a cognitive fatigue headache. And this is the simplest of all the prescription meds I use actually and that's Amantadine. I use it with 100 mg with breakfast for 5 days and 100 mg with breakfast and lunch and it really does improve their quality of life. And I've seen that from a subjective standpoint with my patients. I see hundreds of concussion patients and the ones that this works for they just are very thankful for it. It gets some bad rap though. One of the Indianapolis Colts, Tyler Varga, had been suggested this medication and looking into it he had asked some other physicians and they said no, no, no, you can get psychotic features with this. I have not seen that yet in my population. It can happen, it's a side effect, but what he said is oh they said you can never stop this medicine, you have to keep increasing the dosage until your symptoms go away, that's the way I understand it. That's the problem, he wasn't understanding it appropriately. And that's where my job comes in to educate our patients on these meds because it really does help a lot of them if they have cognitive fatigue headaches, if they have slow reaction time, slow speed on their testing.
Rarely do I use some of the psychostimulants. If they've used them in the past or they have that deconditioning form their previous ADHD their coping techniques are down, I may go to those, but infrequently.
And then finally kind of one of the biggest things, so I should probably put this at the beginning of my talk is the neuropsychiatric portion. Mood changes do occur often following concussion and I'll be honest I'd like to see, I'd like to almost at some point say the majority or most patients have some type of neuropsychiatric issue. And that's because concussion can make them nervous, can make them irritable. Ask their parents, they are very irritable. They can have the sleep disturbance and sadness and increased emotions. If you haven't yet you are going to see a football player who is crying on the sideline after his injury or crying in your office later which is unusual right? But it's very real. There is fear because they don't like the way they feel, they don't know what's going to happen or will they recover. There is social stress, family stress, so there is reason to have these increased emotions. And our goal is to be their support and to educate them. I can't say that enough.
Conservative psychotherapy, is that really conservative though? I mean that's pretty important and it is kind of moderate to aggressive because one, they don't want to do it, that's the problem. And so explaining to them why this is so important you know you may have been able to handle these situations and you are going to handle them again but we have to just remember you know how to train our brain to think a different way as opposed to being scared just to being confident again. So that confidence key is huge, they definitely lose that during this process.
And sometimes I am heading to the SSRIs and that's okay, again medications can be scary but if you get comfortable with them and you use them on the appropriate patients and you educate them they are not as scary. And so some of your athletes may be on Lexapro or Zoloft or Prozac and that's because they have a real issue with that anxiety or that depression. And it could be worsening their symptoms, triggering their migraines. And so if they are on it help them to understand that it's not just meds that are going to get you better, we've got to work through this, we've got to talk through this.
Benzos I use on a limited basis but if they are having panic attacks I'm going to help them out a little bit. And again Klonopin I use for that vestibular related anxiety. And it's usually supplemented with vestibular therapy. All of this is of course short term for the benzos.
So early education on postconcussion symptoms, and I like symptoms not syndrome because once they are labeled with postconcussion syndrome that will go with them their entire life so I really have tried to back off on using that term a lot. Initiate therapies when needed, we've talked about them today and we are going to continue after my presentation, vestibular/ocular, psychotherapy, cognitive therapy, exertion therapy. We don't always want to get them in all of those therapies but in the right ones. And then determine if meds will be needed. Regular followup is key, I do not do my best work when they are coming every 6 months, even when they are coming every 3. So I'm usually trying every 4 to 6 because I need to watch these changes, I need to watch their recovery from their therapies and adjust my meds during that time period. My associates will say when I see one coming it's been 6 months I like go oh what am I going to do for this one? You know I really need that close followup, it's critical.
And my advice to the clinician is keep calm, whatever happens think positive. These athletes will get better faster I've noticed in my own practice if they are staying positive. The ones that come in and are like this is miserable, I'm like I get it, it's miserable but it's going to be more miserable if you keep with this attitude. So let's think positively, let's think forward. I know everybody has told you that but it really works, I see them get better faster.