Typical Flow for a Concussion Clinic

Many variations are possible. Our clinic runs as follows:Patient is referred to the clinic. Clinic administrator requests medical records. Provider reviews the records and approves initial office visit. Clinic administrator schedules the initial office visit as routine or semi-urgent. Clinic administrator makes sure that the patient brings a reliable collateral source. Patient completes Rivermead Post-Concussive Symptoms Questionnaire. Provider obtains history and exam with documentation performed on a preprinted sheet outlining the most important issues following concussion. Physical therapist and psychometrician see the patient. Provider reviews the data from the physical therapist and psychometrician, performs additional testing, obtains additional history, formulates assessment and discusses plans with patient and collateral source. Provider gives the patient and collateral source a brief hand-written or printed summary of the assessment and plan, then sends medical records to other medical providers.

Special Topics in Military Personnel

The best collateral source may be another service member with whom the patient has served in addition to a family member. Evaluate explicitly post-traumatic stress disorder (PTSD), chronic pain, sleep disorders, balance, and hearing loss, as these are common in military personnel with concussion, especially blast-related injuries. Maintain confidentiality. If the patient has been using drugs and/or alcohol, it may be wise to refer them for rehabilitation discretely, since active duty military personnel do not have the same privacy protections that civilians have, and this can jeopardize their future careers. Return-to-duty decision-making is best done in collaboration with military physicians and occupational therapists. Refer to community resources specifically dedicated to wounded warriors.

Special Topics in Contact Sport Athletes and Others with Multiple Concussions

This chapter considers issues in patients with multiple concussions. These patients must consider when to retire from contact sports. Help the patient, family, and peers think through the decision carefully. Educate them about the risk of serious and currently untreatable long-term problems such as chronic traumatic encephalopathy (CTE). Discuss potential for a future professional sports career versus other career as well as interpersonal and family aspirations. Patients want to know if they have CTE. There is no way to tell for sure while they are alive. High-risk features may include progressive worsening over time, prominent mood and behavioral abnormalities, parkinsonism, and a cavum septum pellucidum on MRI scan. Treatment is entirely based on relieving symptoms and keeping the patient safe.

Special Topics in Adolescents

Adolescents may be less able to make good judgments about their own abilities than adults. The collateral source becomes even more important than usual. Address questions about drug and alchohol use privately and give advice without the parents present. Peer influences may have a big impact on decision-making. Obtain collateral history from peers and educate peers as well as parents. Preexisting attention deficit, learning disabilities, and mood instability can get substantially worse after concussion and may require intensified treatment. For patients at the cusp of starting to drive, consider advising extra caution: go back to the beginning of driver’s education and get a professional driving evaluation. Consider preemptively addressing questions that the adolescent may be afraid to ask or cannot formulate accurately.

Seizures

Concussion rarely causes recurrent seizures. A patient with a brief seizure that occurs within the first 30 minutes of concussion does not need to be treated with antiepileptics or have driving restrictions. However, a seizure occurring later than 30 minutes after the injury, a seizure that lasts more than one minute, or a seizure after concussion in a patient with a previous seizure disorder requires a different approach. Consider hospital observation, brain MRI, EEG, laboratory studies, assessment for infection, and a screen for drug and alchohol use or withdrawal. If seizures need to be treated, often the best approach includes mood stabilizing medications with minimal cognitively impairing side effects. An oxcarbazepine (Trileptal) bridge during lamotrigine (Lamictal) titration is a reasonable choice. Carbamazepine generic is a good option when cost is an issue.

Sexual Dysfunction

This chapter addresses issues surrounding sexual dysfunction after concussion. Ask the patient specifically about sexual dysfunction in private, and if appropriate ask the collateral source separately. Assess for depression, severe fatigue or hypersomnia, untreated pain, and alcohol or drug abuse (especially marijuana). Check medications for sexual side effects; serotonin specific reuptake inhibitors are the most common culprits. Test for hormonal imbalances and unrecognized cauda equina or lower spinal cord injury. Consider a trial of a PDE5 inhibitor and refer to urology for more advanced options.

Memory Impairment

Many complaints of memory problems after concussion actually turn out to be attention deficit. Take a careful collateral history regarding memory function in everyday life. Consider both bedside testing and formal neuropsychological testing of memory, but treat the patient, not the test results. Reduce barriers to optimal memory function: Optimize sleep; treat chronic pain; taper or stop cognitively impairing medications; stop alcohol and illicit drugs; prescribe moderate cardiovascular exercise; test for vitamin B12 deficiency, hypothyroidism, electrolyte disorders, hypo- or hypergylcemia, renal failure, liver failure, and anemia. Refer to speech therapy and occupational therapy for memory training. Stimulants can allow more intense cognitive rehabilitation when attention or fatigue are limiting. Consider pharmacological enhancers of memory including caffeine, donepezil, or rivastigmine. These have modest benefits, and the nonpharmacological interventions are more important.

Fatigue

A systematic approach to fatigue: figure out how bad it is; rule out the complaint of concussion-related fatigue as an excuse to get out of school, work, or unpleasant chores at home by asking the collateral source about how fatigued the patient acts in everyday life; rule out depression; rule out a primary sleep disorder; rule out alcohol, sedating medications, and other drugs; rule out withdrawal from stimulants; rule out a systemic cause such as hypotension, hypoxemia, renal failure, liver failure, anemia, hyponatremia, hypothyroidism, vitamin D deficiency, or chronic urinary tract infection. If these are not present or fatigue persists after treatment, consider prescribing one or more of the following: a very gradually progressive exercise program, bright light treatment, complete alcohol cessation, a diet that is low in refined sugar, a stimulant, amantadine, and modafinil.

Post-Traumatic Stress Disorder

In many contexts, the trauma that caused the concussion can also trigger a strong stress response. Take a focused history from the patient and collateral source for hyperarousal, nightmares, avoidance, emotional numbing, dissociation, and prior diagnosis of post-traumatic stress disorder (PTSD). Assess safety. Severe PTSD can lead to suicide. Refer to a psychologist or counselor with specific expertise in PTSD for prolonged exposure therapy or cognitive behavioral therapy. Optimize sleep. Start an anxiolytic antidepressant. Prescribe prazosin for nightmares. Ideally, use short-acting benzodiazepines only for emergencies. Advise the patient to stop drinking alcohol. Treat chronic pain aggressively if present. Consider a second-line mood stabilizer if necessary. Don’t be afraid to use stimulants if the patient also has impairing attention deficit once the PTSD symptoms are under reasonable control.

Anxiety and Depression

First, assess safety. Severe anxiety and depression can lead to suicide. Second, distinguish between reactive anxiety and depressive symptoms versus an impairing mood disorder. The “treatment” for reactive anxiety and depressive symptoms is education, reassurance, and a good plan to get the patient’s life back on track. If the patient has an impairing (but not immediately dangerous) mood disorder, it can be treated for the most part just like a mood disorder in the absence of concussion. The optimal approach usually involves both nonpharmacological and pharmacological interventions: exercise, treat sleep disturbances, psychological counseling, avoid substances that worsen mood overall such as alcohol and street drugs, consider appropriate long-term antidepressant/antianxiety medications. There are many options, but fluoxetine (Prozac) and venlafaxine (Effexor) may be good choices for patients where low energy is more concerning than anxiety, whereas paroxetine (Paxil) or sertraline (Zoloft) may be preferred when anxiety is a major component.