When Is It Safe to Fly or Travel to High Altitude?

Most commercial airplanes are pressurized to the equivalent of about 7000 to 8000 feet. U.S. Air Force researchers have shown that uninjured people experience very little change in cognitive function or symptoms at this altitude, but that this is not the case after concussion. Symptoms and deficits that had resolved can come back at altitude, most notably headaches, slowing of cognitive performance, and impaired balance. Inform the patient and family about this risk and then let them make their own decisions about whether it is worth it. No evidence of permanent harm from flying or traveling to moderate altitude in concussion patients exists, but it has not been carefully studied.

Psychosis

New onset hallucinations and delusions are rare after isolated concussion and should trigger a search for other causes: Schizophrenia (relatively common in young adults), drug abuse, alcohol or drug withdrawal, and delirium due to infection or sleep deprivation should be considered. Importantly, if the psychosis is dangerous or potentially dangerous, think about safety first. This may require inpatient admission to a psychiatric service. If outpatient treatment is required, atypical antipsychotics should be used in as low a dose as possible to minimize cognitive side effects. Aripiprazole (Abilify) is associated with less weight gain than other atypical antipsychotics. Risperidone (Risperdal) is the least expensive. Quetiapine (Seroquel), or rarely Clozaril, are the best choices when parkinsonism is a comorbidity.

Dizziness

Dizziness means many different things to different people: lightheadedness, vertigo, poor balance, mental fogginess, and other concerns. Lightheadedness, meaning a feeling like the patient may pass out, is usually due to low blood pressure, often orthostatic hypotension. Vertigo, meaning a sensation of spinning or movement, can be an inner ear problem or a brain problem. Stop toxic substances; if there is nystagmus, refer to an ear, nose, and throat specialist (ENT) for a full evaluation. Perform the Dix Hallpike maneuvers to assess for benign paroxysmal positional vertigo and refer to physical therapy for repositioning maneuvers if positive. Consider vestibular rehabilitation; consider a short course of medication such as scopolamine or meclizine; consider ordering a magnetic resonance imaging (MRI) scan of the brain, because the concussion sometimes unmasks another unrelated problem. Dizziness meaning “mental fogginess” usually turns out to be attention deficit. Dizziness meaning vague and nonspecific malaise usually turns out to be fatigue, depression, or anxiety.

Mood Instability and Irritability

Often the complaint of mood instability comes from the collateral source. First priority: assess safety. Severe mood instability can lead to suicide. Next, determine whether the problem is actually mood instability, as opposed to sustained major anxiety, depression, or post-traumatic stress disorder. Nonpharmacological interventions are the most important, and include education, sleep management, prescription for cardiovascular exercise, pain control, cessation of alcohol and other disinhibiting substances, such as levetiracetam and cognitive behavioral therapy. Preferred pharmacological options that do not substantially impair cognitive recovery include lamotrigine (Lamictal) and oxcarbazepine (Trileptal). Other options include carbamazepine (Tegretol) when cost is an issue, propranolol (Inderal) when violence is a concern, and low-dose atypical antipsychotics.

Attention Deficit

Many concussion patients who complain about problems with memory actually have an attention deficit. General measures: treat insomnia, stop alcohol, treat migraine with cogniphobia, prescribe moderate cardiovascular exercise, and refer for cognitive rehabilitation (occupational and speech therapy). Consider treatment with a stimulant such as methylphenidate (Ritalin) or amphetamine mixed salts (Adderall) if appropriate with careful monitoring for side effects. Contraindications include uncontrolled seizures, dangerous anxiety, active cardiovascular or cerebrovascular disease, active psychosis, drug abuse, irresponsible criminal behavior, dangerously underweight, and uncontrolled headaches. Recommend use 6 days per week 51 weeks per year to reduce tolerance. Additional benefit in some patients from donepezil (Aricept), rivastigmine (Exelon), and regulated caffeine use. Approach options: “aggressive” involving treatment with stimulants primarily based on history, “moderate” involving treatment with stimulants only in patients with attention performance impairments documented with neuropsychological evaluation, and “conservative” not including stimulants unless there is a well-documented preinjury history of attention deficit disorder.

Introduction

This manual is for everyone who treats people with concussion. There are more than 3 million brain injuries each year in the United States and millions more around the world. Most of these injuries are concussions. After concussion, 30% or maybe even more can have prolonged symptoms and deficits. Much of this manual is written for the people who take care of the 30%. There is not one specific “post-concussion syndrome.” Instead, there are many post-concussive paths, and this manual is written to help those who are tasked with figuring this out, one patient at a time. This manual is about pragmatic approaches to taking care of patients in the absence of true scientific evidence. This manual is written to be used “on the fly,” right now, without a lot of prior studying or memorization. This manual is meant to supplement, not replace, the knowledge and judgment of medical providers caring for concussion patients.

Typical Flow for a Concussion Clinic

Many variations are possible. One successful 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 semiurgent. Clinic administrator makes sure that the patient brings a reliable collateral source. Patient completes Rivermead Post-Concussive Symptoms Questionnaire, Neurobehavioral Symptom Inventory, or other self-report form. Provider obtains history and exam with documentation recorded 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 handwritten or printed summary of the assessment and plan, then sends medical records to other medical providers.

Staffing

Pick the right people: a concussion clinic requires greater than average interpersonal skills to handle patients with mood instability and cognitive impairment. The clinic administrator needs to have good judgment. The administrator needs to be able to determine whether to contact the provider right away for an urgent issue, whether to recommend that the patient go straight to an emergency department, or whether a patient would be more appropriate for another clinic. Train the staff well right from the beginning and keep them happy to build team dynamics and reduce turnover. Options to enhance available care include an in-clinic physical therapist to perform balance testing and exertional testing, a social worker to coordinate care, and an in-clinic psychometrician to perform brief cognitive testing.

Special Topics in Contact Sport Athletes and Others Who Have Had Multiple Concussions and Subconcussive Impacts

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. Discuss potential for a future professional sports career versus other career, interpersonal, and family aspirations. Does the patient have Chronic Traumatic Encephalopathy (CTE)? There is no way to tell for sure while the patient is alive. High-risk features may include progressive worsening over time, prominent mood and behavioral abnormalities, parkinsonism, and a cavum septum pellucidum on magnetic resonance imaging (MRI) scan. At present, treatment is entirely based on relieving symptoms and keeping the patient safe.

Concussion in Children

Rules for children under 12 years of age with concussion: (1) Take the history twice: Once from the child and once from the parents or guardians. Young children can reliably report headache, nausea, balance problems, problems concentrating, and irritability. Other concerns, as well as preinjury problems, should be assessed from the parents or guardians. (2) Use age-appropriate language and simplified assessments of severity. Consider using the Child SCAT5. (3) Carefully assess for secondary-gain factors. A child may over-report or under-report symptoms to please the parents or guardians. (4) With regard to return to school, sports, and daily life, help the parents or guardians find the “middle way”: Not too protective and not too lax. Most children do not need to be “cocooned” or totally isolated from all stimuli. (5) In complex concussion, assess for attention deficit and atypical presentations of migraine, depression, and anxiety. (6) Consider treatment with glucose (e.g., 100 to 200 calories of a high glycemic index snack or drink 20 minutes prior to school or rehabilitation-related activity) to improve cognitive performance and reduce pain. This seems to be specific to children and does not appear to be effective in adults. Consider using the Child SCAT5.