Looking Beyond Rest to Active and Targeted Treatments for Concussion

VANCOUVER—Prescribed rest is an important component of treating concussion, but it may not be the most appropriate intervention for all patients and may worsen symptoms in some cases, said Anthony P. Kontos, PhD, at the 68th Annual Meeting of the American Academy of Neurology (AAN).

Anthony P. Kontos, PhD

“We need to move the discussion on concussion toward more active and targeted treatments,” said Dr. Kontos, Research Director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program.Concussion is a heterogeneous injury with varying clinical profiles and recovery trajectories. Approaches to treatment should account for these differences and involve multidisciplinary teams when necessary, he said.

In October 2015, Dr. Kontos, Michael “Micky” Collins, PhD, and David O. Okonkwo, MD, PhD, directed a meeting with 37 participants from the fields of neurology, neuropsychology, neurosurgery, primary care, athletic training, and physical therapy to create a summary agreement that can assist clinicians with concussion treatment.

Nineteen guests, including representatives from professional sports organizations, the military, and public health, also attended the Targeted Evaluation and Active Management (TEAM) Approach to Treating Concussion meeting. The National Football League and UPMC sponsored the meeting, which was held in Pittsburgh.

Consensus documents have predominantly focused on things like the various definitions of concussion, how to assess concussion, and how to manage it, said Dr. Kontos. “We really wanted to focus on more of that end point of treatment and potentially more active treatment,” he said.

The TEAM participants developed and agreed upon 17 statements, which they plan to publish. At the AAN meeting, Dr. Kontos provided a brief review of some of the statements and discussed them in the context of recent research.

Rest’s Benefits and Limitations

Physical and cognitive rest, as part of an individualized treatment plan, are currently “the foundation of sport-related concussion management,” according to National Collegiate Athletic Association interassociation concussion guidelines. Rest after concussion conserves needed energy in the brain and reduces the likelihood of second impact syndrome and other catastrophic events, Dr. Kontos said. Furthermore, some studies have suggested that rest improves recovery. Brown et al reported in 2014 that athletes who self-reported more cognitive activity after a concussion took longer to recover than those who reported less cognitive activity.

However, the evidence to support rest is limited. In 2013, the Institute of Medicine and National Research Council published a report on sports-related concussion in youth that found little evidence regarding the efficacy of rest following concussion or to inform the best timing and approach for return to activity. Their statement “still resonates now,” Dr. Kontos said. “There’s very little empirical data to support what we do with rest. It’s largely an across-the-board policy that’s not data-driven, and we need to change that.” The TEAM group agreed “there is limited empirical evidence for the effectiveness of prescribed physical and cognitive rest, with no multisite trials for prescribed rest following concussion.”

Prescribed rest can have psychologic consequences, including emotional distress, depression, and anxiety. Rest allows individuals time to ruminate on their injury, which can exacerbate symptoms in self-report. Individuals who somaticize are particularly vulnerable to this effect. Jeremy M. Root, MD, of Children’s National Medical Center in Washington, DC, Dr. Kontos, and colleagues reported in April in the Journal of Pediatrics that patients who had high somatization scores were approximately five to seven times more likely to report an increase in symptoms at two weeks and four weeks, compared with those who were not in the highest quartile of somatization.

In addition, patients who are prescribed rest may think, “Wow, I must have a really bad injury such that I can’t do anything for a week.” This contextual framing effect may also influence the outcome, said Dr. Kontos.

Thomas et al in 2015 published the results of a randomized controlled trial that found that, after a concussion, patients ages 11 to 22 who were prescribed five days’ rest reported more daily postconcussive symptoms, compared with patients who were prescribed two days’ rest with progressive return to activity. Symptoms peaked at four days, and differences between groups remained at 10 days. “They have higher symptoms when they’re told to rest longer than if they’re told to rest less,” Dr. Kontos said. Clinically, there was no significant difference between groups in neurocognitive or balance outcomes, however.

The effect of treatment on the number of postconcussive symptoms may not be that straightforward, however. When Dr. Kontos, Dr. Thomas, and colleagues reanalyzed the data to look at patients who only reported symptoms (eg, headache, nausea, dizziness) but did not otherwise have early signs of concussion (eg, loss of consciousness, posttraumatic amnesia, disorientation, confusion), the symptoms-only group reported more symptoms at 10 days when prescribed five days’ rest, compared with two days’ rest with progressive return to activity. Patients who had early signs of concussion, however, reported fewer symptoms when prescribed five days’ rest versus two days’ rest with progressive return to activity.

“We have a sort of dichotomy here. We don’t want to say rest is bad. It may be very good for these people who have a high organic level or severity to their injury, and we may need to think in terms of resting them longer, whereas these patients [with symptoms only] certainly need to get more active, probably earlier in the process,” Dr. Kontos said.

Activity and social interaction may provide benefits. Miller et al in 2013 reported that environmental enrichment, including cognitive, physical, and social activity, is associated with improved outcome and sparing of hippocampal atrophy in the chronic stages of traumatic brain injury.

The TEAM group agreed, “Active treatment strategies may be initiated early in recovery following concussion.” The group also agreed, “strict brain rest (eg, ‘cocoon’ therapy) is not indicated and may have detrimental effects on patients following concussion.”

A Heterogeneous Injury

A focal point of the TEAM meeting was the concept of various clinical profiles of concussion. The group agreed, “Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.”

“We need to think in terms of what type of concussion does this individual have and is it multiple types,” such as cognitive-fatigue, vestibular, or ocular, said Dr. Kontos. “We don’t typically just see one of these.” For example, a patient may have a predominant vestibular concussion with some posttraumatic migraine and neck involvement. “Oftentimes we see misdiagnoses when people show up. They’ve been diagnosed with cognitive issues when in reality they’re having vision or oculomotor difficulties.”

There are many potential approaches to categorizing, classifying, or profiling concussion, including those that consider posttraumatic mood and migraine as modifying factors, he said.

Multidisciplinary Teams

In addition, the TEAM group stated, “thorough multidomain assessment is warranted to properly evaluate the clinical profiles of concussion.” Various experts may be needed to assess cognitive, exertional, oculomotor, vestibular, and other symptoms and impairment.

As part of a multidisciplinary team, a neurologist, neuropsychologist, or primary care physician could “serve as kind of a point guard, to use a basketball analogy,” said Dr. Kontos. When an aspect of a patient’s assessment or treatment needs to be addressed more in depth, such as with regard to medication, vestibular therapy, or imaging, the patient may be referred to experts in those areas. “We try to work as a team and work back through the point guard to coordinate that care system,” he said. Telemedicine might allow for multidisciplinary treatment in remote geographic areas where establishing multidisciplinary teams otherwise might not be feasible, Dr. Kontos noted.

“Pharmacological therapy may be indicated in selected circumstances to treat certain symptoms and impairments related to concussion,” the TEAM group agreed.There is “very little” evidence for medicine in concussion, and drugs can exacerbate symptoms in some situations, Dr. Kontos said. Randomized controlled trials will help researchers better understand medication’s role in treating concussion.

More Active Treatment

In particular, patients who do not receive appropriate management after a concussion and then go to a clinic several months later with chronic symptoms may benefit from more active approaches to treatment, such as brisk walking.

Dr. Kontos described the case of an ice hockey player who was prescribed rest following a first concussion. After resting, the athlete began a return-to-play protocol that focused on aerobic exertion with no dynamic movements. As soon as the player returned to the ice, however, dizziness and headache came flooding back.

Several months later, the athlete was referred to a concussion clinic. The patient underwent a thorough evaluation that included vestibular and oculomotor assessments. Clinicians determined that the athlete needed more active treatment, including vision training and walking with head movements. In three weeks, the athlete returned to the ice. About a week later, the athlete resumed full-contact ice hockey.

“Prescribing rest is not the only approach,” Dr. Kontos said. “We need to move the discussion in different directions. We need to be more active with certain people and we need to be more targeted with our approaches.”

—Jake Remaly

VANCOUVER—Prescribed rest is an important component of treating concussion, but it may not be the most appropriate intervention for all patients and may worsen symptoms in some cases, said Anthony P. Kontos, PhD, at the 68th Annual Meeting of the American Academy of Neurology (AAN).

Anthony P. Kontos, PhD

“We need to move the discussion on concussion toward more active and targeted treatments,” said Dr. Kontos, Research Director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program.Concussion is a heterogeneous injury with varying clinical profiles and recovery trajectories. Approaches to treatment should account for these differences and involve multidisciplinary teams when necessary, he said.

In October 2015, Dr. Kontos, Michael “Micky” Collins, PhD, and David O. Okonkwo, MD, PhD, directed a meeting with 37 participants from the fields of neurology, neuropsychology, neurosurgery, primary care, athletic training, and physical therapy to create a summary agreement that can assist clinicians with concussion treatment.

Nineteen guests, including representatives from professional sports organizations, the military, and public health, also attended the Targeted Evaluation and Active Management (TEAM) Approach to Treating Concussion meeting. The National Football League and UPMC sponsored the meeting, which was held in Pittsburgh.

Consensus documents have predominantly focused on things like the various definitions of concussion, how to assess concussion, and how to manage it, said Dr. Kontos. “We really wanted to focus on more of that end point of treatment and potentially more active treatment,” he said.

The TEAM participants developed and agreed upon 17 statements, which they plan to publish. At the AAN meeting, Dr. Kontos provided a brief review of some of the statements and discussed them in the context of recent research.

Rest’s Benefits and Limitations

Physical and cognitive rest, as part of an individualized treatment plan, are currently “the foundation of sport-related concussion management,” according to National Collegiate Athletic Association interassociation concussion guidelines. Rest after concussion conserves needed energy in the brain and reduces the likelihood of second impact syndrome and other catastrophic events, Dr. Kontos said. Furthermore, some studies have suggested that rest improves recovery. Brown et al reported in 2014 that athletes who self-reported more cognitive activity after a concussion took longer to recover than those who reported less cognitive activity.

However, the evidence to support rest is limited. In 2013, the Institute of Medicine and National Research Council published a report on sports-related concussion in youth that found little evidence regarding the efficacy of rest following concussion or to inform the best timing and approach for return to activity. Their statement “still resonates now,” Dr. Kontos said. “There’s very little empirical data to support what we do with rest. It’s largely an across-the-board policy that’s not data-driven, and we need to change that.” The TEAM group agreed “there is limited empirical evidence for the effectiveness of prescribed physical and cognitive rest, with no multisite trials for prescribed rest following concussion.”

Prescribed rest can have psychologic consequences, including emotional distress, depression, and anxiety. Rest allows individuals time to ruminate on their injury, which can exacerbate symptoms in self-report. Individuals who somaticize are particularly vulnerable to this effect. Jeremy M. Root, MD, of Children’s National Medical Center in Washington, DC, Dr. Kontos, and colleagues reported in April in the Journal of Pediatrics that patients who had high somatization scores were approximately five to seven times more likely to report an increase in symptoms at two weeks and four weeks, compared with those who were not in the highest quartile of somatization.

In addition, patients who are prescribed rest may think, “Wow, I must have a really bad injury such that I can’t do anything for a week.” This contextual framing effect may also influence the outcome, said Dr. Kontos.

Thomas et al in 2015 published the results of a randomized controlled trial that found that, after a concussion, patients ages 11 to 22 who were prescribed five days’ rest reported more daily postconcussive symptoms, compared with patients who were prescribed two days’ rest with progressive return to activity. Symptoms peaked at four days, and differences between groups remained at 10 days. “They have higher symptoms when they’re told to rest longer than if they’re told to rest less,” Dr. Kontos said. Clinically, there was no significant difference between groups in neurocognitive or balance outcomes, however.

The effect of treatment on the number of postconcussive symptoms may not be that straightforward, however. When Dr. Kontos, Dr. Thomas, and colleagues reanalyzed the data to look at patients who only reported symptoms (eg, headache, nausea, dizziness) but did not otherwise have early signs of concussion (eg, loss of consciousness, posttraumatic amnesia, disorientation, confusion), the symptoms-only group reported more symptoms at 10 days when prescribed five days’ rest, compared with two days’ rest with progressive return to activity. Patients who had early signs of concussion, however, reported fewer symptoms when prescribed five days’ rest versus two days’ rest with progressive return to activity.

“We have a sort of dichotomy here. We don’t want to say rest is bad. It may be very good for these people who have a high organic level or severity to their injury, and we may need to think in terms of resting them longer, whereas these patients [with symptoms only] certainly need to get more active, probably earlier in the process,” Dr. Kontos said.

Activity and social interaction may provide benefits. Miller et al in 2013 reported that environmental enrichment, including cognitive, physical, and social activity, is associated with improved outcome and sparing of hippocampal atrophy in the chronic stages of traumatic brain injury.

The TEAM group agreed, “Active treatment strategies may be initiated early in recovery following concussion.” The group also agreed, “strict brain rest (eg, ‘cocoon’ therapy) is not indicated and may have detrimental effects on patients following concussion.”

A Heterogeneous Injury

A focal point of the TEAM meeting was the concept of various clinical profiles of concussion. The group agreed, “Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.”

“We need to think in terms of what type of concussion does this individual have and is it multiple types,” such as cognitive-fatigue, vestibular, or ocular, said Dr. Kontos. “We don’t typically just see one of these.” For example, a patient may have a predominant vestibular concussion with some posttraumatic migraine and neck involvement. “Oftentimes we see misdiagnoses when people show up. They’ve been diagnosed with cognitive issues when in reality they’re having vision or oculomotor difficulties.”

There are many potential approaches to categorizing, classifying, or profiling concussion, including those that consider posttraumatic mood and migraine as modifying factors, he said.

Multidisciplinary Teams

In addition, the TEAM group stated, “thorough multidomain assessment is warranted to properly evaluate the clinical profiles of concussion.” Various experts may be needed to assess cognitive, exertional, oculomotor, vestibular, and other symptoms and impairment.

As part of a multidisciplinary team, a neurologist, neuropsychologist, or primary care physician could “serve as kind of a point guard, to use a basketball analogy,” said Dr. Kontos. When an aspect of a patient’s assessment or treatment needs to be addressed more in depth, such as with regard to medication, vestibular therapy, or imaging, the patient may be referred to experts in those areas. “We try to work as a team and work back through the point guard to coordinate that care system,” he said. Telemedicine might allow for multidisciplinary treatment in remote geographic areas where establishing multidisciplinary teams otherwise might not be feasible, Dr. Kontos noted.

“Pharmacological therapy may be indicated in selected circumstances to treat certain symptoms and impairments related to concussion,” the TEAM group agreed.There is “very little” evidence for medicine in concussion, and drugs can exacerbate symptoms in some situations, Dr. Kontos said. Randomized controlled trials will help researchers better understand medication’s role in treating concussion.

More Active Treatment

In particular, patients who do not receive appropriate management after a concussion and then go to a clinic several months later with chronic symptoms may benefit from more active approaches to treatment, such as brisk walking.

Dr. Kontos described the case of an ice hockey player who was prescribed rest following a first concussion. After resting, the athlete began a return-to-play protocol that focused on aerobic exertion with no dynamic movements. As soon as the player returned to the ice, however, dizziness and headache came flooding back.

Several months later, the athlete was referred to a concussion clinic. The patient underwent a thorough evaluation that included vestibular and oculomotor assessments. Clinicians determined that the athlete needed more active treatment, including vision training and walking with head movements. In three weeks, the athlete returned to the ice. About a week later, the athlete resumed full-contact ice hockey.

“Prescribing rest is not the only approach,” Dr. Kontos said. “We need to move the discussion in different directions. We need to be more active with certain people and we need to be more targeted with our approaches.”

—Jake Remaly

VANCOUVER—Prescribed rest is an important component of treating concussion, but it may not be the most appropriate intervention for all patients and may worsen symptoms in some cases, said Anthony P. Kontos, PhD, at the 68th Annual Meeting of the American Academy of Neurology (AAN).

Anthony P. Kontos, PhD

“We need to move the discussion on concussion toward more active and targeted treatments,” said Dr. Kontos, Research Director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program.Concussion is a heterogeneous injury with varying clinical profiles and recovery trajectories. Approaches to treatment should account for these differences and involve multidisciplinary teams when necessary, he said.

In October 2015, Dr. Kontos, Michael “Micky” Collins, PhD, and David O. Okonkwo, MD, PhD, directed a meeting with 37 participants from the fields of neurology, neuropsychology, neurosurgery, primary care, athletic training, and physical therapy to create a summary agreement that can assist clinicians with concussion treatment.

Nineteen guests, including representatives from professional sports organizations, the military, and public health, also attended the Targeted Evaluation and Active Management (TEAM) Approach to Treating Concussion meeting. The National Football League and UPMC sponsored the meeting, which was held in Pittsburgh.

Consensus documents have predominantly focused on things like the various definitions of concussion, how to assess concussion, and how to manage it, said Dr. Kontos. “We really wanted to focus on more of that end point of treatment and potentially more active treatment,” he said.

The TEAM participants developed and agreed upon 17 statements, which they plan to publish. At the AAN meeting, Dr. Kontos provided a brief review of some of the statements and discussed them in the context of recent research.

Rest’s Benefits and Limitations

Physical and cognitive rest, as part of an individualized treatment plan, are currently “the foundation of sport-related concussion management,” according to National Collegiate Athletic Association interassociation concussion guidelines. Rest after concussion conserves needed energy in the brain and reduces the likelihood of second impact syndrome and other catastrophic events, Dr. Kontos said. Furthermore, some studies have suggested that rest improves recovery. Brown et al reported in 2014 that athletes who self-reported more cognitive activity after a concussion took longer to recover than those who reported less cognitive activity.

However, the evidence to support rest is limited. In 2013, the Institute of Medicine and National Research Council published a report on sports-related concussion in youth that found little evidence regarding the efficacy of rest following concussion or to inform the best timing and approach for return to activity. Their statement “still resonates now,” Dr. Kontos said. “There’s very little empirical data to support what we do with rest. It’s largely an across-the-board policy that’s not data-driven, and we need to change that.” The TEAM group agreed “there is limited empirical evidence for the effectiveness of prescribed physical and cognitive rest, with no multisite trials for prescribed rest following concussion.”

Prescribed rest can have psychologic consequences, including emotional distress, depression, and anxiety. Rest allows individuals time to ruminate on their injury, which can exacerbate symptoms in self-report. Individuals who somaticize are particularly vulnerable to this effect. Jeremy M. Root, MD, of Children’s National Medical Center in Washington, DC, Dr. Kontos, and colleagues reported in April in the Journal of Pediatrics that patients who had high somatization scores were approximately five to seven times more likely to report an increase in symptoms at two weeks and four weeks, compared with those who were not in the highest quartile of somatization.

In addition, patients who are prescribed rest may think, “Wow, I must have a really bad injury such that I can’t do anything for a week.” This contextual framing effect may also influence the outcome, said Dr. Kontos.

Thomas et al in 2015 published the results of a randomized controlled trial that found that, after a concussion, patients ages 11 to 22 who were prescribed five days’ rest reported more daily postconcussive symptoms, compared with patients who were prescribed two days’ rest with progressive return to activity. Symptoms peaked at four days, and differences between groups remained at 10 days. “They have higher symptoms when they’re told to rest longer than if they’re told to rest less,” Dr. Kontos said. Clinically, there was no significant difference between groups in neurocognitive or balance outcomes, however.

The effect of treatment on the number of postconcussive symptoms may not be that straightforward, however. When Dr. Kontos, Dr. Thomas, and colleagues reanalyzed the data to look at patients who only reported symptoms (eg, headache, nausea, dizziness) but did not otherwise have early signs of concussion (eg, loss of consciousness, posttraumatic amnesia, disorientation, confusion), the symptoms-only group reported more symptoms at 10 days when prescribed five days’ rest, compared with two days’ rest with progressive return to activity. Patients who had early signs of concussion, however, reported fewer symptoms when prescribed five days’ rest versus two days’ rest with progressive return to activity.

“We have a sort of dichotomy here. We don’t want to say rest is bad. It may be very good for these people who have a high organic level or severity to their injury, and we may need to think in terms of resting them longer, whereas these patients [with symptoms only] certainly need to get more active, probably earlier in the process,” Dr. Kontos said.

Activity and social interaction may provide benefits. Miller et al in 2013 reported that environmental enrichment, including cognitive, physical, and social activity, is associated with improved outcome and sparing of hippocampal atrophy in the chronic stages of traumatic brain injury.

The TEAM group agreed, “Active treatment strategies may be initiated early in recovery following concussion.” The group also agreed, “strict brain rest (eg, ‘cocoon’ therapy) is not indicated and may have detrimental effects on patients following concussion.”

A Heterogeneous Injury

A focal point of the TEAM meeting was the concept of various clinical profiles of concussion. The group agreed, “Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.”

“We need to think in terms of what type of concussion does this individual have and is it multiple types,” such as cognitive-fatigue, vestibular, or ocular, said Dr. Kontos. “We don’t typically just see one of these.” For example, a patient may have a predominant vestibular concussion with some posttraumatic migraine and neck involvement. “Oftentimes we see misdiagnoses when people show up. They’ve been diagnosed with cognitive issues when in reality they’re having vision or oculomotor difficulties.”

There are many potential approaches to categorizing, classifying, or profiling concussion, including those that consider posttraumatic mood and migraine as modifying factors, he said.

Multidisciplinary Teams

In addition, the TEAM group stated, “thorough multidomain assessment is warranted to properly evaluate the clinical profiles of concussion.” Various experts may be needed to assess cognitive, exertional, oculomotor, vestibular, and other symptoms and impairment.

As part of a multidisciplinary team, a neurologist, neuropsychologist, or primary care physician could “serve as kind of a point guard, to use a basketball analogy,” said Dr. Kontos. When an aspect of a patient’s assessment or treatment needs to be addressed more in depth, such as with regard to medication, vestibular therapy, or imaging, the patient may be referred to experts in those areas. “We try to work as a team and work back through the point guard to coordinate that care system,” he said. Telemedicine might allow for multidisciplinary treatment in remote geographic areas where establishing multidisciplinary teams otherwise might not be feasible, Dr. Kontos noted.

“Pharmacological therapy may be indicated in selected circumstances to treat certain symptoms and impairments related to concussion,” the TEAM group agreed.There is “very little” evidence for medicine in concussion, and drugs can exacerbate symptoms in some situations, Dr. Kontos said. Randomized controlled trials will help researchers better understand medication’s role in treating concussion.

More Active Treatment

In particular, patients who do not receive appropriate management after a concussion and then go to a clinic several months later with chronic symptoms may benefit from more active approaches to treatment, such as brisk walking.

Dr. Kontos described the case of an ice hockey player who was prescribed rest following a first concussion. After resting, the athlete began a return-to-play protocol that focused on aerobic exertion with no dynamic movements. As soon as the player returned to the ice, however, dizziness and headache came flooding back.

Several months later, the athlete was referred to a concussion clinic. The patient underwent a thorough evaluation that included vestibular and oculomotor assessments. Clinicians determined that the athlete needed more active treatment, including vision training and walking with head movements. In three weeks, the athlete returned to the ice. About a week later, the athlete resumed full-contact ice hockey.

“Prescribing rest is not the only approach,” Dr. Kontos said. “We need to move the discussion in different directions. We need to be more active with certain people and we need to be more targeted with our approaches.”

—Jake Remaly