Oct 7, 2016
A New Approach

The traditional approach of “watchful waiting” for post-concussion care in young people is challenged by a new study conducted by the Seattle Sports Concussion Research Collaborative. Published online by Pediatrics, the investigation examined an active treatment model focused on using collaborative care to address prolonged mental and physical concussion symptoms in adolescents.

“When concussion symptoms do not resolve within a month following injury, patients may need to be more proactive in seeking additional help and may find that working with a psychologist or therapist with expertise in cognitive behavioral therapy [CBT] to be helpful, in addition to their medical treatment,” Carolyn McCarty, PhD, Research Associate Professor of Pediatrics at the University of Washington and Seattle Children’s Hospital and the lead author of the study, told Reuters. “It is also important to screen for depression among these youth, because concussion and depression tend to co-occur frequently.”

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Within the study, 25 participants were randomly assigned to a collaborative care group, while 24 were placed in a traditional care group. Those undergoing collaborative care were introduced to strategies for reducing symptoms through behavioral and psychological methods, such as guided imagery, relaxation, and activation. They each had a case manager assigned to work with their school employees, medical providers, and coaches to verify concordance across the board.

All of the participants’ symptoms had reduced six months later. However, those in the traditional care group hit a plateau between three and six months. Conversely, the youth in the collaborative care group continued to see symptom severity reduced throughout that time frame. In addition, the participants in the collaborative care group who reported depression saw a greater decline in symptoms compared to their counterparts in the control group.

“I am not surprised by these results of the study,” Cynthia LaBella, MD, Director of the Concussion Program at Ann and Robert H. Lurie Children’s Hospital in Chicago told Clinical Neurology News in response to the study. “A large proportion of the adolescents I treat for concussions are those referred from their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including [CBT], patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills.” 

Similarly, a case study reported by Andrew Russman, DO, Co-Medical Director of Cleveland Clinic’s Concussion Center, adds support to the potential of collaborative care. In this case study, a 13-year-old female soccer player continued to experience high symptom severity 90 days following her injury, despite receiving prompt care.

Initially, the student-athlete had received conservative care, which consisted of taking medication to help with her headaches, increasing salt intake to treat orthostatic tachycardia, taking melatonin for sleep and headache, and avoiding activities that aggravated her symptoms. A week after her injury, she was still experiencing high symptom levels. As a result, she received intense outpatient treatment that included CBT, biofeedback therapy, and medication for headache prevention.

Symptoms persisted, so the patient underwent a pain rehabilitation program to obtain a mix of treatment, such as physical therapy, CBT, biofeedback, and pain management. After the three-week intensive program, she was able to go back to school in a limited capacity. 

In the weeks that followed, the student-athlete began working with a speech therapist to build on cognitive skills and memory, in addition to continuing her outpatient therapy. Eventually, she was allowed to participate in non-contact sports and saw improved academic performance.

“When I see this patient now, it feels like a successful journey,” Dr. Russman writes in the case study. “Progress toward clinical recovery for this patient involved a tremendous amount of time and collaborative care.”



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