Concussion: Evaluation and management
ABSTRACT
Concussion is a common problem often managed by nonneurologists. It is often accompanied by headaches, dizziness, sleep disturbance, psychiatric symptoms, and cognitive issues. Here, we outline how to evaluate and manage concussion, including treatment of the most common symptoms.
KEY POINTS
- Concussion results from a traumatic acceleration of the brain that leads to a metabolic mismatch, with an increased demand for adenosine triphosphate but decreased blood flow to the brain. This “energy crisis” results in variable signs and symptoms, most commonly headache, dizziness, sleep disturbance, cognitive problems, and emotional difficulties.
- Initial therapy involves several days of cognitive and physical rest, followed by a gradual return to physical and cognitive activities.
- There is no direct treatment for the physiology of concussion, but early treatment of symptoms and education about recovery and accommodations aids functional recovery.
IF SYMPTOMS PERSIST
With the interventions suggested above, most patients with concussion have a resolution of symptoms and can return to preinjury levels of performance. But some have prolonged symptoms and sequelae. Approximately 10% of athletes have persistent signs and symptoms of concussion beyond 2 weeks. If concussion is not sport-related, most patients recover completely within the first 3 months, but up to 33% may have symptoms beyond that.52
Four types of patients have persistent symptoms:
Patients who sustained a high-force mechanism of injury. These patients simply need more time and accommodation.
Patients who sustained multiple concussions. These patients may also need more time and accommodation.
Patients with an underlying neurologic condition, recognized prior to injury or not, may have delayed or incomplete recovery. Even aging may be an “underlying condition” in concussion.
Patients whose symptoms from an apparently single mild concussion do not resolve despite appropriate treatments may have identifiable factors, but intractable pain (usually headache) or significant emotional disturbance or both are common. Once established and persistent, this is difficult to treat. Referral to a specialty practice is appropriate, but even in that setting effective treatment may be elusive.
PATIENT EDUCATION
Most important for patient education is reassurance. Ultimately, concussion is a self-limited phenomenon, and reinforcing this is helpful for patients. If concussion is not sport-related, most patients recover completely within 3 months.
The next important tenet in patient education is that they should rest for 3 to 5 days, then resume gradual physical and cognitive activities. If resuming activities too soon results in symptoms, then they should rest for a day and gradually resume activity. If their recovery is prolonged (ie, longer than 6 weeks), they likely need to be referred to a concussion specialist.
