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Cognitive-behavioral therapy eases postconcussive symptoms in teens

Key clinical point: Adolescents with persistent postconcussive symptoms and depressive symptoms improved significantly after the addition of CBT to usual care.

Major finding: After 6 months, 13% of teens who underwent CBT plus usual care reported high levels of postconcussive symptoms, compared with 42% of controls.

Data source: A randomized trial of 49 adolescents aged 11-17 years with persistent postconcussive symptoms at least 1 month after a sports-related concussion,

Disclosures: The researchers had no financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.

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Adding CBT adds value if patients are receptive

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than 2 weeks, 10%-15% will have prolonged symptoms (greater than 1 month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient’s being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by these results of 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, and the bonus is that these skills are incredibly useful across one’s lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10-20 years down the road.

Cynthia LaBella, MD, is director of the concussion program at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. LaBella said she had no relevant financial disclosures.


 

FROM PEDIATRICS

References

Adolescents who underwent cognitive-behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive symptoms and depressive symptoms in a randomized trial of 49 patients aged 11-17 years. The report was published online Sept. 12 in Pediatrics.

“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, of Seattle Children’s Hospital, Washington, and her colleagues. “The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools” (Pediatrics. 2016. doi: 10.1542/peds.2016-0459).

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To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients to usual care or a collaborative care plan that included usual care plus CBT.

After 6 months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of CBT patients reported a depressive symptom reduction of more than 50%, compared with 46% of controls.

Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacological consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at 1, 3, and 6 months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15 years, approximately 65% were girls, and 76% were white.

Overall, 83% of the CBT patients and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.

“Although patients in both groups showed symptom reduction in the first 3 months, only those who received collaborative care demonstrated sustained improvements through 6 months of follow-up,” Dr. McCarty and her colleagues wrote.

The results were limited by several factors including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion,” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.

Dr. McCarty and her colleagues had no relevant financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.

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