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Act Fast: Early Intervention and Treatment for Concussions

December 8, 2016 12:00 PM with Dr. Nicole Reams

For student athletes, the school year represents the peak sports seasons when they are most at risk for concussions. If you’re a parent, a coach or an athlete yourself, recognizing the signs of a potential concussion are incredibly important, as is knowing the steps that are taken afterwards to diagnose and treat the condition. Join Dr. Nicole Reams, Sports Neurologist within NorthShore’s Neurological Institute as she takes questions on the symptoms of a concussion, and provides expertise on the latest early intervention techniques for accurately diagnosing and treating the damage.

Kathryn (Moderator) - 12:00 PM:
Our chat on concussion is now open. You can submit questions at any time during the hour.

  Sheri (Vernon Hills, IL) - 12:02 PM:
Is it true that the more concussions you have, the longer it takes for the brain to heal and the headaches to stop?
Dr. Nicole Reams (NorthShore)
This is a complicated question. If each concussion is treated appropriately, we expect full recovery. There is an unknown threshold where more successive concussions increase the risk of long-term consequences such as cognitive difficulties, making it difficult or impossible for the brain to fully recover. We, as a field, don't know where exactly that threshold lies.

  Lauren (Grayslake, IL) - 12:05 PM:
Do you believe there is a benefit in using concussion headbands for soccer?
Dr. Nicole Reams (NorthShore)
No. Research has not supported the use of concussion headbands for soccer. They have not been shown to reduce concussion incidence and, in fact, may increase the risk if players that use them feel more invincible.

  Michael (Chicago, IL) - 12:08 PM:
My daughter is 15 and has a history of head injuries. Only recently after an onset of depression and anxiety, her doctor ordered a psychological evaluation for her history of head injuries, and to verify a previous diagnosis of ADHD. A possibility of NVLD has previously been suggested. 2 mixed specialties clinics have declined to test her based on the group of possible issues. What might be the best type of testing for such a combination of conditions? Could the concussions be the nexus?
Dr. Nicole Reams (NorthShore)
Formal neuropsychological testing can be helpful in teasing out diagnoses of ADD/ADHD, as well as learning disorders. It is difficult for me to comment on the contribution from concussions without knowing more of her head injury history. As a general rule, concussion cannot cause ADHD or learning disability on its own. It has been described that concussion may lower the threshold for genetic contributions for disease such as migraine or depression/anxiety. It may be possible that history of concussion made these problems come on earlier or be more significant than they may have been otherwise. Without more information about your daughter, it is difficult to know.

  Kim (Glenview, IL) - 12:12 PM:
If your child has had some type of injury to their head, say during a soccer game, when/how quickly should you seek a medical evaluation? Is it okay to watch and wait at home before going to see a health care provider?
Dr. Nicole Reams (NorthShore)
I would advise that your child be seen by a healthcare provider within 24-48 hours. This can be helpful for diagnosis and initial management to help ensure that their recovery isn't delayed or complicated. Most concussions do not require evaluation in an ER, but if there are concerns for prolonged loss of consciousness >1 minute, or deteriorating neurological status, such as worsening alertness, or new signs such as trouble speaking, weakness or numbness, the patient should be seen immediately in an ER to rule out a bleed in the brain.

  Doug (St. Charles, IL) - 12:16 PM:
Concussions can produce a variety of symptoms, but sometimes it is unclear whether a symptom has a physical basis. Are there reliable changes in the brain that can be detected following a concussion, and if so, can you use associate brain damage with specific symptoms?
Dr. Nicole Reams (NorthShore)
Great point. Symptoms of concussion can be vague and nonspecific, which is challenging for diagnosis in some cases. At this time, there are not clinically used tools that can corroborate symptoms with changes in the brain to ensure correct diagnosis (ie. there is no blood test or scan that is used currently to confirm diagnosis of concussion). There are many types of testing being researched currently and we hope to have this type of tool in the coming years. Right now, concussion is a clinical diagnosis made based on the nature of the impact, the presence of symptoms, the nature of the symptoms and timing and evolution of the symptoms. It can be supported by some exams such as computerized neurocognitive testing, testing of eye movements, or balance testing, but these additional tools cannot be relied upon for diagnosis.

  Jennifer (Evanston, IL) - 12:22 PM:
My son took a test at school called the impact test. He said it was just a computer test. Are you aware of the impact test; what are your thoughts on it?
Dr. Nicole Reams (NorthShore)
Yes. The ImPACT test is a computerized neurocognitive test that measures reaction time, verbal and visual memory. This test can be helpful in determining recovery from concussion to ensure a safe return to play. It is especially helpful when the athlete has a baseline test (a test performed prior to any injury) to compare it to. This test has limitations, however, and cannot be used to diagnose concussion on its own and is used as one part of the clinical assessment. For example, patients who had not slept well the night before, have pain or are distracted possibly due to a busy testing environment, can all show abnormalities on this testing that have nothing to do with continued injury or not. It can be helpful in some cases, but again, needs to be part of a more comprehensive assessment.

  Ivelisse (Chicago IL) - 12:28 PM:
What should coaches look for when there athletes take a hit? What should be the steps following a possible concussions?
Dr. Nicole Reams (NorthShore)
Ask general mental status questions: Where are you, who are we playing, what play did we just run, etc to get a sense of if they are confused or if they have slow mental processing. I ask them to describe the hit and any symptoms that happened afterwards (headaches, nausea, sensitivity to lights and sounds, dizziness). I hold up a finger and ask them to follow it to ensure they don't have double vision or nystagmus (jumping of the eyes), and ask them to stand on one foot to see how their balance is doing. If they report any symptoms that could be consistent with concussion or show any abnormalities during the quick exam, sit them out. They should not return to sports that day if there is any concern for concussion. It's okay if you're wrong and sat them without needing to. Their safety is the most important thing. They should then be seen by a healthcare provider for further diagnosis and instructions.

  Heather (Chicago, IL) - 12:32 PM:
Have you had any experience with suboccipital nerve blocks/injections for concussed patients with severe headache pain? I have heard that these can alleviate headache pain in these patients significantly, but don't know if there is actual evidence for it.
Dr. Nicole Reams (NorthShore)
Yes. I perform these in my clinic for appropriate patients. They can be successful in patients with prolonged headaches outside of the expected time window for recovery of concussion, and in particular, in patients who had cervical strain as part of their injury and headaches are likely stemming from continued cervical dysfunction. Their story typically is posterior or frontal aching or pressure headaches, present upon wakening in the morning, worse with head movements or sustained postures, may worsen as the day goes on. I don't perform these in the acute recovery phase, or for continued headaches that are likely from another source (ie. migraine). There are scientific publications to back their efficacy for cervically-related headaches.

  Sheri (Vernon Hills, IL) - 12:36 PM:
Is returning to personal exercise programs after a concussion more accepted now than in the past. (as long as it's not traumatic to the head or cause dizziness)?
Dr. Nicole Reams (NorthShore)
Recent scientific data as well as expert opinion is supporting earlier return to physical activity. Data has shown that prescribing complete rest or prolonged rest can worsen symptoms and cause the symptoms to last longer. We are now encouraging light physical activity towards the end of acute recovery, even while symptoms are still present and instruct that it be "symptom-limited". This means that the exercise should not continue if it provokes exacerbation of symptoms. We still advise that return to exercise follow a progressive graded approach (starting with something easy and stationary like bike, followed the next day but jogging or running, followed the next day by agility or weight-lifting, then on to non-contact practice, then contact practice, then full release for those in contact sports), even if its a home exercise program, to ensure that the concussion has resolved. If symptoms exacerbate during these stages, you should stop and attempt that stage again the next day.

  Jeremy (Chicago, IL) - 12:41 PM:
Given that concussion headaches are so broad in their scope, what 'at home' behaviors, exercises or treatments do you find you most often recommend to patients to more effectively support your own treatment plan?
Dr. Nicole Reams (NorthShore)
Treatment recommendations change depending on where in the recovery pathway the individual is. If they are in the acute time frame (typically within 2--3 weeks out from injury), I advise them that it's okay to take over-the-counter pain medications as needed, but to try to limit their use if possible. If I'm concerned about cervical strain as part of their injury, I will give them some simple home neck stretches to start with. If they are subacute (3-6 week out from injury), I typically recommend scheduled anti-inflammatories such as Aleve twice daily, every day for 5 days, which can reduce headache. Consider PT for the neck at this time also. If the patient has more chronic headaches, we consider more long-term medications for headache prevention, which may include nortriptyline or gabapentin depending on the headache type.

  Jean (Libertyville) - 12:44 PM:
Is there any hereditary connection linked to recovery from concussion, meaning if one family member has a difficult and long recovery, there is a higher incidence a sibling could have the same result? I have 2 daughters, both with concussions and long-term recoveries. Also is neurobiofeedback helpful for cognitive recovery? It is recommended to my daughter and to be performed by a speech pathologist.
Dr. Nicole Reams (NorthShore)
I am not aware of any direct hereditary or genetic factor that would cause prolonged concussion recovery in family members. That being said, it has been well-described that personal or family history of migraine, ADD or depression/anxiety can prolong recovery. If these diagnoses are present in your family, they may affect your children and their ability to recover from concussion in a similar manner. There may also be non-physiologic factors such as their social environment. Neurofeedback can be helpful for recovery in some people. The scientific data beyond it is somewhat lacking, but anecdotally, I've had success with it in some of my patients.

  Lynne (Evanston, IL) - 12:47 PM:
If a parent thinks that their child might have a concussion or damage from a head injury, should they take their child to their regular pediatrician or the ER?
Dr. Nicole Reams (NorthShore)
If the injury is within the last 24 hours AND you are concerned about deteriorating status: They are becoming more lethargic, more confused or have new vomiting, then take them to the ER. The real reason to take someone to the ER is to rule out the possibility of a bleed in the head. If the injury is >24 hours old OR they do not have deteriorating signs, they should be seen by their pediatrician or a concussion specialist. Though if there are ever concerns about deteriorating status as mentioned above, an ER visit should be considered.

  Janet M (Chicago IL) - 12:50 PM:
What progressive neurological disorders that transfer over to personality disorders or behaviors can one expect from someone suffering from CTE diagnosed 11 years prior? I know everyone is different, but, I know a former professional NFL football player that suffers from CTE, diagnosed 11 years ago, that currently has problems sleeping and problems with depression, irrational thoughts and violent outbursts, plus memory loss. Is it expected that he will worsen to the point of complete incapacity?
Dr. Nicole Reams (NorthShore)
This is a difficult question, because we just don't have the science to answer your question. At this time, CTE is a pathological diagnosis (one that is made under the microscopis of a brain at autopsy). We do not have much information about the clinical symptoms that may or may not be related to the changes they see under the microscope, nor do we know much about the typical clinical course or symptoms to expect in patients with progressive neurological degeneration related to repetitive head trauma. We expect that the clinical course could cause progressive cognitive changes and personality, mood or behavioral changes.

  Sarah (Shorewood, IL) - 12:54 PM:
What is your recommended guidelines for exertional training or return to play following a concussion?
Dr. Nicole Reams (NorthShore)
I advise starting light physical exertion such as walking and stationary bike towards the end of their acute recovery (i.e. they can still have mild symptoms at this time). This should be symptom-limited and not aimed at exacerbating symptoms. Following symptom stabilization or resolution, you can start through progressive return to play stages as follow: 1. Stationary bike 2. Running or Jogging 3. Agility or weight-lifting 4. Non-contact practice 5. Contact practice 6. Full release for competition Progression through these stages requires that the previous stage did not cause return of symptoms. The player should not return to contact play unless they are at their pre-injury baseline and until they have been seen by a physician for clearance. They should also be back to full school if they are a student athlete prior to return to sport.

  Sheri (Vernon Hills, IL) - 12:57 PM:
Is there a "standard " for when the concussion headaches will cease? I realize certain activities can affect the day and the headaches but will they cease in an approximate length of time?
Dr. Nicole Reams (NorthShore)
Most patients with concussion will see total resolution of their symptoms in 2-3 weeks. If symptoms last longer, we look for reasons for this, such as not the right amount of rest, genetic factors that could prolong recovery, additional injuries such as neck strain or psychological factors that could promote injury.

Kathryn (Moderator) - 1:00 PM:
This will be the end of our chat. Thank you for your questions. For more information on concussion, or to speak with a specialist like Dr. Reams, contact the NorthShore Neurological Institute.

This chat has ended.

Thank you very much for your participation.