Concussion: Its Diagnosis and Treatment
(Inside Science) -- When someone arrives at an emergency room in a coma, someone with a serious brain injury, there is a long and well-established set of processes in place that allow for doctors to rapidly evaluate, triage and manage their treatment. The procedures for evaluating people who have a milder form of traumatic brain injury, a concussion, have historically been a little less well-defined. But experts say things have gotten better in recent years.
"At this point, our emergency department colleagues are quite adept at the evaluation and management of the patient with a concussion and the proper triage and steering of those patients into the expert hands, and that is often a neurosurgeon or a neurologist. But we also have primary care physicians who have sought additional specialty training. And we now have a pretty large army in the United States of people who can properly evaluate a patient with a concussion," said David Okonkwo, clinical director at the UPMC Brain Trauma Research Center.
"It is a heterogeneous disorder. No two concussions are alike. And we see people have issues with migraines. We see people who have issues with dizziness and vestibular problems. We see other patients who have issues with memory and cognition. And then we also see patients who have a mental health manifestation of their concussion, be it in the form of anxiety or mood disturbance. These are just a short list of an even longer list of the ways in which a concussion can manifest itself," said Okonkwo.
Dealing with concussion is complicated by the fact that people with the injury can experience completely different symptoms. The proper identification of the exact form of concussion an individual suffers is key, the experts say, because it helps to guide treatment.
"If it's a balance-related issue, then you work on balance therapy. If it's a visual-related issue, you work on visual therapy," said Mark Proctor, neurosurgeon-in-chief at Boston Children's Hospital.
For the majority of folks, treatment for a concussion starts with rest. The question of how long to rest has also evolved in recent years.
"So there used to be this concept of brain rest being, well, you put a child in a dark room until every symptom is gone. And it was discovered through some work at our hospital that that's not always the right -- well, clearly that's not the best way to treat them. There's a real benefit to near-total rest for about two to three days. But you don't have to wait till someone's completely asymptomatic before you get them out, you get them back to school, etc., because there's other determinates such as social isolation and depression that start to factor in if you keep them out for too long," said Proctor.
Proctor and his colleagues treat 400 to 500 mostly sports-related injuries every month at the brain injury center he directs. His experience there and the experience of doctors at other hospitals suggest a mostly good prognosis.
"For most people who sustain a concussion, there can be an expectation of the spontaneous resolution of symptoms and the spontaneous resolution of the problem over the course of days to a few weeks," said Okonkwo.
"Eighty, 90 percent will be better in 10 to 14 days. And really no treatment is necessary other than the rest. What really is the vexing problem is that sort of 10 to 15 percent where those symptoms go on for a prolonged period of time," said Proctor.
However, it's very hard to predict who is going to be fine in two weeks and who isn't. One of the challenges is that there is no specific biological test for concussion.
"We see this in so many other fields of medicine, where if you have a blood test that would clearly show that you had a concussion, that would be an enormous asset," said Okonkwo.
Nor are there imaging biomarkers -- ways of spotting a concussion on an MRI or CT scan. But many tools are now moving through development.
"We can have a reasonable expectation in the next two to three years of things crossing that FDA clearance hurdle and being put to use in routine clinical practice," said Okonkwo.
For now, coaches and trainers have different forms of assessment tools. Cognitive tests can indicate if there’s a problem to determine if a player needs to be taken off the field, and taken to a doctor for further evaluation. Another advance that doctors hope for are better ways to treat specific types of brain injuries and concussions. There are still no existing FDA-approved drugs for the management of brain injury.
"However, we do understand that there are numerous rehabilitation strategies that are effective in this condition, and the key is the proper and precise diagnosis of what the problem is, with targeted treatment only against the form of concussion that the person has that is in front of you that you're taking care of. I think the critical needs in the field right now that we would love to see happen in this next decade are more specific tools and technologies that allow for precision medicine and precision diagnosis in the field of concussion and TBI," concluded Okonkwo.