Mar

Current treatments for post-concussion syndrome

For a certain subset of concussed athletes recovery is a dishearteningly slow process. Just ask Penguins' Sidney Crosby who has been on and off the ice -- mostly off -- for over a year. Or Justin Morneau who hopes to make it through baseball training camp without suffering symptoms from a concussion that sidelined him for the last six months. Many athletes are told to rest their brains for prolonged periods in order to recover. But Dr. Michael Collins, Director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program has a different approach for some injured patients whose recovery has stalled. Well-known for treating high profile athletes suffering from post-concussion syndrome (PCS), his schedule is also full of recently injured youth athletes. His success with any patient lies in the variety of treatment modalities he tailors to each individual, with a goal of returning to activity as quickly -- and safely -- as possible.

A different view

Depending on the case, Dr. Collins may take the road less traveled. Take the brain-rest-for-recovery issue, for instance.

"Athletes who follow the regimen of initial rest and have not seen their symptoms resolve are more at risk for prolonged recovery if they remain inactive," said Dr. Collins. "We concentrate on rehabituating the brain at a steady pace to be able to handle stimulation found in their everyday lives. The rehabilitation program we design for them may include sub-threshold exercise, specific academic accommodations, vestbular therapy, vision therapy, medication, or more. It depends on what they need."

The key to his approach is finding what neurological systems in the brain have been affected and creating a rehabilitation program that guides a quick 7-10 day recovery, or using his knowledge of certain key factors --such as vestibular-ocular issues -- to predict who is likely to experience a prolonged recovery and treating accordingly.

Based on several new research papers, Dr. Collins is better able predict who is on track to recover quickly. Those who exhibit pronounced deficits on computerized neurocognitive testing or have symptoms like dizziness, feeling physically " foggy" or have migraine-type symptoms at three days post-injury seem most at risk for symptoms that may last a month or more. (A recent study found that on-field dizziness is a predictor of prolonged recovery.)

There is no "golden cookbook" for concussion management, said Collins. But keeping athletes inactive for long periods of time does not yield benefits for some and may exacerbate symptoms. As they withdraw from their daily activities like seeing friends, attending practices and being socially connected to their world, they often feel depressed or anxious. Low moods further drain the brain's energy stores at a time when they are most needed for repair, creating a vicious cycle. More symptoms mean more rest, more rest leads to further isolation which opens the door to depression and other psychological struggles. "The same neurotransmitter system that regulates mood affects the vestibular system," said Collins. It is often thought that depressed or anxious athletes will feel better once their physical symptoms have resolved. It may be more complicated than that, particularly if a biological basis for post-concussion mood issues is established.

Numerous therapies

The UPMC team employs a variety of therapies ranging from vestibular, vision, pharmacutical, psychotherapy, and sub-threshold physical excercise, to name a few. Recovery recommendations are individualized based on which neurological systems are compromised.

One common misperception is that vestibular therapy simply refers only to balance issues. More accurately, "vestibular" refer to dizzines, balance and spatial disorientation and includes occular (eye) and hearing components, according to Collins, who noted that 70% of the brain is devoted to activity involving vision. Athletes who cannot visually "track" after concussion are not uncommon.

According to the American Academy of Neurology the vestibulo-ocular reflex (VOR) is a reflex that acts at short latency to generate eye movements that compensate for head rotations in order to preserve clear vision during locomotion. The VOR is the most accessible gauge of vestibular function. Evaluating the VOR requires application of a vestibular stimulus and measurement of the resulting eye movements.

Rehabilitating the brain

Collins' team of specialists often recommend increasing stimuli to rehabilitate the brain, "keep the foot softly on the pedal." The focus is on identification of the affected systems through testing then slowly and systematically rebuilding the brain's ability to handle the stimulation of busy environments found in everyday situations like school lunch rooms or stores.

Donna Mello of Portsmouth, Rhode Island, remembers when her 17-year-old son Dylan couldn't walk into a convenience store without feeling overwhelmed by the sheer number of items on the shelves. He also struggled with crowded hallways at school. Both situations triggered symptoms in him and panic in her because she had no idea if he would ever recover.

"Concussion management remains an incredibly complex issue and we need to remember that no two cases are alike," said Collins. "Every athlete's response to concussion is unique and requires an individualized approach."

Questions/comments? Contact Jean Rickerson at This e-mail address is being protected from spambots. You need JavaScript enabled to view it.