Patients are increasingly going to the ED and to their internists with concerns about concussions, likely in response to the recent media spotlight on the risks to professional athletes—especially football players. In many cases, however, patients are presenting with what even five years ago would have been dismissed as mere bumps and bruises, according to traumatic brain injury (TBI) experts.
“There's no question that historically these injuries were not given enough attention. Unfortunately over the last several years we've gone too far in the other direction,” said Ramon Diaz-Arrastia, MD, PhD, a professor of neurology at the University of Pennsylvania Perelman School of Medicine and director of the clinical traumatic brain injury initiative at Penn Presbyterian Medical Center in Philadelphia. “There's a change in public perception from concussion being totally ignored to it being the cause of everything.”
He noted that TBI accounts for three million ED visits a year and at least another three to six million visits for outpatient medical care several days after the injury, without an ED visit. According to the CDC, rates of TBI-related ED visits increased by 47% from 2007 to 2013.
Still, Dr. Diaz-Arrastia said, heightened awareness offers physicians the opportunity to educate patients about TBIs and reassure them that most patients—85%—who have a mild one recover within a week or two.
“It's the role of the internist who sees the patient within a few days of the accident to reassure the patient that [he or she] will get better [given] a commonsense rate of return to activity,” Dr. Diaz-Arrastia said.
More public awareness also gives physicians the opportunity to discuss the risks of repeated TBIs amid concerns about their long-term impact, as well as to dispel misconceptions, he noted.
“I've had people come to me who bang their head on a cabinet in the kitchen and think they have a concussion. No, that's not a concussion because it doesn't involve enough mechanical injury,” Dr. Diaz-Arrastia said.
Now the pressure's on internists, who have traditionally received little training in concussions, to get up to speed on diagnosing and managing them, said Selina Shah, MD, FACP, a sports medicine physician with the Bass Medical Group in Walnut Creek, Calif., who provides comprehensive concussion management.
She said most patients who have been referred to her from a primary care clinician were not improving because they didn't get enough cognitive rest early on. “We know it's important to avoid a stimulus like loud noises or cellphones. [But] I see patients because they haven't had an adequate break from stimuli. Usually, if they do, they recover,” she said.
Diagnostic tools have limitations, said Christina L. Master, MD, a sports medicine physician at the Children's Hospital of Philadelphia and co-author of “In the Clinic: Concussion,” published in July 2018 by Annals of Internal Medicine. Not only does imaging not rule out a concussion, but neither does the Brain Trauma Indicator blood test, she said, which is manufactured by Banyan and which the FDA authorized for marketing in February 2018 under its Breakthrough Devices Program.
Instead, internists have to do the heavy lifting. “Since there are no lab or imaging tests to show or confirm a concussion, clinicians still have to rely on getting a very thorough history … recognizing common symptoms and performing a targeted physical examination, paying particular attention to the visual and vestibular systems,” she said. “Concussion is still clinical diagnosis.”
Is it a concussion?
It's not always obvious that a patient has a concussion, cautioned Dr. Master, professor of clinical pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Not everyone experiences transient loss of consciousness, only one of many signs of concussion, and not every headache is because of a TBI, even if there was a head injury, she said. The pain could be due to a localized contusion on the scalp, whereas a concussion might feel more like fullness or pressure in the head, she noted.
To get started, internists can use a checklist such as the Post-Concussion Symptom Scale to help measure the severity of symptoms, Dr. Master said. But she noted that it's most useful to evaluate the patient for a constellation of somatic, cognitive, and/or emotional TBI symptoms: persistent headaches; dizziness; problems with balance, vision, and coordination; nausea; light sensitivity; and fatigue. Post-traumatic amnesia also is a telling symptom, said Dr. Diaz-Arrastia.
Knowing the circumstances of the accident helps. A concussion can be transmitted from the torso or trunk or from a fall even if the patient doesn't hit his or her head, Dr. Master said. She also noted that patients not diagnosed in the ED with a concussion may develop symptoms a few hours or even a day later.
Dr. Master recommended using a guideline to help frame open-ended questions for the patient, such as:
- Tell me about your injury?
- What new symptoms did you develop after the injury?
- How have your symptoms evolved since the injury?
- Have you had a concussion before?
- Do you have any other conditions like migraines, anxiety or depression, or attention-deficit/hyperactivity disorder or learning disorders?
For example, consider a 25-year-old patient who was playing flag football, fell and hit his head, and then got up and felt woozy and dizzy. A sideline evaluation was performed and ultimately the player was diagnosed with a concussion. When dizziness is a part of the patient's concussion symptoms, the vestibular system is involved, and it suggests that the concussion recovery may be prolonged, said Kathleen Weber, MD, director of primary care/sports medicine and women's sports medicine at Rush University Medical Center in Chicago.
More subtle signs include diminished concentration, focus, and executive functioning, which may become apparent over time, said Dr. Weber, who is also team physician for the Chicago Bulls and Chicago White Sox and co-head team physician for the DePaul Blue Demons.
Biomarker tests not yet useful
While there is hope for the future that an objective biomarker test will eventually be developed to help assess the presence and severity of a concussion and also play a role in predicting recovery, the test approved for marketing last February is not it, said Dr. Master.
The test, which measures two proteins (UCH-L1 and GFAP) that may be released within 12 hours of head injury, was approved by the FDA for marketing based on data from a multicenter, prospective clinical study of 1,947 individual blood samples from adults with suspected mild TBI or concussion. When results of blood tests were compared with CT results, the Brain Trauma Indicator predicted intracranial lesions on a CT scan 97.5% of the time and identified those who did not have intracranial lesions on a CT scan 99.6% of the time, according to a Feb. 14, 2018, FDA press release. Most concussions, however, do not have intracranial lesions on CT, and thus, this test could still be negative in someone with a concussion, Dr. Master said. “There was excitement about the possibility of a blood test for concussion, but this is really a blood test that only correlates with findings on a CT scan,” she said.
The idea behind the test is that measuring these levels would reduce unnecessary ED imaging by helping predict which patients may have intracranial lesions. But emergency physician James Williams, DO, said that doesn't help much, since he already only orders a CT scan if there's a risk of fracture or intracranial bleeding.
“You don't need a CT scan to find a concussion,” he said. The new blood test? “I don't use it.”
Other studies continue to examine the potential of serum biomarkers in diagnosing concussion. However, those studies have had limitations, said Dr. Diaz-Arrastia. For example, a recent study in Neurology had limited participation and insufficiently sensitive assays, he pointed out. Still, he said other studies are promising and further research may lead to better tests.
“Just like using troponin to assess cardiac ischemia, having something you can measure in the blood to help diagnosis and clinically measure would be useful,” he said.
The art of patient management
A patient who has been diagnosed in the ED with a concussion should be seen by his or her pediatrician, family practitioner, or internist for follow-up before returning to regular activities, said Dr. Williams, spokesperson for the American College of Emergency Physicians and clinical associate professor at Texas Tech University Health Sciences Center School of Medicine in Lubbock. The physician should note, for example, if headache is worsening or if executive function is improving.
Most patients who have a mild TBI will recover within 7 to 10 days, up to a few weeks in adolescents, said Dr. Master. To promote recovery, she prescribes activity modification, not bed rest. “It's about relative rest or activity modification to keep headaches and symptoms at a minimum” while the brain recovers from the injury, she said.
Pushing through even a nonimpact aerobic activity that elicits a headache may delay recovery, cautioned Dr. Diaz-Arrastia. “It's a big problem, especially among young people who go back to school with a headache or cognitive problem,” he said.
To avoid those setbacks, Dr. Diaz-Arrastia recommends that patients who go back to work right after a TBI not schedule a work trip or intensive assignment and that students go back to school for half-days during their first week.
Although some research is pointing to benefits of early introduction of activity—for example, a 2016 study in JAMA found that physical activity within seven days of acute injury for participants 5 to 18 years of age was associated with reduced risk of persistent postconcussive symptoms at 28 days compared with no physical activity—recovery strategies need to be individualized, Dr. Shah said. “The art of figuring out at what level and when to start activity comes with experience, and it is best to begin conservatively,” she recommended.
Medications have a limited role. Headache may initially respond to over-the-counter pain medication, but Dr. Master noted that EDs often do not recommend NSAIDs due to the theoretical concern for bleeding. There is also risk of medication-associated headache with prolonged use of any over-the-counter pain medication, so daily ongoing use should be avoided, she said. Moreover, she said most of her patients report that these medications don't help much.
Dr. Weber said internists can use the increased patient awareness as an opportunity for prevention. For example, contact sports players can be made safer just by knowing not to lead with their heads. And while it's hard to argue for lifestyle changes for patients who have had one concussion, it's important to do so after a second or third, especially if they were hard-hitting, sports-related concussions, said Dr. Diaz-Arrastia. Because the brain recovers more slowly and less thoroughly after a subsequent concussion, symptoms become more pronounced, last longer, and may be permanent, he said.
Dr. Diaz-Arrastia noted that the rate of recovery from a second or third even relatively minor concussion is related to the severity of the first one. “The patient used up a lot of cognitive reserve to recover from the first [concussion]. Even though the second one was smaller in magnitude, it tipped the patient over the edge,” he explained.
Vestibular deficits are a concern for the elderly, who may already have balance or other vestibular impairments, Dr. Master said. She may recommend active rehabilitation to restore full function in certain cases.
For athletes, Dr. Weber relies on current concussion research and return-to-play protocols issued in 2016 at the 5th International Conference on Concussion in Sport. Even so, she's had pushback. The parent of a player who took an elbow to the head during a showcase invitational game kept insisting his daughter was fine. But she was dazed and had a headache. Although the interaction was tense, “I made her sit,” said Dr. Weber. “I side on caution and looking out for the athlete.”
Dr. Diaz-Arrastia said symptoms that persist for three to six months might be considered permanent. It's still unclear whether other long-term consequences of TBI might include elevated risk of epilepsy, dementia, chronic traumatic encephalopathy, Parkinson's disease, or suicide. There's also a question as to whether inherited factors play a role in recovery and persistent symptoms, said Dr. Master.
While more research is needed to verify any of these connections, Dr. Williams said he doesn't think it's worth taking a chance for someone who has had repeated injury. “We're not sure of the cause and effect, but because the brain is so unforgiving, why put it at risk?” he asked.
The 10% to 15% of patients who typically continue to have problems with headache, sleep, anxiety, or depression after two or four weeks should be referred to a concussion specialist, TBI experts said.
Dr. Shah said sports medicine physicians and neurologists can help if the internist is not comfortable managing a patient who doesn't improve as expected or whose symptoms are difficult to treat. Physical therapists can help patients with balance issues, while occupational therapists can provide visual therapy for those with eye movement issues. Psychologists or psychiatrists should be considered for those with anxiety and/or depression.
But most patients will recover, even the 40% to 50% of patients hospitalized with severe or moderate TBI, and even those who have been in a coma, Dr. Diaz-Arrastia said.
“So the predominant message [to most patients seen with concussion in a physician's office] is, ‘You are going to get better,’” he said.