Earlier Intervention After Concussion Linked to Faster Recovery

January 14, 2020

Earlier initiation of clinical care after a concussion was associated with faster recovery in a new study.

Athletes who presented for evaluation within the first week after injury recovered faster than athletes who initially presented 2 to 3 weeks post injury.

"Our results show that following a concussion, patients should seek specialty care involving a comprehensive assessment and clinical exam that allows for more targeted treatments for specific symptoms and impairments as early as possible," lead author Anthony P. Kontos, PhD, told Medscape Medical News.

Kontos, who is research director of UPMC Sports Medicine Concussion Program, University of Pittsburgh, added: "Earlier care with a trained clinician allows patients to begin behavioral management strategies involving physical and cognitive activity, sleep, nutrition, hydration, and stress management, all of which can enhance the recovery process. Patients should not wait for a week or more to seek care to see if things improve on their own; rather, they should seek care as soon as they can to enhance their recovery process."

The study was published online January 6 in JAMA Neurology.

The researchers note that most athletes who experience a concussion do not receive care beyond an initial evaluation or diagnosis at or near the time of injury and that this may result in prolonged time to recovery.

There has been general reticence among clinicians who treat patients with concussion to engage in earlier active intervention because of perceptions that it may result in a prolonged recovery, but recent research suggests that provision of care in the first few days after a concussion, especially active interventions that target specific symptoms and impairments, may play a pivotal role in influencing recovery, the researchers say.

For the current retrospective, cross-sectional study, Kontos and colleagues analyzed data on 162 young people who experienced a concussion while playing organized or recreational sports and who received treatment at a sports medicine concussion clinic.

They compared time to recovery in the 98 patients seen within the first 7 days post injury (the early group) with 64 patients seen within 8 to 20 days post injury (the late group).

The early and late groups did not differ in age (mean, 15.3 years vs 15.4 years); number of female patients (early, 52.0%; late, 62.5%), or other demographic, medical history, or injury factors. The groups were also similar with respect to symptom severity, as well as cognitive, ocular, and vestibular outcomes at the first clinic visit.

Results from a logistical regression indicated that recovery time was increased for patients in the late-treatment group (adjusted odds ratio, 5.8). Having a score >2 on an assessment of visual motion sensitivity was also associated with increased recovery time (adjusted odds ratio, 4.5).

"We found that early access to clinical care was associated with an almost six times increased likelihood of a recovery within 30 days," Kontos said.

In the early group, 52% of patients recovered within 30 days, compared with 19% of those in the late group. Mean recovery time was 51 days in the early group vs 66 days in the late group.

Kontos pointed out that concussion treatment is not just a matter of prolonged rest. "Some patients may rest for 6 months and still have symptoms, but after 1 month of vestibular therapy they are better. The brain is like any other part of the body ― if it is damaged and you do nothing, it doesn't always repair itself. It needs the right therapy. We used an exposed recovery model which used active targeted treatments for individual symptoms of concussion.

"Earlier care involving a comprehensive assessment and clinical exam allows for more targeted treatments for specific symptoms and impairments," he commented.

"For example, a patient with vestibular impairment would be able to begin therapy earlier and potentially accelerate their recovery simply by coming in for specialty care sooner rather than waiting. In addition, earlier care with a trained clinician allows patients to begin behavioral management strategies involving physical and cognitive activity, sleep, nutrition, hydration, and stress management, all of which can enhance the recovery process."

The researchers note that the earlier initiation of active rehabilitation strategies, including exertion progression and the opportunity to start structured physical therapies (eg, on vestibular, visual, and cervical systems), is one reasonable explanation for the shorter recovery time in the earlier group in this study.

"Further, without clinical guidance and behavioral management recommendations postinjury, athletes may have been engaging in counterproductive recovery strategies, such as strict rest or excessive physical activity," they add.

They point out that this explanation is supported by the fact that athletes recovered in a similar amount of time after the first evaluation. "It appears that all athletes had similar impairments and similar recovery time after they had received initial clinical care, highlighting the importance of clinical care as soon as possible," they conclude.

"As a parent, I would prefer my child to recover quicker from concussion symptoms, and that means accessing care sooner," Kontos added.

Commenting on the study for Medscape Medical News, Sarah Benish, MD, associate professor of neurology at the University of Minnesota, in Minneapolis, said: "I think this article adds to the growing literature that suggest early and active intervention is most likely beneficial to concussion improvement."

However, Benish pointed out that the latter group appeared to have more females, more migraine sufferers, a high rate of loss of consciousness, and a higher rate of posttraumatic amnesia, which may have had a bearing on the results.

"In addition, I would be concerned that there is a selection bias and those who had milder concussion that would self-resolve have been eliminated for the later-care group, as they would not have been seen in the clinic. The only way to truly know would be to do a prospective study where concussion athletes are assigned to an early or late appointment," she added.

"I agree the study suggests patients might benefit from improving access to care for athletes to get help for concussion, but I am not sure this is the definitive study that is needed to convince health systems to invest more money into helping access issues in an area that is historically underserved. However, it is another step towards improving care for concussion patients," she concluded.

Kontos has received grants from the National Football League, personal fees from APA Books, and other compensation from the University of Pittsburgh outside the submitted work.

JAMA Neurology. Published online January 6, 2020. Abstract

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