Concussion: Assessment, Management and Rehabilitation

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Concussion: Assessment, Management
and Rehabilitation
Copyright
List of Contributors
Preface
Introduction
1. Acute Management of Concussion and Diagnostic Criteria
	Introduction
	Diagnostic Criteria
	Epidemiology
	Pathoanatomy and Pathophysiology
		The Clinical Concussion Clock
			Minutes
			Hours to days
				History
				History
				Physical examination
				Physical examination
				Laboratory investigations
				Laboratory investigations
				Imaging
				Imaging
				Initial treatment approach
				Initial treatment approach
			Weeks to Months
	Conclusion
	References
2. Neuropsychological Assessment
	Neuropsychological Methods
		Evidence-based Neuropsychological Practice
		The Physical Examination
		Questionnaires and Interviews
		Computerized Neuropsychological Screening
		The Fixed and Flexible Battery
	Reason and Temporal Impact of Referral
	Neuropsychological Outcome of Concussion
		Misconceptions
		Rate of Cognitive Recovery
		Myth of the “Miserable Minority”
		Base Rate of Postconcussive Symptoms
	Performance and Symptom Validity
	Influence of Expectations on Test Performance
	Comorbidities and Differential Diagnosis
	Special Populations
		Pediatrics
		Geriatrics
		Military/Veterans
		Forensics
	Conclusion
	References
3. Neuroimaging in Traumatic Brain Injury Rehabilitation
	Introduction
	Rehabilitation Relevant Cross-Sectional MRI Finding
		Structural Imaging Findings
		Diffusion MRI Findings
		MRI Summary
	Predicting Outcomes Following TBI
	Imaging Findings Tracking More Traditional Rehabilitation Approaches
	Imaging Findings Tracking More Experimental Rehabilitation Approaches
	Clinical Recommendations
	Future Directions and Conclusions
	References
4. Postconcussive Syndrome (PCS)
	Part 1. Diagnosis, Risk Factors and Evaluation of Postconcussive Syndrome
		Definition and Diagnosis
		Epidemiology
		Pathophysiology
		Risk Factors
		Evaluation
		Prognosis
	Part 2 Treatment of PCS
		Introduction and General Principles of PCS Management
		Education
		General Approach to Somatic Symptoms
		General Approach to Pharmacotherapy
		Overview of Pharmacotherapy for Some Common Individual PCS Symptoms
		Physical Exercise
		General Cognitive Treatment
		General Psychological Treatment
		Cognitive Behavioral Therapy
		Secondary Gain
		Interdisciplinary Programs
		Novel Interventions
		Monitoring Progress
	References
5. Assessment and Management of Psychiatric Symptoms Among Adults With Mild Traumatic Brain Injury
	Epidemiology
		Persistent Postconcussive Symptoms Related to Mood
		Mood Disorders
		Anxiety Disorders
		Post-traumatic Stress Disorder
		Substance Use Disorders
	Assessment
		Persistent Postconcussive Symptoms Related to Mood
		Mood Disorder
		Anxiety Disorders
		PTSD
		Substance Use Disorders
	Management
		Expectation for Recovery
		Psychosocial Interventions
			Persistent postconcussive symptoms related to mood
			Mood and anxiety disorders
			PTSD
			Substance use disorders
		Pharmacotherapy—Neurobehavioral Sequelae of Traumatic Brain Injury
			Persistent postconcussive symptoms related to mood
			Mood disorders
			Anxiety disorders
			PTSD
			Substance use disorders
	Suicide
	Conclusion
	References
6. Postconcussive Headache
	Introduction
	Classification Challenges
	Limitations of Existing Literature
	PCH Pathoetiology
	PCH Clinical Presentations—an Overview
	The PCH History
	The PCH Physical Examination
	PCH Treatment Principles—an Overview
	PCH: Common Presentations and Recommended Treatment Approaches
		Migraine
			Clinical presentation
			Treatment
		Tension Headaches
			Clinical presentation
			Treatment
		Neuritic and Neuralgic Headache
			Clinical presentation
			Treatment
		Myofascial Pain Related Headaches
			Clinical presentation
			Treatment
		Cervicogenic Headache
			Clinical presentation
			Treatment
		Medication Overuse Headache
			Clinical presentation
			Treatment
	PCH Natural History, Prognosis, and Outcome
	Patient and Family Education
	Conclusions
	Resources of Interest for Patients and Practitioners
	References
7. Assessment and Treatment of Sleep in Mild Traumatic Brain Injury
	Introduction
	Relevant Research Regarding Sleep and Traumatic Brain Injuries
		General
		Anatomy of the Sleep Cycle
		Clinical Presentations of Sleep Difficulties in TBI
		Distinguishing Among Insomnia, Daytime Sleepiness, and Narcolepsy
		Sleep Apnea and TBI
		Role of Comorbidities
		Sleep Issues Specific to mTBI
	Collecting a Targeted History and Review of Systems
		Self-Reported Data
	Diagnostic Phase of Sleep/TBI Workup
		Medication Reviews and Laboratory Data
		Actigraphy
		Polysomnography
	Treatment of Sleep Problems in mTBI
		Setting Appropriate Expectations
		Guiding Principles
		CBT-I
		Sleep Hygiene
		Pharmacologic Agents
		Avoidance of Benzodiazepines
		Medications to Consider—First, Do No Harm
		Melatonin
		Light Exposure
		Prazosin for Sleep Maintenance in Patients with Comorbid PTSD
		A Word Regarding Stimulants
	Conclusion
	References
8. Management and Rehabilitation of Cognitive Dysfunction
	Background
	Persistent Cognitive Difficulties and Concussion
	Key Evidence and Emerging Trends
		Cognitive Rehabilitation Improves Cognitive Functioning
		Clinician-Directed Interventions Maximize Rehabilitation Effectiveness
		Cognitive Rehabilitation Should Be Time-Limited and Focused on Function
		Interdisciplinary and Integrated Cognitive Interventions May Facilitate Functional Improvement
	Assessment for Cognitive Rehabilitation
	Rehabilitation of Cognitive Symptoms in the Subacute Period Post Concussion
	Rehabilitation of Chronic Postconcussion Cognitive Difficulties
	An Integrated Approach
	Implementing Cognitive Rehabilitation for Concussion
	Pharmacological Management of Persisting Cognitive Difficulties Post Concussion
	Conclusion
	References
	Further Reading
9. Neurosensory Deficits Associated with Concussion (Auditory, Vestibular, and Visual Dysfunction)
	Auditory Dysfunction After Concussion/mTBI
		Test Battery for Auditory Assessment
			Behavioral auditory tests
			Objective auditory tests
		Patterns of Auditory Dysfunction
			Peripheral auditory dysfunction
			Auditory dysfunction beyond the audiogram
			Central auditory dysfunction
		Rehabilitation Options for Auditory Dysfunction
		Post-Traumatic Tinnitus and Disorders of Sound Tolerance
	Vestibular Dysfunction After Concussion/mTBI in Adults
		Vestibular Symptoms After Concussion/mTBI
		Pathology of Vestibular Dysfunction After Concussion/mTBI
		Vestibular Assessment After Concussion/mTBI
		Management and Rehabilitation of Vestibular Dysfunction After Concussion/mTBI
	Visual Dysfunction After Concussion/mTBI
		Visual Impairment and TBI
		DSI in Civilian and General Veteran Samples
		DSI in Post-9/11 Veterans
		Understanding and Anticipating Current and Future Rehabilitation Needs
	References
10. Rehabilitation and Management of Fatigue
	Introduction
	Pathophysiology of TBI-Related Fatigue
	Fatigue Assessment Instruments
	Sleep and TBI-Related Fatigue
	Neuroendocrine Dysfunction and TBI-Related Fatigue
	Chronic Pain and TBI-Related Fatigue
	Psychiatric Comorbidity and TBI-Related Fatigue
	Clinical Approach for Treatment of TBI-Related Fatigue
	Psychoeducational Interventions
	Exercise Therapy for Fatigue
	Complementary and Alternative Medicine Approaches
	Pharmacotherapy Interventions
	Conclusion
	References
11. Management of Adult Sports Concussion
	Introduction
		Definitions
	Epidemiology
	Assessment
	Management
		Rehabilitation Considerations
		Pharmacology
	List 1. Points to Consider in SRC Pharmacology34
	References
	Further reading
12. Assessment, Management, and Rehabilitation of Pediatric Concussions
	Introduction
	Diagnosis
	Management
	Persistent Concussion Symptoms
	Conclusion
	References
13. Assessment and Treatment of Concussion in Service Members and Veterans
	Background
	The Unique Case of Blast Injury
	Assessment and Rehabilitation in the DoD
	Assessment and Rehabilitation in the VA
	Evidence-Based Treatments for Chronic mTBI
		Psychoeducation
		Cognitive Rehabilitation
		Psychotherapeutic Approaches
	Barriers to Rehabilitation Unique to DoD and VA
	Conclusions
	References
14. Gender and Sex Considerations in Traumatic Brain Injury
	Introduction
	Etiology and Epidemiology
	Pathophysiology
	Prognosis
		Quality of Life
		Employment
		Symptom Reporting
	Medical Complications
		Postconcussive Syndrome
		Mental Health
			PTSD and sexual trauma
			Depression
		Cognition and Neuropsychological Test Performance
		Endocrine/Reproductive Dysfunction
		Osteopenia/Osteoporosis
		Sexuality
		Routine Medical Screening
	Pharmacology
	Conclusion
	References
15. A Look Ahead: Cutting Edge Research in the Diagnosis, Assessment, Rehabilitation Management, and Prevention of Concussion a ...
	Introduction: Cutting-edge Research Advancing Concussion Medicine
	New Developments in Concussion Diagnosis
		Fluid Biomarkers
		Imaging Studies
	New Developments in Concussion Assessment
		Heart Rate Variability in Concussion Assessment
		Functional Brain Network Pathodynamics following Concussion
		Pathophysiological Assessment of Persistent Posttraumatic Headache
	New Developments in Concussion Rehabilitation Management
		Relative Rest
		Systematic Approach to Persistent Postconcussive Symptoms
		The Interdisciplinary Team
		Postconcussive Symptoms: The Somatic Domain
		Postconcussive Symptoms: the Sleep Domain
		Postconcussive Symptoms: The Affective Domain
		Postconcussive Symptoms: the Cognitive Domain
		Community Reintegration
			Return to learn
			Return to work
			Return to play
	New Developments in Concussion Prevention
		Changes in Sports Rules, Participant Conduct, and Training
		The Use and Governance of Protective Equipment
		Helmet Standards
		Innovations in Helmet and Equipment Design
	Conclusion. Moving Concussion Medicine Forward
	References
Index
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