{"title":"Special Topics in Contact Sport Athletes and Others Who Have Had Multiple Concussions and Subconcussive Impacts","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0036","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0036","url":null,"abstract":"\u0000 When to retire from contact sports? Help the patient, family, and peers think through the decision carefully. Educate them about the risk of serious and currently untreatable long-term problems, such as chronic traumatic encephalopathy. Discuss potential for a future professional sports career versus other career, interpersonal, and family aspirations.\u0000 \u0000 Does the patient have Chronic Traumatic Encephalopathy (CTE)? There is no way to tell for sure while the patient is alive. High-risk features may include progressive worsening over time, prominent mood and behavioral abnormalities, parkinsonism, and a cavum septum pellucidum on magnetic resonance imaging (MRI) scan. At present, treatment is entirely based on relieving symptoms and keeping the patient safe.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125325117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Mood Instability and Irritability","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0010","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0010","url":null,"abstract":"Often the complaint of mood instability comes from the collateral source. First priority: assess safety. Severe mood instability can lead to suicide. Next, determine whether the problem is actually mood instability, as opposed to sustained major anxiety, depression, or post-traumatic stress disorder. Nonpharmacological interventions are the most important, and include education, sleep management, prescription for cardiovascular exercise, pain control, cessation of alcohol and other disinhibiting substances, such as levetiracetam and cognitive behavioral therapy. Preferred pharmacological options that do not substantially impair cognitive recovery include lamotrigine (Lamictal) and oxcarbazepine (Trileptal). Other options include carbamazepine (Tegretol) when cost is an issue, propranolol (Inderal) when violence is a concern, and low-dose atypical antipsychotics.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115327940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Concussion in the Elderly","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0033","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0033","url":null,"abstract":"Elderly individuals over age 65 represent the fastest growing group of traumatic brain injury patients. Many elderly individuals are taking anticoagulant medications, and an initial computed tomography (CT) scan is warranted to rule out intracranial hemorrhage, though a second CT scan is generally unnecessary if the first scan is negative and the patient’s neurological condition is stable. Elderly can be more susceptible to side effects of medications; thus, smaller doses may be preferred. Balance training is advised to reduce risk of falls. Concussion may be both a cause and a consequence of neurodegenerative diseases. Driving may be especially problematic in elderly after concussion.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"106 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115571560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Concussion in Military Personnel","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0037","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0037","url":null,"abstract":"Consider treating acute blast-related concussion patients with N-acetyl cysteine (NAC) when starting within 72 hours after injury. For more chronic issues, in addition to family members, the best collateral source may be another service member with whom the patient has served. Evaluate carefully for post-traumatic stress disorder (PTSD), chronic pain, sleep disorders, balance, and hearing loss given that these are especially common in military personnel with concussion. Maintain confidentiality; if the patient has been using drugs and/or alcohol, it may be wise to refer them for rehabilitation discretely, because active duty military personnel do not have the same privacy protections that civilians have, and this can jeopardize their future careers. Return-to-duty decision-making is best done in collaboration with military physicians and occupational therapists. Refer to community resources specifically dedicated to wounded warriors.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"32 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122623523","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"How Do You Make the Diagnosis of Concussion?","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0003","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0003","url":null,"abstract":"To make a diagnosis of concussion, you need a reliable history of 2 things: (1) An acute external physical force applied to the brain AND (2) An impairment in the function of the brain directly caused by the external physical force. One or the other is not enough. You need both. You do not need a scan or lab test to make the diagnosis. No scan or test can “rule in” or “rule out” concussion. You do not need to perform a detailed neurological exam to make the diagnosis. The neurological exam is usually unremarkable except for immediately after the concussion. No exam findings “rule in” or “rule out” concussion.\u0000 A collateral source is key to obtaining a reliable history. The impairment in brain function occurs immediately after the event. The impairment is worst immediately after the event, then gradually improves. There is no other obvious explanation for the impairment.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133710426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Concussion in Adolescents","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0034","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0034","url":null,"abstract":"Adolescents should follow the no return to play for 24 hours rule strictly to improve outcomes and reduce risk of second impact syndrome. Because adolescents may be less able to make good judgments about their own abilities than adults, the collateral source becomes even more important than usual. Address questions about drug and alcohol use privately and give advice without the parents present. Peer influences may have a big impact on decision-making. Obtain collateral history from peers and educate peers as well as parents. Preexisting attention deficit, learning disabilities, and mood instability can get substantially worse after concussion and may require intensified treatment. For patients on the cusp of starting to drive, consider advising extra caution: go back to the beginning of driver’s education and get a professional driving evaluation. Consider preemptively addressing questions that the adolescent may be afraid to ask or cannot formulate accurately.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122539423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Scheduling Return Visits","authors":"D. Brody","doi":"10.1093/MED/9780190054793.003.0040","DOIUrl":"https://doi.org/10.1093/MED/9780190054793.003.0040","url":null,"abstract":"Various concerns are taken into consideration in scheduling return visits to a concussion clinic. Some of the most commonly encountered are listed here:\u0000 Active, immediately dangerous issue (e.g., suicidal, homicidal): Admit to hospital\u0000 \u0000 Active, time sensitive issue: Within 1 week\u0000 Active, potentially dangerous issue: 1 to 3 weeks\u0000 Active, severely impairing issue: 1 to 2 months\u0000 Patient starting a new medication that requires monitoring: 1 week to 3 months\u0000 Typical patient with moderate issues: 3 months\u0000 Stable patient, medications requiring monitoring: 6 months\u0000 Stable patient, no new medications, and no medication requiring monitoring: 1 year","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"95 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124731139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Seizures","authors":"D. Brody","doi":"10.1093/med/9780190054793.003.0025","DOIUrl":"https://doi.org/10.1093/med/9780190054793.003.0025","url":null,"abstract":"Concussion rarely causes recurrent seizures. A patient with a brief seizure that occurs within the first 30 minutes of concussion does not need to be treated with antiepileptics or have driving restrictions. However, a seizure occurring later than 30 minutes after the injury, a seizure that lasts more than 1 minute, or a seizure after concussion in a patient with a previous seizure disorder requires a different approach. Consider hospital observation, brain magnetic resonance imaging (MRI), electroencephalogram (EEG), laboratory studies, assessment for infection, and a screen for drug and alcohol use or withdrawal. If seizures need to be treated, the best approach often includes mood stabilizing medications with minimal cognitively impairing side effects. An oxcarbazepine (Trileptal) bridge during lamotrigine (Lamictal) titration is a reasonable choice. Carbamazepine generic is a good option when cost is an issue. Levetiracetam (Keppra) often causes mood dysregulation in concussion patients.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133615616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Attention Deficit","authors":"David L. Brody","doi":"10.1093/med/9780199383863.003.0008","DOIUrl":"https://doi.org/10.1093/med/9780199383863.003.0008","url":null,"abstract":"Many concussion patients who complain about problems with memory actually have an attention deficit. General measures: treat insomnia, stop alcohol, treat migraine with cogniphobia, prescribe moderate cardiovascular exercise, and refer for cognitive rehabilitation (occupational and speech therapy). Consider treatment with a stimulant such as methylphenidate (Ritalin) or amphetamine mixed salts (Adderall) if appropriate with careful monitoring for side effects. Contraindications include uncontrolled seizures, dangerous anxiety, active cardiovascular or cerebrovascular disease, active psychosis, drug abuse, irresponsible criminal behavior, dangerously underweight, and uncontrolled headaches. Recommend use 6 days per week 51 weeks per year to reduce tolerance. Additional benefit in some patients from donepezil (Aricept), rivastigmine (Exelon), and regulated caffeine use. Approach options: “aggressive” involving treatment with stimulants primarily based on history, “moderate” involving treatment with stimulants only in patients with attention performance impairments documented with neuropsychological evaluation, and “conservative” not including stimulants unless there is a well-documented preinjury history of attention deficit disorder.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131321698","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Blurry Vision","authors":"D. Brody","doi":"10.1093/med/9780199383863.003.0020","DOIUrl":"https://doi.org/10.1093/med/9780199383863.003.0020","url":null,"abstract":"Blurry vision after concussion can mean different things. A loss of acuity in one eye is often due to direct injury to the eye, which happens frequently in concussion. Refer to ophthalmology right away. Intact acuity in each eye, but worse vision with both eyes open is often due to a subtle cranial nerve injury. Subtle third cranial nerve or fourth cranial injuries typically cause vision to be worse looking up or down, whereas sixth nerve injuries are typically worse looking to one side. Consider referral to neuro-ophthalmology and an ocular rehabilitation prescription. Visual attention deficit is sometimes described as blurry vision. Treat the attention deficit. Migraine auras often cause visual impairment of some kind: distorted vision, double vision, loss of central vision, loss of vision on one side of the visual world, sparkling lights, jagged lines, and so forth. Paroxysmal changes in vision after concussion should be treated as presumptive migraine, or migraine equivalent even if there is not a severe headache. Patients will benefit from best corrected vision when starting aggressive cognitive rehabilitation even if preexisting visual impairments didn’t impair them much in everyday life before the concussion.","PeriodicalId":202249,"journal":{"name":"Concussion Care Manual","volume":"184 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122171938","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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