Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial
McCarty CA, Zatzick D, Stein E, Wang J, Hilt R, Rivara FP. Pediatrics 2016;138(4):e20160459
Take Home Message: Adolescents with persistent postconcussive symptoms experienced greater improvements in symptoms and quality of life after receiving a collaborative care treatment compared with adolescents who received the standard of care.
Pediatric patients with persistent concussive symptoms can sustain significant impairments and comorbidities such as depression and anxiety. Watchful waiting remains the standard of care. An active intervention like cognitive behavior therapy is an option; however, there are limited studies that examine the efficacy of this rehabilitation program. Therefore, the authors developed a randomized trial to compare collaborative care (standard care, cognitive-behavioral therapy, and psychopharmacological consultation) with standard of care management for patients aged 11 to 17 with persistent symptoms (> 1 month) following a sports-related concussion. The authors randomized 49 participants (65% female) reporting 3 or more postconcussive symptoms into either collaborative care (25 participants) or standard care (24 participants). They assessed the participants before randomization and after 1, 3, and 6 months. The collaborative care focused on techniques to encourage appropriate coping skills, relaxation strategies, sleep hygiene, and positive thinking. Collaborative Care management also consisted of coordination with the participant’s school for accommodations and conferences with specialists (pediatric psychopharmacology, care manager, pediatrician, psychiatrist, internationalist). The standard care program consisted of pediatric rehabilitation medicine, neuropsychological testing, and hypnosis to help with sleeping issues if necessary. Physical and psychological impairments were based on youth and parent reports using the health and behavior inventory (assessed post concussive symptoms), Patient Health Questionnaire (assessed depressive symptoms), and Pediatric Quality of Life Inventory (assessed physical, emotional, social, and school functioning). Eighty-eight percent of participants in the collaborative care group received > 4 sessions with a median of 8 sessions. One-third of the participants in this group also received psychopharmacologic consultation. Many participants in the standard care group sought medical attention, especially from a mental health professional (33%) or primary care physician (58%). Patients receiving usual care on average had 6 visits to outpatient concussion-related visits including sports medicine, rehabilitation medicine, neurology, and pain medicine visits. Participants in the collaborative care group experienced improvement in postconcussion symptoms and quality of life at 6 months compared to participants in standard treatment group. There were no differences in anxiety or depression reports from parents and youth between groups.
The authors demonstrated the effectiveness of a collaborative care intervention for reducing post concussion symptoms in a sample of adolescent participants. Though both groups had symptom reduction in the first 3 months, only those in the collaborative care group continued to improve through the 6-month follow-up. Additionally, participants in the collaborative care also had quality of life gains at 6 months compared to those in standard treatment group. It was interesting to note that not only did the participants report significant gains, but also the parents reported functional improvements, which suggests the changes were observable and meaningful. Based on these results medical professionals should consider a collaborative-based approach for patient’s suffering with persistent concussion symptoms, and seek the assistance from pediatric specialists.
Questions for Discussion: What do you do for your patient when they have persistent concussion symptoms? Do you think athletic trainers should be working more closely with specialists?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban
Cognitive Rehabilitation for Military Serve Members with Mild Traumatic Brain Injury: A Randomized Clinical Trial