Collaborative Care for Adolescents With Persistent
Postconcussive Symptoms: A Randomized Trial

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.

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.

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?

Jane McDevitt, PhD
by: Jeff Driban


McCarty CA, Zatzick D, Stein E, Wang J, Hilt R, Rivara FP, & Seattle Sports Concussion Research Collaborative (2016). Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial. Pediatrics PMID: 27624513