Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients.

With some experts now looking at treatments beyond rest and progressive return to play, the December 2016 issue of Neurosurgery have published the 16 statement of agreement that were the outcome of the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting which took place in in Pittsburgh, Pennsylvania in October 2015.

Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting.

A total of 16 statements of agreement were supported:
1. Prior expert consensus for management of concussion included the following: no same-day return to play (RTP), prescribed physical and cognitive rest until asymptomatic, accommodations at school/work as needed, and progressive aerobic exertion-based RTP based on symptoms.
2. Previous consensus statements have provided limited guidance with regard to the active treatment of concussion.
3. There is limited empirical evidence for the effectiveness of prescribed physical and cognitive rest, and there has been no multisite randomized controlled trial (RCT) for prescribed rest after concussion.
4. Prescribed physical and cognitive rest may not be an effective strategy for all patients after concussion.
5. Strict brain rest (eg, stimulus deprivation, “cocoon” therapy) is not indicated and may have detrimental effects on patients after concussion.
6. Although most individuals follow a rapid course of recovery over several days to weeks after injury, concussions may involve varying lengths of recovery.
7. Recovery from concussion is influenced by modifying factors, the severity of injury, and the type and timing of treatment that is applied.
8. Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.
9. Thorough multidomain assessment is warranted to properly evaluate the clinical profiles of concussion.
10. A multidisciplinary treatment team offers the most comprehensive approach to treating the clinical profiles associated with concussion.
11. Concussion is treatable.
12. Preliminary evidence suggests that active rehabilitation may improve symptom recovery more than prescribed rest alone after concussion.
13. Active treatment strategies may be initiated early in recovery after concussion.
14. Matching targeted and active treatments to clinical profiles may improve recovery trajectories after concussion.
15. Patients returning to school/work while recovering from concussion benefit from individualized management strategies.
16. Pharmacological therapy may be indicated in selected circumstances to treat certain symptoms and impairments related to concussion.

In addition, the Meeting identified Future Directions: A Call to Research
* There is growing empirical support for the heterogeneity of this injury and clinical profiles, but additional research in these areas is warranted.
* The clinical benefits (more rapid recovery time, more complete restoration of function, reduced risk of repeat injury, etc) of prescribed active interventions require further study, ideally through RCTs.
* Complementary and integrative therapies for concussion require additional research.
* The role of modifying factors on the effectiveness of treatments warrants further investigation.
* Multisite, prospective studies of concussion treatments across various postinjury time points are needed.
* There are a need and a role for empirically and clinically based treatment and rehabilitation approaches as we await validation through prospective studies.
* There is a need for further research on biomarkers (eg, neuroimaging, blood) to assess concussion and the effectiveness of any proposed treatments.

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

Full details are available at Neurosurgey.