Novel Collaborative Care Approach Shows Promise in Treating Youth with Persistent Post-Concussive Symptoms

Hannah Nash suffered a concussion in 2018 and experienced PPCS. Today, she attends the University of Washington.

On Dec. 26, 2018, 18-year-old Hannah Nash, an avid basketball player, was hit in the head while at basketball practice. She initially felt a sharp pain and her head felt foggy. She recalled leaving practice abruptly. The next day, she played in a game, but she didn’t feel like herself.

“I played terribly,” Nash said. “I was just off.”

She went to her pediatrician, and they treated her symptoms like a concussion. She was told to rest. On Jan. 3, 2018, she fainted in her kitchen and hit her head again.

Every year, an estimated 1.1 to 1.9 million youth suffer a sports-related concussion. Common post-concussion symptoms include headache, fatigue, irritability, dizziness and poor academic performance. Depression and anxiety are also commonly reported and have been shown to be associated with prolonged recovery from concussion. For most individuals, symptoms resolve within days or weeks of a concussion, but for youth like Nash, that isn’t always the case. For adolescents who experience persistent post-concussive symptoms (PPCS), the burden on their families, academic achievement and other areas of life can be enormous.

Sports-related concussions account for nearly 15% of all injuries in high school athletes, according to The American Journal of Sports Medicine. While most individuals recover within 30 days, a subset of 20% – 30% experience symptoms that last longer. These prolonged symptoms are called PPCS. Despite so many youth experiencing PPCS, there isn’t currently an evidence-based approach to guide treatment, which is what Dr. Cari McCarty, a researcher in the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute, hopes to do.

In 2016, McCarty, published a study in the journal Pediatrics showing the effectiveness of a novel approach to treatment of concussions. The approach combined cognitive behavioral therapy (CBT) and coordinated care among providers, schools, patients and families.

“Historically, there has been a large focus on the physical symptoms when treating youth who have suffered a concussion,” McCarty said. “We wanted to also address the mental health concerns through behavioral techniques as well. Working solely with a sports medicine physician is a more traditional approach to treatment. Our approach is novel.”

Today, a new study published in JAMA Network Open, builds upon that initial small pilot study and shows that collaborative care with cognitive behavioral therapy (CBT) is a promising treatment to reduce concussion symptoms and improve functioning for youth who have experienced PPCS.

A feeling of hopelessness

When Nash’s concussion symptoms failed to resolve, she felt a sense of hopelessness.

“It was an overwhelming feeling,” Nash said. “Basketball was in my life for so long, and all the sudden it was taken away. I felt like I lost a little bit of myself.”

She couldn’t play basketball and going back to school felt nearly impossible. She fell into a deep depressive state.

It’s not abnormal to experience anxiety and depression after a concussion. For many, the impacts of PPCS are emotionally tolling.

Natalie Childress, 21, suffered a concussion playing soccer.

Natalie Childress, 21, remembers vividly the day she suffered a concussion. According to her mother, Debbie Childress, she said her daughter can’t imagine not knowing that date.

“It changed her life,” she said.

She was playing soccer when she went up for a header and collided with another player. She wasn’t the same after, her mother said. For weeks, all she could do was sit on the couch. At school where she normally excelled, she also faced challenges. “It was a nightmare,” she recalled.

“I couldn’t get past the moment immediately in front of me,” Natalie Childress said. “It was so hard being at school. It wasn’t like I had a broken arm with a cast. I had a brain injury, and no one could see it.”

Her classmates didn’t know why she couldn’t just snap out of it her mother said.

Not only was she dealing with the physical impacts of the concussion, but the emotional aspect was debilitating.

When they went to see Dr. Thomas Jinguji, a sports medicine physician at Seattle Children’s, he told them about the study.

Natalie was enrolled, and finally they could see a glimmer of hope.

Benefits of collaborative care approach

The randomized controlled trial included 200 participants ages 11 to 18 years old who had experienced a concussion with three or more post-concussive symptoms persisting for at least a month or longer. Researchers at Seattle Children’s Research Institute and the University of Washington School of Medicine incorporated approaches to treatment, including CBT, and hypothesized that the collaborative care approach would not only improve concussion symptoms but would also improve other mental health components including depression, anxiety, overall quality of life and school function. The trial measured participants’ symptoms at 3, 6 and 12 months after enrollment.

Included in the collaborative care intervention were three components – care management, CBT and medication consultation. The intervention which included CBT and care management was delivered mostly through telehealth. Both Nash and Childress were enrolled in the CARE4PCS II Study.

Finding hope again

Debbie Childress said she will be forever grateful her daughter had the opportunity to be enrolled in the study.

“I couldn’t have gotten through without that support and lifeline,” she said. “It gave us hope.”

Natalie Childress said she still suffers from some memory issues, but she was able to graduate valedictorian of her class and is now studying nursing at Baylor University.

“She’s always wanted to help other people,” her mother said.

For Nash, her future is bright too.

“The program helped my concussion, but more than that it gave me the tools to help me now and into the future,” Nash said. “I’m a much happier person now. I feel like there is more to life, and I can see a future. I’ve come a long way.”

Nash said she enjoyed the therapy aspect of the collaborative care approach. She said it gave her a safe space to have conversations and open up to her therapist. To others who are going through a concussion diagnosis, Nash says to take it one day at a time.

“Put yourself first and listen to your body,” she said. “Most important, take your time. Heal not just your body but also mental health.”

Today, Nash is studying engineering at the University of Washington.

A new way to approach concussion treatment

While there is no standard for concussion treatment currently, the study provides promising direction and guidance. While both of the groups in the trial showed improvement over time, the group that received collaborative care intervention showed fewer concussion symptoms over time and better quality of life. Furthermore, since the interventions were delivered through telehealth, the future of treatment also lends itself well to reach a broad range of youth, without geographic limitation.

“Having better tools in our arsenal to address the full gamut of needs for young people who suffer from PPCS is critical so that providers can treat this issue most effectively,” McCarty said.