Nothing Works for Concussions

Q:  I've heard a lot about concussions recently. What is the best way to treat them? 

A:  Do nothing.  Absolutely nothing.  And it seems to work well.  

Concussions have been a significant focus of attention in medicine and media in recent years because of the feared consequenses of multiple concussions contributing to impaired thinking, memory loss, depression, and irratic behaviour later in life.  A lawsuit by former NFL players has brought this issue to the forefront in the news from a medical and financial standpoint. 

There are more questions than answers, but progress is being made.  Coaches, trainers and officials are much more aware of an athletes behaviour during a ballgame and will bench a player if suspected of having a concussion.  Sideline screening tests are more reliable and testing performed before the season can be used to assess a players level of concussion in the days between games.  

But what is the best treatment for a concussion? It is difficult to evaluate because concussions are not easy to measure.  There is no scan or blood test that will give an indication of injury, outside a rare, severe life threatening bleed on the brain which can also occur in sports. 

A recent study in the Journal Pediatrics shed some interesting light on a trend we may see in concussion treatment.  

It foung that 'nothing' works for concussion.  

No, really, nothing.  As in no reading, no school attendance, no school work, no school tests, no athletic practice and no strenuous activity.  

This is the point that teenage athletes are saying "Yes!". 

But the study went on to say no texting, no video games, no loud music, minimal TV and minimal thinking or conversations. Simply, lie in bed quietly with no interactions at all. 

Teenage athletes: "Huh?!"

Minimal thinking might be easily embraced by teenagers, but no texting, video games, loud music or TV? For at least five days? Or until they start improving? Good luck with that one. 

The teenage athlete might not be very excited with this new suggested remedy. 

The study showed in a group of about 350 athletes with concussions, those who stuck with the Nothing Therapy were usually symptom free after 40 days.  The athletes who were allowed to continue texting, school work, video games and all the other common mental activities of teenagers while they recovered, had symptoms last until nearly 100 days.  

That is a significant difference. 

The current theory is that a storm of chemicals are released in the brain after blunt trauma affecting the membranes of the cells of the brain.  The absense of mental activity supposedly allows the brain to "heal" itself, restoring normal chemical levels and repairing the walls of the cells membranes. 

It makes sense, actually, in a common sense kind of way.  Athletes with concussions often don't want to hear a lot of noise, have trouble focussing on school work, and try to avoid bright lights.  The brain simply is telling the body what is needs to heal.  

But it makes me wonder about this form of therapy and whether there is a bigger lesson here for all of us.  

Could it be that time away from the daily digital display, data and information flood, audio avalanche (even from the shelves in stores as we shop) takes a toll if we don't take time away from it all and enjoy nothing?  Literally, nothing? 

Maybe this is part of the reason a hike in the mountain seems to provide such mental clarity.  Or maybe sitting on a beach enjoying nothing but sunshine and the sounds of the waves coming ashore.  

Maybe that vacation needs to have less details and more sitting tails. 

Maybe we need to consider the value of finding time, say, oh, weekly, to rest, with minimal input or activity from the outside world and allow our minds to rest and recover from the constant input we receive during the week.  Or else, we too, might be prone to depression, anxiety, difficulty with remembering things and other such conditions.  It would be interesting to research.  

Maybe science of concussion research will lead to the suggestoin we take one day a week, or a portion of one day, to completely rest our brains. To allow healing.  To allow the "chemicals" to come back into a balance. 

Fascinating.  Seems like I've read about the idea of taking one day a week to rest before. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com. 

The Posicor Rule

Doc:  I heard of this new drug, Dangitol, that treats anxiety. Will you prescribe it? (Okay, I stretched that a bit.)

Answer:  Nope. Don’t drive a car that is in its first year of production and don’t be the first to try a new drug. 

I call this my “Posicor Rule” as I learned a tough lesson with the drug Posicor in 1998.  Roche Laboratories launched a new blood pressure pill names “Posicor” in 1997 with a lot of promotion and a lot of hype.  It was a new branch in an old class of medicines, appeared safe, and really worked well.  

Until it seemingly started killing people.  

Unfortunately the studies had not thoroughly covered all of the drug interactions that could occur and a commonly used cholesterol medicine apparently didn’t get along with Posicor too well.  The liver was the battle ground, and reportedly several patients died.  

Roche, a responsible company, immediately pulled the drug from the market and braced for the lawyer commercials. Nevertheless, I was stuck with several patients I had placed on the medicine and didn’t have any way to know which ones to call. (This is a quickly resolved problem now with electronic medical records.)

So I waited.  Waited for the refill requests to come from the pharmacy in order to know who to change medicines for, or for the patient to call in.  Many people weren’t on the internet in 1998 so the information did not quickly spread. While I waited, I decided I would never write a drug that has not been on the market for at least eighteen months. 

That was a good decision, too. 

The FDA has a very thorough process for evaluating drugs prior to release. Seeing the drug used for years in Europe and Asia usually helps approval, but not always.  Some companies spend hundreds of millions of dollars on a drug and then have to abandon the research.  That is why when one is released to the market, it now gets a lot of publicity. 

One drug, which we will call “Poopease” for sake of discussion, came on the market in 1998 to help women, only women, with abdominal pain and constipation.  I thought it was odd that a drug knew if it was in a male or female’s gut, but the drug rep persisted.  She was plucked from some modeling agency or dance team, given some basic education of the drug, and sent out with her Brooklyn accent and attitude to promote this new drug to doctors in Georgia (where I lived at the time). 

She was pushy.  Lots of perfume.  Even more smiles.  The ladies in my office didn’t like her or what she wore.  Or at least tried to wear. Her third time back she said ‘Dr. Littleton, don’t you WANT to help you women patients with abdominal pain?” and that was when I asked her to not come back, partly for the Posicor Rule, and simply because she wasn’t professional.  

She didn’t come back when the drug was recalled, either. 

Or the diabetic drug when it was subtly implied I wasn’t on the cutting edge of caring for my patients if I didn’t write it.  It killed patients with pancreatitis, an incredibly painful way to die. It, too, was pulled from the market. Posicor Rule, again. 

Bextra and Vioxx, however, were a little different. Both were on the market for years and I found they were very successful in treating arthritis and inflammation.  The FDA determined the risk for cardiac complications (heart attack and congestive heart failure) were too great and both were pulled from the market.  I literally had patients in tears when they learned they had to give up these meds as they truly worked well.  A few offered to sign waivers hoping the company would supply them with the meds for their pain. 

So when you see an ad on TV, during the news, showing happy people smiling and enjoying life while a soap opera voice talks about side effects that are worse than the disease, keep in mind those are usually newer medicines with potential unknown secrets.  Maybe it is a great drug that will extend life, reduce hospitalizations, and keep a person functional.  Or maybe it will be appearing in a lawyer commercial next year.  (I’ve often thought they should show  people at the pharmacy when they see the price of the new drug instead of sitting in bathtubs).

The Posicor Rule isn’t perfect, but it has served well.  No rule is perfect, but neither is the hype that often accompanies the launch of a new drug.