Continuing Education Activity

Postconcussive syndrome (PCS) describes the constellation of symptoms that commonly occur after mild traumatic brain injury (TBI), and patients who suffer more than one brain injury are at increased risk. Symptoms may be physical, cognitive, behavioral, and/or emotional in nature. A few common symptoms seen in patients with postconcussive syndrome include headache, fatigue, vision changes, disturbances in balance, confusion, dizziness, insomnia, and difficulty concentrating. Approximately 90 percent of concussion symptoms are transient, and symptoms typically resolve within 10 to 14 days. However, symptoms may linger for weeks. Persistent postconcussive syndrome occurs when symptoms persist beyond 3 months. Research has shown that mild TBI resulting in persistent post-concussive syndrome has lasting effects on cognition, memory, learning, and executive function. This activity reviews the evaluation and management of postconcussive syndrome and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

• Identify the etiology of post concussive syndrome.
• Review the presentation of post concussive syndrome.
• Outline the treatment and management options available for post concussive syndrome.
• Describe interprofessional team strategies for improving care coordination and outcomes in patients with post concussive syndrome.

Introduction

Traumatic brain injury (TBI) occurs in patients of all age groups and is a significant public health issue. In the United States, 1.5 million TBIs occur annually, 75% of TBIs are classified as mild, and costs are generated of $17 billion each year. Most patients that suffer from TBI will have spontaneous resolution of symptoms, but for some patients, symptoms may linger and negatively affect daily cognitive function. Post-concussive syndrome (PCS) demarcates the constellation of symptoms seen most often in prolonged mild TBI, however, it may also occur following moderate and severe TBI.[1] Clinical criteria for PCS are outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).[2]

PCS is a constellation of physical, cognitive, behavioral, and emotional symptoms occurring after TBI. These symptoms include a headache, fatigue, vision changes, disturbances in balance, confusion, dizziness, insomnia, neuropsychiatric symptoms, and difficulty with concentration.[1] Approximately 90% of concussion symptoms are transient, with symptoms resolving within 10 to 14 days but may linger for weeks. Persistent PCS occurs when symptoms persist past 3 months. Fifteen percent of mild TBI patients will suffer from PCS, and a small minority of those patients will experience persistent PCS requiring further evaluation and treatment.[3][4]

Research has shown that mild TBI resulting in persistent PCS has lasting effects on cognition, memory, learning, and executive function. Patients who suffer more than one brain injury are at increased risk for PCS. Due to limited diagnostic tools, those permanent changes in executive function can go undocumented. Thus, the 15% incidence of PCS is an underestimation of the true incidence.[3]

Etiology

Most cases of PCS occur in patients with mild TBI but can occur with TBI of any severity. TBI results from blunt force, nonpenetrating head trauma, trauma, concussion, assault, or sports-related injuries. Mild TBI is defined as a Glasgow coma score (GCS) of 13 to 15 and is further sub-grouped as complicated versus uncomplicated. Complicated mild TBI comprises symptoms of a concussion with associated head computerized tomography scan (CT) abnormalities, including hematoma, subarachnoid or subdural bleed, midline shift, or fractures. Uncomplicated mild TBI presents with a normal head CT scan. Patients with uncomplicated mild TBI are more likely to have a resolution of symptoms in less than 3 months. Patients with complicated TBI or more than one TBI are more likely to suffer from PCS or persistent PCS. Other risk factors include female gender, age, psychiatric history, or a history of chronic pain syndromes.[4]

Epidemiology

Currently, there are two clinical criteria used to diagnose PCS. These are the International Classification of Diseases, 10th revision (ICD-10), and the DSM-IV, both of which can give varying results, even when applied to the same population.[5] Therefore, a wide range of reported incidence in the literature is reported from 30 to 80 percent of patients with mild to moderate TBI experiencing signs and symptoms of PCS.

Previous reports in the literature have attempted to associate the severity of the brain injury with PCS in patients who have suffered mild TBI, however, these have failed to consistently report that the severity of injury correlates with the risk of PCS. Variables and measures utilized in order to define a correlation include initial presenting GCS, duration of loss of consciousness, post-traumatic memory difficulties or amnesia, and imaging traumatic abnormalities on CT scan or magnetic resonance imaging (MRI).[6][5][7][8][9] On the other hand, there is evidence of at least one research study suggesting that medical history of recent or multiple prior concussion episodes, is an associated risk factor for the development of prolonged symptoms after concussion.[10]

Current cohort studies and analysis show that women are at greater risk for persistent PCS.[5][7][11][12] Women are more likely to endorse a headache, irritability, fatigue, and concentration problems. Increases in age are also associated with a higher risk of PCS. Among minors, no comparisons have been made with the symptoms endorsed. Female minors are more likely to endorse symptoms while male minors are more likely to experience loss of consciousness at the time of injury and seek medical attention in an emergency department. It is also thought minors are less likely to experience PCS due to increased neuroplasticity when compared to adults. These studies were conducted in sports-related cases, but experts believe that similar trends occur in any mechanism of TBI.[2]

Pathophysiology

The pathophysiology of concussion includes a combination of metabolic, physiologic, and microstructural injuries to the brain. Other theories in the literature have stated a psychogenic origin in nature, however, it is possible that both provide a significant contribution to PCS.[13] Symptoms are consistent with PCS result from autonomic nervous system damage. This damage occurs to the white matter tracks between cortical control centers and vagal nerve control via the spinal cord. This affects both the sympathetic and parasympathetic nervous systems. As a result, patients will often experience symptoms consistent with depression. Autonomic nervous system damage also causes difficulties with control of cerebral blood flood, blood pressure, and heart rate leading to dizziness, headache, confusion, difficulty with concentration, and orthostatic intolerance. Decreases in cerebral blood flow at rest in the immediate post-injury period can account for PCS symptoms outlined above. Also, increased cerebral blood flow post-injury can cause headaches, vision changes, and dizziness leading to exercise intolerance. Heart rate variability due to damage in the vagal nerve tracts results in disproportionate increases in blood pressure and heart rate during exercise causing early fatigue.[14]

In terms of neurobiological factors related to the pathophysiology of PCS, both structural and biochemical changes have been described and documented in animals and humans, such as increased atrophy and increased regional volume loss.[15]

In terms of psychogenic factors contributing to the development of PCS, it has been suggested by a number of empiric and clinical observations. The cardinal symptoms presented in PCS patients include headache, dizziness, and sleep impairment, which in turn, are all similar to the somatization seen in psychiatric disorders including depression, anxiety, and post-traumatic stress disorder (PTSD). The cognitive deficits seen in anxiety and depression are similar to those seen in PCS and improve with antidepressant treatment.[16][17]

History and Physical

A thorough history and physical exam are crucial in the evaluation of PCS patients. Mechanism of injury, date of injury, loss of consciousness at the time of injury, the number of times injured and reported symptoms are all critical in the initial and subsequent evaluation. Past medical history is especially helpful for identifying patients who are at increased risk of PCS. Important past medical history to document includes headache history, history of depression, anxiety or mood disorders, dizziness, fatigue, irritability, insomnia, loss of concentration and memory, noise sensitivity, and chronic pain history. The physical exam should include a full neurological exam including evaluation of cranial nerves, visual acuity, reflexes, strength, proprioception, and sensation, and should be completed with each encounter.[2][14]

Evaluation

Evaluation of PCS requires recognition of residual symptoms following TBI. Due to the ambiguity of symptoms, recognition takes time, and thus, treatment is often delayed. Concussion refers to the condition that resolved within 30 days of injury and symptoms identified during this time attributed to the concussion or mild TBI before the diagnosis of PCS is made. As outlined in the DSM-IV, PCS is diagnosed with the presence of cognitive deficits in attention or memory and at least 3 of the following:

• Fatigue
• Sleep disturbance
• Headache
• Dizziness
• Irritability
• Affective disturbance
• Apathy or personality changes that persist for 3 months or longer. 

The ICD-10 defines PCS as the symptoms outlined above persisting for longer than 3 weeks, is more general, and encompasses more patients. Most patients recover in the first 7 to 10 days following an injury and will require no further evaluation.

The initial evaluation will include a thorough history and physical exam. Initial evaluation can occur on the scene in sports-related cases, in the emergency department (ED) during trauma or emergency, or by a primary care physician on an outpatient basis in patients who do not seek medical care at the time of injury. Highlighted areas include clearance of the cervical spine (if emergency), mental status, cranial nerves (including visual acuity), balance, strength, proprioception, sensation, and reflexes. Patients should be screened with vestibular-ocular motor screening exams to be repeated once the patient becomes asymptomatic. Any neurological or mental status deficits should be documented regarding the time elapsed from the time of injury.

Each patient will present with different clinical features and diagnostic testing should be used judiciously.[18] As a result, proposed treatment strategies should be individualized for each patient. If patients present with complaints of visual symptoms, ophthalmology referral should be considered. If patients, on the other hand, present with signs and symptoms of vertigo, otorhinolaryngologist referral should be prompted. For patients who present with psychiatric symptoms, both psychology and psychiatry evaluation should be considered.

The evaluation may also include imaging if completed in the emergent setting via head CT. An MRI can be performed in patients who continue to endorse symptoms at greater than 1-month post-injury. Imaging allows for the evaluating physician to rule out other etiologies that may be responsible for symptoms before referral for symptom-specific therapies.[14] Other advanced neuroimaging techniques, such as functional MRI, magnetic resonance spectroscopy, and diffusion tensor imaging (DTI), are under investigation in the evaluation of patients with TBI.[19][20]

Treatment / Management

Treatment of PCS is individualized to each patient and the patient's particular complaints. Simple reassurance is often the major treatment. It is important to note that most patients will improve within three months. In the absence of specific treatments to be provided for each patient, clinicians can adopt a symptomatic approach.[21]

In 85% to 90% of cases, mild TBI is self-limited and does not progress to PCS. In the minority of cases that do not recover to baseline at 4 weeks post-injury, management, and physiological treatment is important in patients returning to baseline mental and physical activity. Physical and cognitive rest is recommended for at least the first 24 to 48 hours post-injury as outlined by Zurich guidelines. In terms of advanced recovery or long-term clinical outcomes, cognitive and physical rest after a concussion has not been able to demonstrate convincing evidence of its benefits.[7][22] Patients are only to return to play or usual activity once symptom-free at rest, and should avoid the risk of suffering from a second concussion while symptomatic from the initial event. It has been shown in studies reviewed that patients who rested for 2 days versus 5 days returned to baseline more quickly.

Some of the following medications and treatment algorithms have been utilized for the management of headache syndromes, specifically in the post-traumatic setting: Amitriptyline, intravenous dihydroergotamine and metoclopramide, greater occipital nerve block, propranolol, and indomethacin.[23][24][25][26][27]

For patients continuing to endorse visual and balance symptoms, the vestibular-ocular motor screening tool may be completed in the outpatient setting. By using the screening tool to identify the root cause of a patient’s residual post-concussive symptoms, the provider can prescribe active forms of therapy, which include cervical physical therapy, vision therapy, or vestibular rehabilitation.

Lastly, Zurich guidelines acknowledge that patients with PCS who engage in low-level exercise recover faster. The Buffalo concussion treadmill test assesses when patients may resume full activity by measuring the patient’s ability to achieve target heart rate without experiencing symptoms or early exhaustion. Once patients can achieve age-related maximal heart rate and exercise without symptoms for at least 20 minutes for 2 to 3 consecutive days, the patient is deemed physiologically recovered. For athletes, this may not correlate to return to play but allows the athlete to train aerobically until other post-concussive symptoms resolve.[14]

Differential Diagnosis

• Depression
• Fibromyalgia
• Posttraumatic stress disorder (PTSD)
• Vertebral Artery disease 
• Migraine
• Tension-type headache
• Cluster-type headache
• Insomnia

Prognosis

PCS has a good prognosis in general terms. The symptoms and disability are greatest within the first week in most cases. However, after one month, symptoms are improved and most of the time even resolved.[28] Both repetitive head trauma and greater severity of symptoms at initial presentation have been associated with symptoms persisting for more than one month, although the vast majority of these patients recover by three months.[29][30] A minority of patients (10 to 15 percent) have symptoms that persist for more than one year or longer, however, because of biased reporting, these reported numbers can be overestimated with the overall prevalence is much lower.[31]

A small number of patients can continue with disabling symptoms that persist after several months or a year. On some occasions, these symptoms may be more disabling than they were immediately after the injury. While the entire symptom complex persists in most cases, emotional symptoms seem particularly prominent. 

The literature has reported that patients with litigation or compensation issues consistently have reported persistent symptoms and disability after mild TBI.[32] Repeated head injury resulting in concussions can lead to more severe cognitive deficits, however, more studies are being conducted to strengthen this association.[32] Patients with a GCS score of 13 have higher rates of disability than those with a GCS of 15, but this may be attributable to other injuries.[32] Patients with complicated TBI (intracranial hematoma or depressed skull fracture) may also be at risk for more persistent symptoms.[32]

Complications

• Analgesia overuse
• Cognitive impairment
• Inability to perform activities of daily living
• Sleep disturbances
• Changes in thinking
• Psychological changes
• Impulsive behavior
• Depression
• Aggression
• Suicidal thoughts
• Malingering
• Inability to work
• Anxiety

Consultations

• Physical Medicine and Rehabilitation (PMR)
• Neurology
• Neuropsychology
• Psychology
• Psychiatry
• Ophthalmologist
• Otorhinolaryngologist 
• Neuroradiology
• Physical therapist
• Social work

Deterrence and Patient Education

Education is mandatory for PCS patients, as well as their family members, relatives, and caretakers. Patients may experience anxiety about the symptoms and their long-term health-related consequences. Reassurance that symptoms are often worse in the first week or two after the injury, but typically improve over a few weeks and resolve within a few months, is a critical point to be stressed. Other physicians, members of the healthcare team, nurses, therapists, employers, attorneys, and representatives of medical insurance companies are to be educated in PCS.[33] 

Education will be the best tool for the treatment of the patient. This can be provided in a follow-up appointment or session with the patient, providing an information booklet, scheduled-up phone call addressing education, as well as follow-up multidisciplinary evaluations.[34][35][36][37][38][39][40][41]

Enhancing Healthcare Team Outcomes

Traumatic brain injury is a hallmark injury of veterans and athletes. Most studies reviewed centered on these specific patient populations presenting difficulties in using results for the general patient population. Overall, mild TBI can have lasting effects on neurocognition despite the mild nature of the disease process. If symptoms of mild TBI persist for greater than 4 weeks, patients are diagnosed with PCS and require further intervention. The difficulty of identifying PCS is that symptoms of PCS are ubiquitous in the population and can be due to other causes such as psychiatric disorders, headache syndromes, and chronic pain syndromes as outlined in previous sections of this article. An interprofessional approach to the care of mild TBI patients and those that develop PCS is necessary for the care of these patients.

In a randomized control trial that looked at veterans returning to the workforce, the benefits of an online evaluation tool (CogSMART), supported employment to place veterans with varying degrees of mild TBI and comorbid psychiatric disorders in jobs of varying cognitive demand. The study demonstrated benefit with a rapid return to baseline and decreased prevalence of PCS in patients that used CogSMART with enhanced, supported employment when compared to groups that did not use CogSMART with enhanced, supported employment.

In veterans with comorbid psychiatric disorders, psychiatric care is necessary for a more rapid recovery of PCS symptoms. Specifically, treatment of PTSD is often required in patients with mild TBI to facilitate recovery. Patients that also suffer from chronic headaches and pain syndromes will require additional treatment from specializing physicians to facilitate the recovery. In athletes, reviews completed by sports trainers presented data that early exercise aided in the recovery of mild TBI and prevention of PCS. The benefit comes from the decreased incidence of depression, anxiety, and sleep-related symptoms by allowing the athlete safe return to exercise and conditioning.

In the prevention and treatment of PCS in patients that have suffered mild TBI, patient education is key to a successful recovery. Physicians should educate patients on returning to work or school with a resolution of symptoms at rest. Patient education should include that extended bed rest and delayed cognitive rest can lead to worse outcomes. Addressing patient comorbidities with treatment also helps patients return to baseline in most cases.[42] (Level II)