Post-Concussion Syndrome

What is post-concussion syndrome?

When the symptoms of a mild traumatic brain injury (also known as a concussion) last for a period that is longer than anticipated, it is called post-concussion syndrome (PCS).⁶ Typically, post-concussion symptoms last anywhere from days to weeks. However, when the symptoms persist for longer than three months it is considered post-concussion syndrome (PCS).¹² The symptoms of PCS may range from headaches and dizziness to memory impairment and difficulty concentrating.¹ 

Why is it important to understand post-concussion syndrome?

Following the incidence of a mild traumatic brain injury, 60% of affected individuals are believed to experience symptoms of post-concussion syndrome (PCS).³ Even though PCS symptoms can resolve within a month, they often persist for months or years. This decreases the quality of life, reduces work performance (which consequently affects the economy),^2,4 weakens relationships due to mood changes, and negatively impacts daily interactions because of tiredness and memory problems.¹¹

Based on recent studies, the early treatment of PCS is crucial for improving the disease outcome and preventing the persistence of symptoms.⁴ It is assumed that 5% of the patients exhibit symptoms even after a year.³

What are the symptoms of post-concussion syndrome?

The following symptoms are frequently experienced by patients with post-concussion syndrome (PCS):^2,5,12

• Headache
• Dizziness
• Tiredness
• Irritability
• Anxiety
• Depression
• Increased sensitivity to noise
• Balance problems
• Visual disturbances
• Mood changes
• Memory problems
• Reduced concentration
• Problems with judgement

How is post-concussion syndrome diagnosed?

Even though a specific test cannot prove that a patient has post-concussion syndrome (PCS),^7,8 a physician may arrive at this diagnosis after a thorough analysis of medical history and physical examination. Some key questions for the evaluation include the mechanism of injury, date of injury, initial symptoms, and level of consciousness after the insult. Important past medical facts to document include a history of previous injuries (if any); a history of mood disorders; and a history of headaches, dizziness, irritability, tiredness, reduced concentration, sleep problems, noise sensitivity, long-standing pain, etc.¹² The patient may also be asked to complete a questionnaire regarding their symptoms and referred for a computerised tomography (CT) or magnetic resonance imaging (MRI) scan to detect brain structure abnormalities or bone damage.^6,8 Additionally, a thorough physical examination of the nervous system assessing muscle strength, cranial nerves, visual acuity, reflexes, coordination, movement, sensation, etc. could be carried out.^6,12

What is the differential diagnosis of post-concussion syndrome?

Some conditions that may be considered in the differential diagnosis of post-concussion syndrome include:^12,19

• Post-traumatic stress disorder (PTSD)
• Depression
• Anxiety
• Migraine
• Tension headache
• Factitious disorder
• Chronic pain
• Insomnia

How to treat post-concussion syndrome?

Presently, there is no specific treatment for post-concussion syndrome (PCS). A multidisciplinary approach is the mainstay of treatment, where symptomatic treatment is adopted to treat the symptom(s) of the patient.⁷ For instance, a patient presenting with dizziness may be referred to an ear, nose, and throat (ENT) specialist; a patient experiencing anxiety or depression may be referred to a psychologist or a psychiatrist;⁸ and a patient with visual disturbances may be examined by an ophthalmologist.¹²

Two of the most effective treatment options for PCS include exercise and therapy.⁸ Research has shown that low-intensity sports activities speed up the recovery process.^10,12 However, it is important to avoid overexertion, as it can be detrimental to symptom management.¹⁰ Appropriate therapy, such as neuromuscular therapy, occupational therapy, speech therapy, cognitive therapy, etc., is chosen depending on the presenting symptoms in the patient.⁸ For example, cognitive therapy (CT) and cognitive behavioural therapy (CBT) have been proven beneficial in improving memory problems, whereas speech therapy can alleviate concentration problems.^9,10

Medicines are not always prescribed by physicians when treating PCS symptoms. This is because, medications do not help treat memory and concentration problems that are associated with PCS.⁷ Similarly, tension headache medicines and migraine medicines can both treat a headache that develops after a concussion, however, their overuse can trigger PCS headaches.¹⁰ Likewise, there is a risk of suicidal tendencies, particularly in adolescents, when given anti-depressants for treating depression.⁸ It is also important to practise sleep hygiene, especially if the patient is suffering from fatigue. Staying clear of alcohol and recreational drugs, and lowering stress levels can also facilitate recovery.⁶

What is the prognosis of post-concussion syndrome?

The prognosis of post-concussion syndrome (PCS) is largely positive. Most patients recover fully and swiftly within a few days, weeks, or months.^10,11 Nonetheless, for some (particularly those with complicated TBI)recovery can take up to a year or longer, and for others, the effects can be permanent.^10,12 It has been noted that when PCS symptoms persist, these are usually emotional symptoms. Similarly, a lower Glasgow Coma Scale (GCS) score which denotes a low impairment of consciousness predisposes one to disability more than a higher GCS score (this could also be related to other injuries).¹² In such scenarios, symptoms may be managed with the help of a healthcare provider.

How to prevent post-concussion syndrome?

The best way to prevent post-concussion syndrome (PCS) is to avoid a head injury in the first place by following some practical tips when applicable. Always wear a seat belt when travelling in a car or other vehicle. Prevent falls at home by fall-proofing the home via lightning improvement, using non-slip mats, installing handrails, organising the home and reducing clutter to avoid bumping into things, etc.¹³ Remember to wear a helmet when riding a motorbike or when engaging in activities that pose a risk of head injury, like skating, cycling, snowboarding, etc.⁷ Similarly, wear a hard hat when doing high-risk jobs both at home and in the workplace.⁶

FAQ’s

What makes one more susceptible to post-concussion syndrome?

Individuals who have experienced multiple head injuries are at an increased risk of developing post-concussion syndrome (PCS), with repeated head injuries also being linked to a more severe cognitive impact.¹² The risk for PCS goes up if there are complications associated with the concussion, such as a skull fracture, bleeding inside the brain, or a midline shift.¹⁰ Another study found that women are more likely to experience PCS than men, exhibiting symptoms like tiredness, headaches, irritability, and concentration difficulties. The risk of PCS occurrence also increases with age. Minors are less likely to experience PCS symptoms because of the increased neuroplasticity of the brain.¹² Neuroplasticity is the brain’s ability to change and adapt after an incident like a brain injury.¹⁶ Having other brain conditions like ADHD or behavioural conditions like anxiety or depression also predisposes one to developing PCS.¹⁰

How to manage the fatigue that accompanies post-concussion syndrome?

Understanding what triggers tiredness and knowing one’s energy limits when performing different tasks is essential. Work within said energy limits and schedule regular breaks. Alternate between activities that demand physical and mental energy. Engage in low-intensity physical exercises like walking.¹⁴ Ensure eight hours of sleep per night and observe sleep hygiene by limiting caffeine intake and following a sleep ritual and routine.^14,15 Drink plenty of water and follow a healthy diet to fight fatigue. In this context, research has shown that a Mediterranean diet is the most beneficial in promoting brain health after an injury.^15,17

Summary

Post-concussion syndrome (PCS) is a condition that follows a mild traumatic brain injury. Research has shown that PCS can affect learning, memory, cognition, and/or executive function.¹² Patients may present with cognitive, behavioural, emotional, and/or physical symptoms. It is important to note that symptoms and their magnitude vary from patient to patient. A PCS diagnosis is usually made after assessing symptoms, and their duration, and performing various physical and neuropsychological testing. The treatment of PCS should be individualised depending on the presenting clinical features.⁸ It has been proven that therapy and exercise are key to treating PCS and improving quality of life.

 The overall prognosis of PCS is good, and the condition is likely to resolve within weeks or months. However, sometimes PCS can last longer and even go on to cause permanent disabilities. Consequently, individuals who are experiencing PCS symptoms should seek medical attention since an early intervention not only improves the prognosis but also helps the patient cope better. Finally, it is important to familiarise oneself with safety measures to reduce the risk of future head injuries.