Post-Concussive Syndrome Diagnosis and Treatment

Post-concussive syndrome (PCS) is a persistent condition following traumatic brain injury, where a collection of concussive symptoms manifests beyond the typical recovery period. Diagnosis of PCS requires different approaches, including clinical and neurological examination, and imaging studies such as CT scans to rule out other possibilities that may cause concussion symptoms. It is important to diagnose correctly and accurately to prevent overlooking the severity of the condition and symptoms. 

Introduction

Concussion itself is the collection of symptoms that typically occur after a mild traumatic brain injury. Post-concussive syndrome is essentially a condition of persistent concussive symptoms that persist beyond the typical recovery period of 10 to 14 days following a concussion or mild traumatic brain injury (TBI).¹ Patients who had previous records of TBI or concussion are more likely to suffer from PCS. 

TBI are prevalent in all ages and sexes. According to epidemiologic research, 1.5 million cases of TBI occur annually in the United States, and 75% of them are considered mild.² While mild TBI can also cause PCS, the severity of TBI also correlates with the risk of PCS, including its duration and severity. Athletes of high-impact contact sports like American footballers or MMA fighters are more prone to concussions due to the nature of the sports exposing them to a higher risk of TBI. Hence, more occurrences of concussion also increase their risk of chronic PCS.  

Mild TBI that results in persistent PCS have lasting effects on cognitive and executive function, memory, and learning. More severe cases of TBI include hematoma, subarachnoid or subdural bleed, midline shift, or fractures. These cases can lead to complications in quality of life and lifestyle. 

Diagnosis of post-concussive syndrome

The symptoms of concussion typically impact physical, cognitive, and emotional functions. PCS exhibits the following concussion symptoms, except for an elongated and persistent amount of time. 

• Physical Symptoms: headache, fatigue, vision changes, dizziness, and insomnia
• Cognitive Symptoms: difficulty with concentration, personality changes, confusion, and disturbances in the ability to balance
• Emotional Symptoms include neuropsychiatric symptoms like anxiety

Generally speaking, PCS can technically be defined as when symptoms of concussion persist beyond 10 to 14 days. However, its diagnosis can differ depending on which criteria is used. The diagnostic criteria of PCS depend on which criterion is used in differing locations. The two main criteria used are the International Classification of Diseases 10th revision (ICD-10), and the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV).³ Based on ICD-10, if a patient suffers the symptoms of concussions as mentioned above for longer than 3 weeks, they are diagnosed with PCS. On the contrary, based on DSM-IV, the presence of cognitive deficits in attention or memory, personality changes, and concussive symptoms that persist for longer than 3 months would constitute as PCS. 

Initial evaluation is important in determining the severity of concussions, especially for sports-related trauma. This evaluation includes “clearance of the cervical spine, mental and cognitive status, visual acuity to check for cranial nerves, balance, strength, proprioception, sensation, and reflexes”.¹ Neurological examination allows neurologists to assess neurological or mental status deficits, along with identifying existing conditions that may exhibit similar symptoms as PCS. Imaging studies including computed tomography (CT) scans are often used in an emergent setting, while magnetic resonance imaging (MRI) scans are implemented for PCS symptoms that persist past 1 month.⁴ 

Treatment approaches

Multidisciplinary team

Many different types of symptoms affect various areas of the body, hence treatment plans are often personalised and have a multidisciplinary approach. An ophthalmologist is a specialist in treating PCS-related visual impairment, maintaining optimal visual function, and handling associated problems. When it comes to treating vertigo, a prevalent symptom of PCS, otorhinolaryngologists are important. They offer specialised therapy to relieve symptoms of dizziness and balance issues. In order to manage emotional and behavioural difficulties associated with PCS, psychiatrists and counsellors are essential in treating psychiatric disorders such as personality alterations. Medications for headaches, sleep issues, and mood disorders are prescribed by neurologists, who help with symptom management and general health. In addition to creating rehabilitation plans to treat cognitive deficiencies and improve coping strategies and cognitive abilities, neuropsychologists offer emotional support. Physiotherapists and physical therapists specialise in treating vestibular dysfunction, which is especially important for athletes as it helps them regain balance and coordination. Occupational therapists help people regain their functional independence and quality of life by helping to compensate for cognitive, bodily, or sensory impairments that affect everyday activities. 

Medication

Medications are also prescribed to alleviate the pain and discomfort that PCS patients may experience. Analgesics like ibuprofen (Advil) and naproxen sodium (Naprosyn, Aleve) are often prescribed for instant pain relief.⁵ Different types of antidepressants and anti-anxiety medications are also prescribed to treat numerous symptoms. For example, Amitriptyline is used to treat headaches with tension and migraines all the while its sedative effects can help with sleep disturbances.⁶ Selective serotonin reuptake inhibitors (SSRI) like Trazodone are also commonly used agents for treating sleep disturbances following TBI.⁷ SSRIs work by stopping serotonin reuptake and prolonging serotonin presence in extracellular space, hence alleviating depression and anxiety. Some other therapies that are sometimes considered for PCS include zolpidem, psychotherapy, phototherapy, and chronotherapy.⁸ 

Lifestyle modification

Lifestyle modifications should also be implemented and followed through post-TBI to prevent risks of recurrent PCS. Physical and cognitive rest after TBI is highly recommended. Physical rest includes restraint from strenuous activities including aerobic and resistance training. Cognitive rest after TBI includes minimising activities which require attention and concentration. For dietary changes, a balanced diet including fruits, vegetables, whole grains, beans, nuts, olive oil, and white meat is recommended. Mindfulness should also be practised to manage stress and mental state when going through medical adversities such as TBI.  

Follow-up appointments on PCS involve a structured approach to assessing recovery, particularly in athletes. According to research cited, individuals are considered recovered when they are able to perform exercise for at least 20 minutes over 2 to 3 consecutive days without experiencing symptoms and maintain age-related maximal heart rate.⁴ At this stage, athletes are also cleared to engage in aerobic training until other post-concussive symptoms resolve. Additionally, a vestibular-ocular motor screening assessment is conducted when asymptomatic to verify recovery. This assessment evaluates five areas of vestibular (balance) and ocular (vision) motor impairment, including smooth pursuits (eye movements), rapid eye movements, near the point of convergence, balance vision reflex, and visual motion sensitivity.⁹ These evaluations ensure that individuals have fully recovered and are safe to resume physical activities, including sports participation.

Some factors that would impact the prognosis of PCS are the following: 

• Severity of Injury: the more severe the traumatic brain injury is, the higher the risk of PCS including its duration and severity. 
• Presence of Coexisting Conditions: neurological disorders, psychiatric disorders, or chronic pain conditions can further complicate the course of PCS. 
• Timeliness of Treatment: If there is late treatment, PCS may persist and even worsen. Early treatment and adequate lifestyle modifications are important as they can alleviate the severity of PCS. 
• Age: Younger patients have greater neuroplasticity and resilience in their brains compared to older individuals, making it easier for them to bounce back from TBI and also have less severe symptoms.
• Past concussions: Past TBI might worsen neurological dysfunction and hinder the healing process, which increases the risk of developing PCS and experiencing more severe or prolonged symptoms. 

Despite persistent post-concussive symptoms, a significant number of patients with mild TBI do not obtain appropriate follow-up care.¹⁰ This error may cause serious morbidity and disability. Keeping an eye on symptoms following a concussion is essential for preventing long-term consequences. Plans for therapy should be modified in accordance with the particular symptoms encountered in order to meet the patients' changing requirements. Scheduling routine follow-up appointments enables medical professionals to monitor the development of symptoms, spot any new problems, and adjust treatment plans as necessary to improve results and encourage recovery. 

Prevention strategies

An essential part of post-TBI follow-up care is raising awareness and promoting education. Giving patients and their caretakers TBI educational materials at the time of discharge gives them vital knowledge about how to treat post-concussion symptoms, what signs to look out for, and how to manage them. In addition, people can deepen their understanding of PCS and its care by accessing more thorough materials online. Notably, the CDC fact sheet provides insightful information about diagnosing and treating concussions, enabling people to make decisions about their health and well-being while they work through the healing process. The link can be accessed here. 

When it comes to sports safety precautions, concussion prevention is especially important because head injuries are more likely to occur in high-impact contact sports. During athletic activities, protective gear such as helmets, mouth guards, shin-elbow-knee pads, and goggles is essential in lowering the risk and severity of concussions. The creation of efficient protective equipment requires an understanding of the mechanical aspects of concussions. To optimise protective equipment's effectiveness in preventing concussions, factors including head-impact versus non-head-impact scenarios, rotational versus linear acceleration, and centroidal versus non-centroidal hits should be carefully taken into account during the design and evaluation process.¹¹ Further information on the research and development of concussion prevention techniques can be found in the provided link, offering valuable insights into ongoing efforts to enhance sports safety and reduce the incidence of traumatic brain injuries.

Summary

PCS is a condition that persists for a long time post-TBI and consists of symptoms that can negatively impact the quality of life. When treating PCS, immediate intervention is essential to minimising symptoms and maximising recovery. For those with PCS, early identification and the implementation of suitable treatment plans can minimise the chance of problems, stop symptoms from worsening, and enhance overall results. With the ever-improving technology that improves diagnostic tools and ongoing efforts aimed at enhancing knowledge of the mechanisms of TBI and developing more effective interventions, treatment and prevention of PCS will continue to improve.