What is the recommended management approach for postconcussive syndrome?

From the Guidelines

The recommended management approach for postconcussive syndrome involves a multidisciplinary strategy tailored to specific symptoms, with a focus on active management and treatment through individual disciplines and interdisciplinary rehabilitation, as supported by the most recent evidence 1.

Key Components of Management

• Initial treatment should focus on education, reassurance, and a gradual return to normal activities.
• Nonpharmacological interventions, such as early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and spine, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment, are recommended based on the best available evidence 1.
• The management approach should be tailored to address specific symptoms, including physical, cognitive, and emotional or behavioral symptoms.

Symptom-Specific Management

• Headaches can be managed with acetaminophen or NSAIDs, while persistent headaches may require amitriptyline or topiramate.
• Sleep disturbances can be addressed with sleep hygiene practices and short-term use of melatonin.
• Cognitive symptoms benefit from cognitive rest followed by gradual mental activity resumption.
• Emotional symptoms may require cognitive behavioral therapy and, in severe cases, SSRIs like sertraline.
• Physical therapy is valuable for balance and vestibular issues, with exercises tailored to individual needs.

Importance of Recent Evidence

The most recent studies 1 provide the best evidence for the management of postconcussive syndrome, and their findings should be prioritized in clinical practice.

Limitations of Older Evidence

Older studies, such as the 2002 study 1, may not reflect the current understanding of postconcussive syndrome management and should not be relied upon for guidance on modern treatment approaches.

From the Research

Management Approach

The recommended management approach for postconcussive syndrome involves a multidisciplinary and individualized approach, taking into account the underlying symptom generators and the patient's specific needs.

• Treatment options may include:
  • Sub-symptom threshold aerobic exercise
  • Cervical physical therapy
  • Vestibular therapy
  • Vision therapy
  • Cognitive rehabilitation
  • Cognitive behavioral therapy
  • Pharmacological management
  • A combination of these treatments 2, 3
• The management of concussion and persistent post-concussive symptoms relies on identifying the underlying symptom generators and tailoring the treatment approach accordingly 2
• A structured method for diagnosis, including a history, physical examination, and additional tests, can help identify underlying symptom generators and guide treatment 3

Effective Interventions

Research has shown that certain interventions can be effective in managing post-concussion symptoms, including:

• Cognitive training
• Psycho-education
• Cognitive behavioral therapy
• Graded return to physical activity
• Oculomotor rehabilitation
• Light therapy
• Headache management using repetitive transcranial magnetic stimulation 4
• Pharmaceutical management of post-traumatic headaches, cognitive symptoms, and emotional symptoms may also be effective in some cases 5

Challenges and Future Directions

Despite the availability of various treatment options, the management of postconcussive syndrome remains challenging due to the vague and non-specific nature of the symptoms.

• Further research is needed to improve our understanding of the condition and to develop more effective interventions 6
• The identification of moderating variables contributing to the frequency, intensity, and duration of postconcussive symptoms is an important area of future research 6