What is the optimal treatment for post-concussion syndrome to manage symptoms and speed recovery?

Optimal Treatment for Post-Concussion Syndrome

The optimal treatment for post-concussion syndrome requires an individualized, multidisciplinary approach including graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, psychological treatment, and interdisciplinary coordinated rehabilitation. 1

Initial Management

Physical and Cognitive Rest

• Complete physical and cognitive rest until asymptomatic at rest 1
• Avoid activities that exacerbate symptoms:
  • Limit screen time
  • Avoid loud music if phonophobia is present
  • Consider sunglasses for photophobia
  • Avoid driving if reaction times are slowed 1

Early Information and Advice

• Provide systematic information about expected symptoms and recovery timeline
• Reassure that most patients recover within weeks to months 1

Stepwise Rehabilitation Protocol

Once asymptomatic at rest, follow this structured rehabilitation protocol:

1. No activity: Complete physical and cognitive rest until symptom-free
2. Light aerobic activity: Walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises
3. Sport-specific exercise (if applicable): Specific drills without head impact
4. Non-contact training drills: More complex drills, may start light resistance training
5. Full-contact practice (if applicable): After medical clearance
6. Return to full activities: Normal activity 1

Important: Each step should take at least 24 hours. If symptoms return during any step, return to the previous asymptomatic level after 24 hours of rest. 1

Targeted Interventions for Specific Symptoms

Physical Symptoms

• Graded physical exercise: Sub-symptom threshold aerobic exercise has shown benefit even in persistent symptoms 1, 2, 3
• Vestibular rehabilitation: For dizziness, balance problems, and visual motion sensitivity 1
• Manual treatment of neck and back: For cervicogenic symptoms and headaches 1
• Oculomotor vision treatment: For visual disturbances, though evidence is limited 1

Cognitive Symptoms

• Cognitive rehabilitation: For attention, memory, and executive function deficits 4, 5
• Gradual return to cognitive activities: Start with short periods and gradually increase duration 1

Emotional/Psychological Symptoms

• Psychological treatment: Cognitive behavioral therapy for anxiety, depression, and mood disturbances 1, 5
• Sleep management: Address insomnia and sleep disturbances 3

Interdisciplinary Approach

For persistent symptoms (>4 weeks), an interdisciplinary coordinated rehabilitative approach is recommended, involving:

• Physiotherapists
• Occupational therapists
• Neuropsychologists
• Physicians
• Other relevant specialists 1

This team should provide at least weekly treatment over a period of at least 4 weeks, with a comprehensive approach addressing all symptom domains 1.

Common Pitfalls to Avoid

1. Returning to activities too soon: Never return to play/activities while still symptomatic 1
2. Prolonged complete rest: Extended inactivity can lead to deconditioning and secondary problems including depression 2
3. Ignoring psychological factors: Emotional symptoms can exacerbate and prolong recovery 3
4. One-size-fits-all approach: Post-concussion syndrome is heterogeneous with various symptom clusters requiring targeted treatments 1, 4
5. Overlooking cervical contributions: Neck injuries often accompany concussion and require specific treatment 1, 5

The evidence supports that active management of persistent post-concussion symptoms is more effective than prolonged rest alone, with the most recent guidelines emphasizing the importance of a structured, progressive approach to rehabilitation that addresses specific symptom generators 1, 4, 5.