What is the recommended workup and management for a patient with post-concussion syndrome?

Post-Concussion Syndrome Workup and Management

The recommended workup for post-concussion syndrome should include a comprehensive neurological examination, standardized symptom evaluation tools, assessment of balance and cognitive function, and targeted rehabilitation interventions based on specific symptom clusters rather than prolonged rest. 1

Initial Assessment

• Neurological Examination:

  • Complete cranial nerve assessment
  • Balance testing (Balance Error Scoring System)
  • Cognitive screening (Standardized Assessment of Concussion)
  • Symptom inventory using validated checklists 2, 1

• Imaging Considerations:

  • Neuroimaging is generally not indicated for routine post-concussion syndrome
  • Consider CT scan only if there are concerning features like:
    • Worsening headache
    • Focal neurological deficits
    • Seizures
    • Altered mental status 2

Symptom-Based Assessment

Evaluate for specific symptom clusters to guide targeted treatment:

1. Headache/Migraine Profile:

   • Assess headache characteristics, triggers, and patterns
   • Evaluate for cervicogenic components

2. Vestibular/Ocular Profile:

   • Test for vestibular dysfunction (dizziness, balance problems)
   • Assess oculomotor function (convergence, accommodation, saccades)

3. Cognitive Profile:

   • Evaluate attention, memory, processing speed
   • Consider formal neuropsychological testing for persistent deficits

4. Emotional/Mood Profile:

   • Screen for anxiety, depression, irritability
   • Assess sleep disturbances 1, 3

Management Approach

1. Physical Rehabilitation

• Vestibular Rehabilitation:

  • Recommended for patients with persistent vestibular dysfunction
  • Should be administered at least once weekly for 4 weeks 1

• Graded Exercise Therapy:

  • Implement light aerobic exercise at subsymptom threshold
  • Gradually increase intensity as tolerated
  • Avoid complete rest which can prolong recovery 1, 4

• Manual Therapy:

  • For patients with neck pain contributing to headaches 1

2. Visual/Oculomotor Rehabilitation

• Oculomotor Vision Therapy:
  • For convergence insufficiency, accommodative dysfunction
  • Improves visual symptoms and reduces associated headaches 2, 1

3. Psychological Interventions

• Cognitive Behavioral Therapy:

  • Recommended for emotional symptoms
  • Administer minimally 1 hour/week for at least 4 weeks 2, 1

• Sleep Hygiene Education:

  • Address insomnia and sleep disturbances which can exacerbate symptoms 1

4. Medication Management

• Headache Management:

  • NSAIDs after initial 24-48 hour period (avoid immediately after injury)
  • Consider migraine-specific medications for headaches with migraine features
  • Avoid opioids for chronic post-concussion headaches 1

• Mood Symptoms:

  • Consider appropriate medications for persistent anxiety or depression
  • Decision to restart pre-existing psychiatric medications should be made collaboratively 1

Return to Activities

• Implement gradual return to cognitive and physical activities
• Each step should take minimum 24 hours
• If symptoms return, drop back to previous asymptomatic level 2, 1

Interdisciplinary Approach

For complex cases with persistent symptoms beyond 3-4 weeks, consider referral to an interdisciplinary concussion clinic that includes:

• Neurologist
• Physical therapist
• Occupational therapist
• Neuropsychologist 2, 1

Common Pitfalls to Avoid

• Prescribing complete rest until all symptoms resolve (outdated approach)
• Ignoring cognitive rest in the acute phase
• Using medications to mask symptoms for premature return to activities
• Failing to provide adequate education about expected recovery 1

Patient Education

Provide written and verbal instructions about:

• Expected recovery timeline (most symptoms resolve within 3-6 months) 5
• Warning signs requiring immediate medical attention
• Postconcussive symptoms to monitor
• Gradual return to activities protocol 2

By following this structured approach to post-concussion syndrome workup and management, clinicians can effectively address the multifaceted nature of this condition and optimize patient outcomes.