What is the treatment for post-concussion syndrome?

Post-Concussion Syndrome: Understanding and Treatment

For post-concussion syndrome, treatment should include a combination of graded physical exercise, vestibular rehabilitation, psychological treatment, and interdisciplinary coordinated rehabilitative approaches, tailored to specific symptom clusters. 1, 2

What is Post-Concussion Syndrome?

Post-concussion syndrome (PCS) refers to persistent symptoms that continue beyond the typical recovery period after a concussion (usually beyond 4 weeks). It involves a complex set of symptoms across multiple domains:

• Somatic symptoms: Headaches, dizziness, fatigue, sensitivity to light and noise
• Cognitive symptoms: Difficulty concentrating, memory problems, slowed processing
• Emotional symptoms: Irritability, anxiety, depression, mood changes
• Sleep disturbances: Insomnia, altered sleep patterns

Treatment Approach Based on Symptom Clusters

Physical Rest and Gradual Return to Activity

• Initial period of rest should be 24-48 hours 1
• Avoid complete prolonged rest as this can lead to deconditioning and may worsen symptoms 2
• Implement a graded return to activity program:
  • Each step should take at least 24 hours
  • Return to previous level if symptoms recur 1, 2

Cognitive Rest and Management

• Limit activities requiring concentration and attention 1, 2
• Temporarily reduce screen time (computers, phones, TV)
• Consider temporary accommodations for school/work:
  • Reduced workload
  • Extended time for tasks
  • Postponed standardized testing 1, 2

Physical Exercise Therapy

• Implement graded physical exercise starting with light aerobic activity at subsymptom threshold 1, 2
• Exercise should be performed at least once weekly for a minimum of 4 weeks
• Gradually increase intensity as tolerated 1, 2
• This approach has shown positive effects on overall symptom burden, physical functioning, and emotional symptoms 2

Vestibular Rehabilitation

• For patients with persistent vestibular dysfunction (dizziness, balance issues)
• Include habituation exercises, adaptation exercises, and balance training
• Should be administered at least once weekly for 4 weeks 1, 2

Manual Therapy

• Consider for patients with neck pain contributing to headaches
• Includes mobilization and manipulation of the spine
• Shows positive effects on physical functioning and pain reduction 1, 2

Vision Therapy

• Recommended for patients with convergence insufficiency and accommodative dysfunction
• Improves visual symptoms and reduces associated headaches 2
• Oculomotor vision therapy can be beneficial even though formal studies are limited 1

Psychological Treatment

• Cognitive behavioral therapy for emotional symptoms
• Should be administered at least 1 hour weekly for a minimum of 4 weeks
• Targets anxiety, depression, and adjustment to injury 1, 2

Medication Management

• For headaches:
  • Avoid NSAIDs and aspirin immediately after injury due to bleeding risk 2
  • After 24-48 hours, NSAIDs may be used for mild to moderate headaches
  • For migraine-like headaches, consider triptans
  • Avoid opioid analgesics due to dependency risk and rebound headaches 2

Interdisciplinary Approach

• For complex or persistent cases (beyond 3-4 weeks), consider referral to an interdisciplinary concussion clinic 1, 2
• Team should include neurologist, physical therapist, occupational therapist, and neuropsychologist
• This approach has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1

Return to Play/Work Guidelines

• Athletes should never return to play on the same day as injury 1
• Complete symptom resolution should occur before returning to contact sports
• Follow the principle: "When in doubt, sit them out!" 1
• Each step of the return protocol should take at least 24 hours 1
• Avoid returning to play while taking medications for concussion symptoms 1

Common Pitfalls to Avoid

1. Prescribing complete rest until all symptoms resolve - this outdated approach can prolong recovery 2
2. Ignoring cognitive rest - can worsen symptoms 2
3. Using medications to mask symptoms for premature return to activities 2
4. Failing to provide adequate education to patients and families about expected recovery 2
5. Allowing same-day return to play after concussion 1
6. Overlooking psychological factors that may contribute to persistent symptoms 1, 2

By addressing the multiple symptom domains through targeted interventions, most patients with post-concussion syndrome can experience significant improvement in their symptoms and quality of life.