What is the typical workup and management of post-concussion syndrome in a neurology clinic?

Workup and Management of Post-Concussion Syndrome in Neurology Clinic

The recommended approach for post-concussion syndrome management includes an interdisciplinary coordinated rehabilitative treatment with multiple targeted interventions based on specific symptom clusters, including graded physical exercise, vestibular rehabilitation, psychological treatment, and when indicated, manual therapy and oculomotor vision treatment. 1

Initial Workup

• Symptom Assessment: Evaluate the collective burden of postconcussion symptoms, including physical (headache, dizziness, blurred vision, sleep disturbance, neck pain, fatigue), cognitive (attention, concentration, memory difficulties), and emotional symptoms (irritability, emotional lability) 1, 2
• Vestibular Evaluation: Assess for persistent vestibular dysfunction that may contribute to dizziness, balance problems, and visual disturbances 1
• Visual/Oculomotor Assessment: Screen for vergence, accommodative, or eye movement dysfunction that may cause headache, visual symptoms, and concentration difficulties 1
• Cervical Spine Assessment: Evaluate for cervicogenic contributions to headache and neck pain 1
• Psychological Assessment: Screen for emotional symptoms, including depression, anxiety, and post-traumatic stress 1, 2

Management Approach

Early Intervention (First 4 Weeks)

• Patient Education: Provide systematic information and advice regarding symptom management, expected recovery course, and self-care strategies 1
  • This intervention has shown positive effects on reducing overall symptom burden and preventing memory problems 1

Physical Interventions

• Graded Physical Exercise: Implement sub-symptom threshold aerobic exercise with gradual increase in intensity/complexity 1

  • Begin with at least one session weekly for 4 weeks 1
  • Exercise has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1, 3

• Vestibular Rehabilitation: For patients with persistent vestibular symptoms 1

  • Include otolith manipulating procedures, habituation exercises, adaptation exercises, substitution training, and balance training 1
  • Administer at least once weekly for 4 weeks 1
  • Has demonstrated positive effects on physical functioning and return to sport/activities 1

• Manual Therapy: Consider spinal mobilization/manipulation for patients with neck pain 1

  • Typically performed by physiotherapists or chiropractors 1
  • Has shown positive effects on pain reduction and readiness to return to activities 1

Visual/Oculomotor Intervention

• Oculomotor Vision Treatment: For patients with persistent visual symptoms 1
  • Include vergence training, accommodative training, and eye movement exercises 1
  • Administer at least once weekly for 4 weeks 1
  • Clinical experience suggests improvements in visual symptoms, headache, and fatigue 1

Psychological Interventions

• Psychological Treatment: Offer individual or group therapy for emotional symptoms 1
  • Administer at least one hour weekly for a minimum of 4 weeks 1
  • Cognitive-behavioral therapy has shown particular benefit 4, 2
  • Associated with positive effects on overall symptom burden, emotional symptoms, and quality of life 1

Comprehensive Approach

• Interdisciplinary Coordinated Rehabilitation: Implement treatment from at least two different healthcare disciplines 1
  • Combine multiple interventions (vestibular, physical, psychological, etc.) based on symptom profile 1
  • Administer at least once weekly for 4 weeks 1
  • Has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 1

Important Considerations and Pitfalls

• Avoid Prolonged Rest: Extended rest leads to deconditioning and may worsen symptoms including depression 3
• Symptom-Limited Approach: Exercise and other interventions should be kept below the threshold that worsens symptoms 3, 2
• Medication Management: Consider targeted pharmacotherapy for specific symptoms (headaches, sleep disturbances, mood) when non-pharmacological approaches are insufficient 5, 4
• Regular Reassessment: Monitor symptom progression and adjust treatment approaches accordingly 6, 2
• Return to Activities: Implement gradual return to cognitive and physical activities with appropriate accommodations 4, 2

Evidence Quality Considerations

• The evidence supporting these interventions ranges from very low to low certainty 1
• Recommendations for most interventions are weak but consistent across guidelines 1
• The recommendation for oculomotor vision treatment is based primarily on clinical consensus rather than controlled trials 1
• Despite limited high-quality evidence, a multi-modal approach addressing specific symptom clusters shows the most promise for improving outcomes 6, 2