How to manage a patient with persistent concussion symptoms, Generalized Anxiety Disorder (GAD) score of 21, and Patient Health Questionnaire-9 (PHQ-9) score of 20, who is currently undergoing physiotherapy?

Management of Persistent Concussion Symptoms with High Anxiety and Depression Scores

For a patient with persistent concussion symptoms following an MVA, with GAD score of 21 and PHQ-9 score of 20, an interdisciplinary coordinated rehabilitation approach is strongly recommended as the most effective treatment strategy.

Comprehensive Assessment

• Evaluate the collective burden of symptoms across physical, cognitive, and emotional domains 1
• Assess for vestibular dysfunction that may contribute to dizziness and balance problems 1
• Perform visual/oculomotor assessment to screen for vergence, accommodative, or eye movement dysfunction 1
• Evaluate the cervical spine for potential contributions to headache and neck pain 1
• Screen for psychological factors, particularly given the high GAD and PHQ-9 scores 1

Treatment Approach

Psychological Interventions (Priority Given High GAD/PHQ-9 Scores)

• Implement psychological treatment by qualified professionals for at least 1 hour weekly for a minimum of 4 weeks 2
• Address anxiety and depression as these are strong predictors of persistent post-concussion symptoms 3
• Target emotional symptoms through individual or group therapy, which has shown positive effects on overall symptom burden 2
• Consider that high post-injury anxiety is the strongest predictor of persistent symptoms, with 97.1% of adolescents with high anxiety meeting criteria for persistent symptoms 3

Physical Interventions

• Continue physiotherapy with a focus on graded physical exercise below symptom threshold 2, 1
• Implement vestibular rehabilitation if vestibular symptoms are present 2, 1
• Consider manual therapy for cervical spine if neck pain is present 2, 1
• Gradually increase exercise intensity as symptoms permit 2

Visual/Oculomotor Interventions

• Implement oculomotor vision treatment if visual symptoms are present 2, 1
• Include vergence training, accommodative training, and eye movement exercises 1
• Note that clinical experience suggests improvements in visual symptoms, headache, and fatigue with oculomotor vision treatment 2

Patient Education

• Provide systematic information about symptom management and expected recovery course 1
• Explain the relationship between anxiety, depression, and persistent concussion symptoms 4
• Emphasize that anxiety and depression can persist for years and are associated with diminished quality of life if not properly addressed 4

Interdisciplinary Coordination

• Implement treatment from at least two different healthcare disciplines who collaborate on rehabilitation 2, 1
• Ensure coordination between physiotherapy and psychological services given the high anxiety and depression scores 5
• Consider additional specialists based on symptom profile (e.g., neuropsychologist, occupational therapist) 1
• Schedule treatment at least once weekly for a minimum of 4 weeks 2

Special Considerations

• The high GAD and PHQ-9 scores indicate significant psychological distress that requires immediate attention 3
• Multiple concussions are correlated with elevated anxiety and depression, suggesting a potential organic cause 4
• Persistent symptoms beyond 10 days occur in 10-15% of concussions and require multidisciplinary management 6
• Quality of life measures should be incorporated into treatment to enhance understanding of recovery trajectory 4

Monitoring and Follow-up

• Regularly reassess GAD and PHQ-9 scores to monitor progress 3
• Adjust treatment intensity based on symptom response 1
• Monitor for improvement in physical, cognitive, and emotional symptoms 1
• Consider longer-term follow-up as anxiety and depression can persist for years after concussion 4