Post-Concussion Syndrome: Causes and Treatment
Post-concussion syndrome results from ongoing physiological and neurometabolic dysfunction following mild traumatic brain injury, and should be actively managed with graded physical exercise, vestibular rehabilitation for dizziness, and interdisciplinary treatment rather than prolonged rest. 1, 2
What Causes Post-Concussion Syndrome
Post-concussion syndrome develops from a neurometabolic cascade triggered by biomechanical forces to the brain, creating increased local energy demand in the presence of decreased cerebral blood flow and mitochondrial dysfunction. 3 This leads to ongoing central and systemic physiologic regulatory dysfunction affecting autonomic function, cerebral autoregulation, sleep, and circadian rhythms. 2
The syndrome manifests as somatic, cognitive, and affective symptoms including:
- Headache, sleep disturbances, dizziness/vertigo, nausea, and fatigue 3
- Oversensitivity to noise and light 3
- Attention/concentration problems and memory deficits 3
- Irritability, anxiety, depression, and emotional lability 3
Key epidemiological facts:
- Approximately 15-20% of concussion patients develop persistent symptoms, though objective cognitive testing suggests the incidence may be higher 3
- Most adults recover within 3 to 12 months post-injury 3
- Patients presenting with headache, nausea, AND dizziness in the emergency department have a 50% chance of developing persistent symptoms at 6 months 3
How to Treat Post-Concussion Syndrome
Immediate Post-Injury Phase (First 4 Weeks)
Provide systematic early education and advice within the first 4 weeks. 3, 1 This includes oral and written information about symptom management, expected recovery course, and self-care strategies, which has shown positive effects on reducing overall symptom burden and preventing memory problems. 1
Critical pitfall to avoid: Prolonged complete rest leads to deconditioning and may cause secondary depressive symptoms. 2 After initial 24-48 hours of rest, begin active management. 4
Primary Treatment Approach
Implement graded sub-symptom threshold aerobic exercise as the cornerstone of treatment. 3, 1 This means physical exercise with gradual increase in intensity and complexity, performed at least once weekly for 4 weeks, staying below the threshold that triggers symptoms. 3 This approach has demonstrated positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 1
The rationale: Controlled aerobic exercise reduces physiologic regulatory dysfunction and prevents deconditioning, directly addressing the underlying pathophysiology. 2
Symptom-Specific Interventions
For persistent vestibular symptoms (dizziness, balance problems):
- Provide vestibular rehabilitation including otolith manipulating procedures, habituation and adaptation exercises, substitution training, and balance training at least once weekly for 4 weeks 3, 1
- This has demonstrated positive effects on physical functioning and return to activities 1
For visual symptoms (headache, visual disturbances, concentration difficulties):
- Implement oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 1
- Clinical experience suggests improvements in visual symptoms, headache, and fatigue 1
For neck pain and cervicogenic headache:
- Provide spinal mobilization and manipulation of the neck and spine 3, 1
- This has shown positive effects on pain reduction and readiness to return to activities 1
For emotional symptoms (depression, anxiety, irritability):
- Offer individual or group psychological treatment 3, 1
- This is associated with positive effects on overall symptom burden, emotional symptoms, and quality of life 1
Comprehensive Management Strategy
For patients with multiple persistent symptoms, implement interdisciplinary coordinated rehabilitation involving at least two different healthcare disciplines. 3, 1 This comprehensive approach has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 1
Evidence Quality and Clinical Decision-Making
The available evidence ranges from very low to low certainty, primarily due to risk of bias, small sample sizes, and limited number of studies. 3 However, the recommendation for active management is consistent across all available guidelines regardless of methodology. 3 Given that these interventions carry low risk of harm and prolonged rest has known negative consequences, active treatment is strongly preferred over watchful waiting. 3, 2
Critical Clinical Pitfalls
Do not advise prolonged complete rest beyond the initial 24-48 hours. 4, 2 This outdated approach leads to deconditioning and secondary complications. 2
Do not dismiss symptoms as purely psychological. The organicity of post-concussion syndrome is well-documented through neuropathologic, neurophysiologic, neuroimaging, and neuropsychologic studies. 5 Most patients have genuine complaints, and contrary to popular perception, most with litigation claims are not cured by a verdict. 5
Recognize that symptoms may be multifactorial. Preexisting mood disorders and high symptom load immediately after injury are the most consistent predictors of persistent symptoms. 3 Many patients have treatable coexisting conditions that require assessment. 3