What is the optimal treatment approach for post-concussion syndrome in veterans?

Post-Concussion Syndrome in Veterans: Optimal Treatment Approach

Veterans with post-concussion syndrome should receive an interdisciplinary coordinated rehabilitation program that combines graded sub-symptom threshold aerobic exercise, vestibular rehabilitation, psychological treatment, and cervical spine therapy, initiated within 2 weeks of persistent symptoms to prevent chronic disability. 1

Initial Management and Risk Stratification

Veterans with persistent post-concussion symptoms require immediate active management rather than passive observation. The critical window is at 2 weeks post-injury—waiting for spontaneous recovery increases risk of chronic disability. 2

Key risk factors in veterans that predict persistent symptoms include:

• Pre-existing psychiatric conditions (depression, anxiety, PTSD) 1, 3, 4
• Limited social support and lower cognitive reserve 4
• Female gender 2
• High initial symptom burden 1

Avoid complete rest beyond 24-48 hours, as prolonged rest negatively impacts recovery and mental/physical wellbeing. 2

Core Treatment Components

1. Graded Aerobic Exercise (First-Line Intervention)

Implement sub-symptom threshold aerobic exercise with gradual increases in intensity, performed at least once weekly for minimum 4 weeks. This demonstrates positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 1, 2

The exercise should remain below the threshold that exacerbates symptoms, with progressive increases in duration and intensity as tolerated. 2

2. Domain-Specific Rehabilitation

For vestibular dysfunction:

• Initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks 1, 2
• This improves physical functioning and readiness to return to activities 1

For visual symptoms:

• Provide oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises 1, 5
• Clinical experience shows this reduces headache and fatigue in addition to visual symptoms 1
• Administer at least once weekly for minimum 4 weeks 5

For cervical pain and headache:

• Implement spinal manual therapy (mobilization/manipulation) at least once weekly for 4 weeks 1, 2
• This shows positive effects on pain reduction and readiness to return to activities 1

3. Psychological Treatment (Essential Component)

Provide psychological treatment as individual or group therapy administered at least 1 hour weekly for minimum 4 weeks. 1, 2

This is particularly critical in veterans given the high co-occurrence of PTSD with post-concussion syndrome. Service utilization patterns in veterans with persistent post-concussion symptoms are heavily influenced by PTSD presence. 3

The psychological intervention demonstrates:

• Reduced overall symptom burden 1
• Improved emotional symptoms and quality of life 1
• Better long-term outcomes at follow-up 1

4. Psychoeducation and Self-Management

Provide systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period. 2

Tailor information to individual patient needs rather than using generic handouts—this has strong evidence for reducing overall symptom burden and preventing memory problems. 2

Interdisciplinary Coordinated Approach

The optimal treatment model involves health professionals from at least 2 different disciplines collaborating on rehabilitation, administered at least once weekly for minimum 4 weeks. 1

This comprehensive approach should include:

• Physiotherapists for vestibular and exercise rehabilitation 1
• Occupational therapists for daily activity management 1
• Neuropsychologists for cognitive and psychological intervention 1
• Optometrists for visual dysfunction 1
• Physical medicine specialists for cervical and headache management 1

The interdisciplinary model demonstrates positive effects on overall symptom burden, physical functioning, emotional symptoms, quality of life, and return to daily activities. 1

Critical Pitfalls in Veteran Population

Do not rely solely on patient self-report—systematically evaluate specific domains (vestibular, visual, cervical, cognitive) with objective assessment. 2

Recognize the complexity of overlapping conditions: In veterans, persistent post-concussion symptoms commonly co-occur with PTSD and chronic pain, creating a symptom complex that requires integrated treatment rather than isolated management of individual conditions. 3, 4

Address psychiatric comorbidities early: Early life psychiatric difficulties such as anxiety or depression are the most salient predictors of persistent post-concussion symptom complex in veterans, accounting for more variance than loss of consciousness itself. 4

Long-Term Considerations

Veterans with persistent symptoms may require continued medical care for at least 6 months, along with social assistance for driving support, employment issues, and financial assistance during recovery. 2

The goal is functional improvement rather than complete symptom resolution in most cases, with variable recovery depending on injury severity and individual resilience factors. 5, 4

Cognitive rehabilitation should be considered for veterans with multiple areas of cognitive impairment, using compensatory strategies particularly for memory deficits. 1, 6