What is the recommended management approach for a patient with post-concussive syndrome following head trauma?

Post-Concussive Syndrome Management

Implement graded sub-symptom threshold aerobic exercise as the cornerstone of treatment for post-concussive syndrome, combined with targeted interventions based on specific symptom patterns—vestibular rehabilitation for dizziness, manual therapy for neck pain, oculomotor training for visual symptoms, and psychological treatment for emotional symptoms. 1

Abandon Prolonged Rest

Prolonged rest is contraindicated—active management with graded physical exercise, vestibular rehabilitation, and interdisciplinary treatment is the evidence-based approach recommended by the American College of Physicians and American Academy of Neurology. 1 This represents a fundamental shift from outdated "rest until better" protocols that can actually worsen outcomes.

Core Treatment: Graded Aerobic Exercise

Start all patients on sub-symptom threshold aerobic exercise with gradual increases in intensity and complexity, regardless of their specific symptom profile. 1, 2 This intervention demonstrates positive effects across multiple domains:

• Overall symptom burden reduction 1
• Improved physical functioning 1
• Reduced emotional symptoms 1
• Enhanced quality of life 1

The exercise should remain below the threshold that exacerbates symptoms—if symptoms worsen during activity, reduce intensity but maintain the exercise program. 2

Symptom-Specific Targeted Interventions

For Vestibular Symptoms (Dizziness, Balance Problems)

Provide vestibular rehabilitation at least once weekly for minimum 4 weeks, including: 1, 2

• Otolith manipulating procedures 1
• Habituation and adaptation exercises 1
• Substitution training 1
• Balance training 1

This demonstrates positive effects on physical functioning and return to activities. 1

For Visual Symptoms and Concentration Difficulties

Implement oculomotor vision treatment including: 1, 2

• Vergence training 1
• Accommodative training 1
• Eye movement exercises 1

Clinical experience suggests improvements in visual symptoms, headache, and fatigue, though evidence is based primarily on clinical consensus rather than controlled trials. 2

For Neck Pain and Cervicogenic Headache

Provide spinal mobilization and manipulation of the neck and spine, which shows positive effects on pain reduction and readiness to return to activities. 1, 3

For Emotional Symptoms (Anxiety, Depression, PTSD)

Offer individual or group psychological treatment (such as cognitive behavioral therapy) administered at least 1 hour weekly for minimum 4 weeks. 1, 2 This is associated with positive effects on overall symptom burden, emotional symptoms, and quality of life. 1

Interdisciplinary Coordination for Multiple Symptoms

When patients present with multiple persistent symptoms (which is typical), implement coordinated rehabilitation involving at least two different healthcare disciplines. 1, 2 This comprehensive approach demonstrates positive effects on:

• Overall symptom burden 1
• Physical functioning 1
• Emotional symptoms 1
• Quality of life 1

Treatment should include at least 2 interventions administered minimally once weekly for 4 weeks. 2

Early Intervention Strategy

Within the first 4 weeks, provide systematic patient education regarding symptom management, expected recovery course, and self-care strategies. 2 This early education shows positive effects on reducing overall symptom burden and preventing memory problems. 2

Critical Pitfalls to Avoid

Do not prescribe prolonged rest—this outdated approach contradicts current evidence-based guidelines. 1 Most adults recover within 3 to 12 months post-injury, but approximately 15-20% develop persistent symptoms requiring the active interventions described above. 1, 2

Do not wait for spontaneous resolution—patients presenting with headache, nausea, and dizziness in the emergency department have a 50% chance of developing persistent symptoms at 6 months. 1 Early active management is crucial.

Do not treat in isolation—the neurometabolic cascade triggered by biomechanical forces creates multiple overlapping symptom generators requiring coordinated multidisciplinary care. 1, 4

Evidence Quality Acknowledgment

The available evidence ranges from very low to low certainty, primarily due to risk of bias, small sample sizes, and limited number of studies. 1 However, the recommendation for active management over prolonged rest is consistent across all available guidelines regardless of methodology. 1 The consistency of guideline recommendations despite varying methodologies strengthens confidence in this approach for real-world clinical practice.