What is the recommended evaluation and management for persistent fatigue, depression, and gait instability since my concussion on [date]?

Management of Persistent Post-Concussion Symptoms

You need a comprehensive multidisciplinary evaluation and treatment plan that includes graded aerobic exercise, vestibular rehabilitation for your gait instability, psychological treatment for depression, and consideration of cervical spine therapy, all initiated as soon as possible. 1, 2

Immediate Evaluation Priorities

Your symptom constellation requires assessment for specific treatable conditions rather than generic "post-concussion syndrome" management:

• Gait instability assessment: Requires formal vestibular function testing to identify specific vestibular dysfunction patterns (otolith dysfunction, habituation deficits, balance impairments) that guide targeted rehabilitation 1

• Depression screening: Use validated instruments (Hospital Anxiety and Depression Scale) as depression is both a predictor and consequence of persistent symptoms, with individuals experiencing persistent post-concussion symptoms having 4.56 times higher odds of depressive symptoms 3, 1

• Cervical spine evaluation: Neck pain and cervicogenic contributions to dizziness and headache are common and treatable with manual therapy 1

• Fatigue characterization: Distinguish between sleep disturbance, deconditioning from activity avoidance, and primary post-concussive fatigue, as each requires different interventions 1

Evidence-Based Treatment Algorithm

First-Line Interventions (Start Immediately)

Graded aerobic exercise is your foundation treatment:

• Begin at sub-symptom threshold intensity (exercise that does NOT worsen symptoms) 2, 4
• Perform at least once weekly for minimum 4 weeks, though more frequent sessions are beneficial 1
• Gradually increase intensity and complexity over time as tolerated 1, 2
• This intervention has demonstrated positive effects on overall symptom burden, physical functioning, behavioral reactions, emotional symptoms, and quality of life 1

Vestibular rehabilitation for your gait instability:

• Includes otolith manipulating procedures, habituation exercises, adaptation exercises, and balance training 1, 2
• Administered minimally once weekly for 4 weeks 1
• Shows positive effects on both overall symptom burden and specific vestibular dysfunction 1

Second-Line Interventions (Add Based on Specific Findings)

Psychological treatment for depression:

• Cognitive behavioral therapy is specifically recommended for persistent symptoms 1, 4
• Depression is a consistent predictor of prolonged symptoms and requires direct treatment, not just expectation it will resolve with physical recovery 1, 3
• Early intervention for mood symptoms improves overall outcomes 5, 6

Cervical spine manual therapy if neck pain present:

• Mobilization and/or manipulation of spine and joints 1
• Shows positive effects on physical functioning and pain 1

Coordinated Interdisciplinary Care

Consider interdisciplinary rehabilitation if single-modality treatments insufficient:

• Combines multiple interventions (physical therapy, vestibular therapy, psychological treatment, occupational therapy) in coordinated fashion 1
• Particularly important given your combination of physical (gait), cognitive (fatigue), and emotional (depression) symptoms 1, 4

Critical Prognostic Information

Timeline expectations: 15-20% of concussion patients develop persistent symptoms lasting months to years 1, 2

Risk factors you may have: Female gender, high early symptom burden, psychiatric history (depression), and multiple symptom domains all predict prolonged recovery 1, 5

Symptoms at 3-6 months: Studies show 34-44% of patients still symptomatic at this timeframe, with 5-20% symptomatic at 12 months 1

Common Pitfalls to Avoid

Do NOT continue complete rest: Prolonged rest beyond initial 24-48 hours actually worsens outcomes and contributes to deconditioning 2, 1

Do NOT ignore the depression: Depression is not just a reaction to persistent symptoms—it's an independent predictor of poor outcomes requiring specific treatment 3, 1

Do NOT treat generically: Your specific symptom profile (gait instability, depression, fatigue) requires targeted interventions for each domain rather than waiting for spontaneous resolution 1, 4

Do NOT delay specialist referral: If symptoms persist beyond 3 weeks post-injury, referral to traumatic brain injury specialist is recommended 2

Monitoring and Adjustment

Track specific outcomes for each intervention:

• Gait stability measures for vestibular rehabilitation 1
• Depression scores for psychological treatment 3
• Exercise tolerance and fatigue levels for graded exercise program 1
• Overall symptom burden using validated post-concussion symptom scales 1

Adjust interventions every 4 weeks based on objective progress, not just subjective symptom reporting 1