Postconcussion Syndrome: Symptom Management

William C. Walker and Richard D. Kunz

TREATMENT OF POSTCONCUSSION SYNDROME

Introduction

A “miserable minority” of patients who sustain mild traumatic brain injury (MTBI; concussion) have symptoms that persist beyond several months. Such lingering symptoms are termed postconcussion syndrome (PCS), which is further defined in Chapter 15. The focus of this chapter is the treatment of PCS; for the treatment of MTBI refer to Chapter 7. Evidence to guide treatment of PCS in the form of randomized controlled trials is lacking, but review of the literature reveals a relative expert consensus concerning appropriate treatment principles. This chapter will review these principles along with author recommendations on specific interventions.

General Principles of PCS Management

• Management of postconcussion symptoms should focus on promoting recovery and avoiding harm.

• Patients with prolonged symptoms are often suffering, distressed, and in need of guidance, education, support, and understanding.

• A patient-centered approach [1] should be used to provide the needed reassurance and motivation.

• Treatment of somatic complaints (e.g., insomnia, dizziness/incoordination, nausea, alterations of smell/taste, appetite problems, vision/hearing changes, numbness, headache, and fatigue) should be based on individual factors and symptom presentation.

• Any medications added for symptom control must be carefully prescribed after consideration of sedating properties or other side effects.

• In patients with persistent postconcussion symptoms (PPCS) that have been refractory to treatment, consideration should be given to other factors including psychiatric, psychosocial support, and issues of compensation/litigation.

• Depending on symptoms, lab work to screen for secondary neuroendocrine disorders should be considered [2].

• One effective semiquantitative way to monitor the course of PCS and success of applied treatments is by quantifying the number and intensity of individual symptoms using one of the available standardized inventories such as the PCS Checklist [3], Rivermead Postconcussion Symptoms Questionnaire [4], Concussion Symptom Checklist [5], or Neurobehavioral Symptom Inventory (NSI) [6].

Education [7]

Education is the mainstay of PCS treatment. A randomized controlled trial in which patients with concussion received telephone counseling, focused on education and symptom management, showed significantly less PCS symptoms at 6 months postinjury compared to patients who received standard hospital discharge materials [8].

• Assure the patient that symptoms are part of the normal recovery process, and not a sign of permanent brain dysfunction.

• Noncontact, aerobic, and recreational activities should be encouraged within the limits of the patient’s symptoms; increased headache or irritability suggests that this level has been exceeded. (See section “Physical Rehabilitation” for further details.)

• Encourage resumption of occupational, educational, and social responsibilities in a graded fashion to minimize stress and avoid fatigue.

• Ascertain current sleep/wake cycle and provide counseling regarding appropriate sleep hygiene as needed (see Table 16.1).

• Provide printed and verbal education.

TABLE 16.1 Education for Sleep Hygiene

Good sleep hygiene:

• Avoid going to bed too early in the evening

• Avoid stimulants, caffeinated beverages, power drinks, and nicotine during the evening

• Avoid stimulating activities before bedtime (e.g., exercise, video games, TV)

• Avoid alcohol

• Restrict the nighttime sleep period to about 8 hr

• Wake up and arise from bed at a consistent time in the morning (e.g., 7 a.m.)

• Reduce (to less than 30 min) or abolish daytime naps

• Engage in daytime physical and mental activities (within the limits of the individual’s functional capacity)

Source: Adapted from Ref. [7]. Va/DoD Clinical Practice Quideline for Managment of Concussion/Mild Traumatic Brain Injury (MTBI). 2009. Available from http:/www.healthquality.va.gov/mtbi/concussion_mtbi_full

Physical Rehabilitation

• Subsymptom-threshold exercise appears to be safe and may be beneficial. Physical (or cognitive) exertion can temporarily increase postconcussion symptoms at any point in recovery, but it is unclear if there are any long-term consequences from brief increases in symptoms [9].

• A general exercise program that includes strength training, core stability, aerobic activities, and range of motion is ideal.

• Gradually increase duration and intensity to accommodate the activity intolerance and fatigue that is commonly associated with PCS.

• Targeted and customized vestibular, visual, and proprioceptive therapeutic exercise are recommended for persistent dizziness, disequilibrium, and spatial disorientation impairments based on evidence of efficacy in different populations with vestibular disorders [10–12].

• Targeted therapeutic exercise is also recommended for any persisting focal musculoskeletal impairments.

• If a person’s normal activity involves significant physical activity, exertional testing (i.e., stressing the body) should be conducted before permitting full resumption.

Psychological Treatment

• Psychological treatment early after sustaining MTBI may protect against developing PCS. Specifically, meta-analysis of the literature suggests that patients who receive brief psychological treatment after MTBI have a significantly reduced incidence of persisting PCS compared to patients who receive standard acute care alone [13].

• Treatment typically includes education, reassurance, teaching of anxiety reduction techniques, and cognitive behavioral therapy to target and modify cognitive biases and misattribution. Psychotherapy can also be useful in identifying psychosocial factors contributing to symptom presentation and the teaching of specific coping skills for dealing with psychosocial pressure [14].

• Efficacy data are lacking once PCS is established (i.e., if symptoms persist for greater than 3 months), but physicians often include psychologist referral in their treatment plans [13]. In these authors’ opinion, referral to a neuropsychologist or psychologist with expertise in PCS is indicated when there is failure to respond to initial treatments, worsening stress, deterioration in function, or significant impairment in vocational or social function.

Cognitive Rehabilitation

Patients who have cognitive symptoms that do not resolve or have been refractory to treatment should be considered for referral for neuropsychological assessment. Individuals with memory, attention, and/or executive function deficits that do not respond to initial treatment (e.g., reassurance, management of sleep dysfunction, mood disorders, and somatic complaints) may benefit from cognitive therapy (e.g., speech and language pathology, neuropsychology, or occupational therapy) for development of compensatory strategies (e.g., use of external memory aids such as a smart phone or pocket notebook).

PHARMACOLOGIC MANAGEMENT OVERVIEW

Postconcussion symptoms are frequently treated with medications despite the paucity of randomized controlled trials. A survey of treatments prescribed by a representative sample of physicians showed that nonsteroidal anti-inflammatory analgesics were most often recommended. Antidepressant medications were the second most commonly prescribed overall, and the treatment preferred by neurologists [15]. Where evidence-based data exists to direct pharmacotherapeutic decision making, it will be presented; where such data is not presented, the recommendations made represent the opinions of the author.

Thorough medication reconciliation is crucial. The existing medication list should be reviewed for agents that can cause neurologic abnormalities (centrally acting medications, pain medications, sleep aids, anticholinergics, etc.). If a medication with neurologic side effects is identified, consider discontinuing or decreasing dose and re-evaluate after 1 week.

Headache Pharmacologic Management

Headache is the most common PCS symptom. Management should be tailored to the subtype of headache (see Chapter 56 for a detailed discussion of this subject).

Mood Disorders Pharmacologic Management

• Anxiety and depression symptoms can be treated with a variety of medications. The choice is usually dictated by comorbid symptoms and the side effect profile of the various agents.

• In general, selective serotonin reuptake inhibitors (SSRIs; e.g., sertraline, citalopram, fluoxetine, paroxetine) are preferred first line agents because of their relatively benign side effect profiles and lower cost generic availability. Serotonin–norepinephrine reuptake inhibitors (SNRIs; e.g., duloxetine, venlafaxine) and atypicals (e.g., mirtazapine, bupropion) may also be considered.

• In the authors’ experience, irritability and anger also often respond to the aforementioned antidepressants. The antiepileptic mood stabilizers (e.g., valproic acid and carbamazepine) may also be acceptable options, especially if neither depression nor anxiety is prominent. Although PCS was not specifically studied, a recent randomized controlled trial showed amantadine improved irritability and aggression in chronic TBI of mixed severity [16].

Fatigue Pharmacologic Management

• Fatigue symptoms may be secondary to comorbid conditions. After conditions such as depression, insomnia, and sleep apnea have been ruled out or treated, stimulant medications may be appropriate.

• An activating antidepressant (e.g., flouxetine) is a reasonable agent to try initially. If the patient is already on an antidepressant medication, consider switching to one with a less sedating profile.

• Amphetamine-like stimulants (e.g., methylphenidate and dexedrine) may be beneficial, although careful monitoring is needed given their abuse potential.

• Modafinil, a medication approved by the Food and Drug Administration (FDA) for narcolepsy and shift work sleep syndrome, is a higher cost alternative. However, a study of 53 patients on an average of 6 years after TBI severe enough to require inpatient rehabilitation showed no consistent benefit for fatigue or excessive daytime sleepiness [17].

• Amantadine has mixed evidence of efficacy for fatigue symptoms in multiple sclerosis and is considered by some to be an option for PCS-related fatigue.

• Methylphenidate is another option for mental fatigue. A recent small crossover trial showed efficacy for mental fatigue and processing speed in MTBI patients [18]. Methylphenidate often elevates blood pressure and heart rate so caution should be exercised with cardiac patients.

Sleep Dysfunction

• Primary sleep disorders should be considered and ruled out with a sleep study as indicated.

• Behavioral interventions, including meditation, relaxation training, and white noise devices, are preferred over pharmacotherapy.

• Benzodiazepines should be avoided.

• Additional management recommendations can be found in Chapter 53.

Dizziness and Disequilibrium

• Medication review and reconciliation are crucial because numerous medications have dizziness as a potential side effect.

• Vestibular suppressants (e.g., meclizine) might be helpful during the acute period of several vestibular disorders but have not been shown to be effective in chronic dizziness after concussion [19].

• The mainstays of treatment for persisting symptoms are the aforementioned vestibular exercises in combination with habituation and coping strategies.

• Specific treatments may be indicated for some subtypes (e.g., Semont and modified Epley maneuvers for benign paroxysmal positional vertigo).

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