Transcript Virginia Commonwealth University Medical College of

Virginia Commonwealth University
Medical College of Virginia Hospital
Department of Physical
Medicine and Rehabilitation
http://www.pmr.vcu.edu/
http://www.worksupport.com/
Post-Concussive Syndrome:
Prevention and Management
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and Chairman
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University
Overview

TBI incidence
– 1-5 million injuries/year
– 500,000 hospital admissions/year
– 50,000 rehabilitation admissions/year

TBI demographics
– 16-34 years old is most common age range
– >60 years is second most common age
range
– <5 years is a close third
Overview

Mild TBI is most common injury (by a
factor of 20x). Vast majority return to
pre-injury level of function and work.

Rapid identification of mild TBI and
possible sequelae (Post-concussive
syndrome) is vital to effective
management.
TBI Classification

Mild TBI = Concussion

Glasgow Coma Score of 13-15

Brief loss or alteration of consciousness (“see
stars”, “dazed”) for up to 30 minutes

Non-focal neurological exam by 30 minutes
TBI Classification

No indication for imaging study if normal
exam by 30 minutes. Need to be monitored
for 24 hours.

If persistent symptoms (e.g., confusion) or
focal exam by 30 minutes, then CT Scan.

Nml CT and MRI scans in >99% of mild TBI.
No clinical role for PET or SPECT scans.
Post-Concussive Syndrome:
Definition

Persistent non-focal neurologic symptoms >
24 hours post-TBI = PCS
• Dizziness
• Headache (+/- N/V)
• Cognitive deficits (attention, memory, judgement)
• Behavioral changes (irritability, depression, nightmares)
• Sleep disturbance
Post-Concussive Syndrome:
Management

Symptoms rapidly resolve (2-4 weeks) in
>85% individuals.

5-10% may have persistent difficulties by 12
months.

Significant medicolegal overlay common.
Post-Concussive Syndrome:
Management

Early assessment of injury (i.e., recognizing a
concussion occurred), referral for
comprehensive treatment, and reintegration
into pre-injury life is essential to full recovery.

Limiting treatment to professionals with good
understanding of process and motivation to
return patient back to maximal function is
important.
Post-Concussive Syndrome:
Management

Extensive research in NCAA athletes
demonstrates initial changes in cognitive
testing after concussion with return to
baseline by 2 weeks.

Research in E.R.’s demonstrates that early
detection of concussion and in-depth
discussion of potential difficulties minimizes
short and long-term symptoms.
Post-Concussive Syndrome:
Management

Treatment includes physical activity,
counseling, limited medication usage, and
supportive care.

Most patients can return to full-duty in 24-72
hours. Close monitoring of performance and
symptoms in first 7 days is crucial.

Operating machinery/driving should only
occur if symptom free.
Headache: Management

Headache pain predominantly from muscle
and soft-tissue injury to neck or skull.

Early use of anti-inflammatory and analgesic
medications is important. Antispasmodics
have little efficacy, but can assist in sleep and
relaxation.

Rapid muscle mobilization is key. Structured
PT or HEP needed. Local heat or ice.
Headache: Management

Headache specific medication may be needed
if symptoms not resolving by 1 week.
– Fiorinal/Fioricet (1 tab q 4-6 hours)
– Midrin (2 tabs at HA onset, repeat q1 hour x 3)

True post-traumatic migraine HA’s are rare
(confirm pre-injury history). May respond to
more traditional migraine treatments (refer to
neurologist)
Headache: Management

Persistent HA’s that are not resolving by 3-4
weeks may be the result of undertreatment,
missed diagnosis (e.g., skull fracture), or
psychological overlay.

Psychologic intervention often helpful:
–
–
–
–
Relaxation training
Frontalis Muscle biofeedback
Counseling
Pain Management strategies
Dizziness: Etiology

Usually resolves in 7 days.

Persistence of symptoms may be secondary
to muscular injury to neck limiting full ROM.
Responds to active mobilization program.

True neurologic cause may be injury to
labyrinthian mechanism of inner ear.
Dizziness: Etiology

Contusion to semicircular canals may result in
abnormal movement of otoliths, causing a
delayed response to head movement. This
results in:
– a temporal difference in information supplied to
the cerebellum by the visual, proprioceptive and
labyrinthian systems.
– A feeling of dizziness

HallPike-Dix Maneuver diagnostic of
labyrinthain cause.
Dizziness: Management

Vestibular rehabilitation is effective but labor
intensive. Focuses on:
– Optimizing three components of balance



Neck ROM
Visual Tracking
Proprioceptive Input
– Identifies positions and motions that cause
dizziness and progressively exposes patient to
these situations.
– Rapid mobilization outside of therapy is also
important (e.g., return to work).
Dizziness: Management

Medications have limited efficacy, typically
mildly sedate patient to decrease reaction to
dizziness (e.g., Meclizine, Scopolamine)

Novel use of buspirone (Buspar) has been
demonstrated effective in 3 case reports (510 mg tid).
Sleep Hygiene Disturbance

Common following mild TBI. Often
multifactorial, including pain, psychologic
factors, pre-injury factors, and true
alterations in arousal.

First-line management involves appropriate
sleep hygiene (e.g., eliminating caffeine,
“winding down”, eliminating naps, appropriate
environment).
Sleep Hygiene Disturbance

Early (48-72 hours) use of sleep medications
is appropriate. Scheduled agents for 3-7 days
is preferable to prn dosing.

Trazadone 50-300 mg qhs is preferred agent.
Sonata is second line agent.
Ambien may have cognitive side effects.
Avoid benzodiazapines (e.g., Restoril)
secondary to depressive and addictive
propoerties.



Deficits of Arousal and Attention

Typical in the first 24-72 hours post-TBI. Will
prevent optimal memory, concentration, and
judgement. May persist to some extent in
most patients for first 2 weeks.

Optimizing sleep hygiene and eliminating
sedating medications (e.g., pain medications)
is important first line treatment.

Can profoundly impair function and work.
Deficits of Arousal and Attention

Stimulant agents an appropriate and effective
intervention.
–
–
–
–

Rapid working (24-72 hours)
Limited side effects or drug interactions
Also assist in managing depressive symptoms.
Can be inexpensive (generic Ritalin)
Ritalin, Atteral, Cylert, and Provigil are
common agents.
Deficits of Arousal and Attention

Treat with stimulants for 4 weeks (at
therapeutic dose) and then begin to wean.

If acute condition, rarely need to restart. If
chronic condition may need 6+ months
treatment.
Memory and Processing Deficits

Cognitive deficits are universal after TBI,
however excellent recovery is common.

Neuropsychological Testing best captures the
spectrum of deficits. The skills of the tester
and interpreter greatly influence relevance of
testing.

Depression may present as memory
difficulties.
Memory and Processing Deficits

Good evidence for utility of cognitive
therapies for up to 18 months, although
objective criteria for improvement are
necessary.

The use of memory aides (PDA’s, memory
logs) has been highly successful.
Memory and Processing Deficits

Similar strategies and medications as for
arousal and attention deficits are employed.

Probable role for SSRI antidepressants (e.g.,
Zoloft), even in absence of clinical or major
depression.

Possible role for anti-Alzheimer’s agents (e.g.,
Aricept and Excelon).
Depression

Although not well studied, available data
suggests 25-50% of individuals with TBI and
persistent symptoms can develop clinical
depression in first 12 months.

Major depression probably less common with
in post-concussive syndrome, however use of
antidepressants is extremely common in this
population. Post-traumatic stress disorder
may also be present.
Depression

Patients should fit criteria for major
depression (at least 5 of 9 vegetative
symptoms) before implementing medication
treatment. Counseling therapy alone
indicated if minor depression.

Medication treatment must be treated for a
minimum of 12 months, otherwise risk of
relapse elevated.
Depression

Professionals with specific training, an
interest in improving the patient, and an
understanding of the need for objective
criteria for treatment are vital.

Selective serotonin reuptake inhibitors are
most widely used (Zoloft, Paxil, Prozac,
Celexa). Appropriate durations and dosages
of treatments are important.
Agitation/Irritability

Difficulties in interpersonal relationships and
stress management post-TBI may be the
result of increased irritability (or behavioral
dyscontrol).

Typically resolves by 2 weeks post-concussion
(when cognitive skills return to baseline)

May be a sign of depression.
Agitation/Irritability

Normalizing sleep hygiene, controlling
environmental stimulation, enriched
interactions at home/work, and appropriate
pain control are often highly effective.

Psychological counseling is often necessary if
there is little improvement by 2-4 weeks postinjury
Agitation/Irritability

Medications may have a role for persistent
agitation:
– Anxiety - Buspar 5-10 mg tid
- Paxil 10-40 mg qday
– Irritability - VPA 250-500 mg tid
- CBZ 100-200 mg tid

Treatment usually requires 3-6 months
duration.
TBI: Psychiatric

Following mild TBI psychiatric manifestations
(psychosis, OCD, hallucinations) may present
without specific TBI-related cause.

Typically, individuals had “subtle” evidence of
pre-injury issues. Alcohol or drug use may
have masked.
TBI: Psychiatric

Unusual to see resolution of symptoms
without treatment.

Appropriate management with psychoactive
medications and psychological therapy is
necessary.