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.
Measurement Tools

Functional Capacity Evaluation (FCE):
– medical evaluative tool to assess the injured
individual’s physical capacity to return to a specific
job or level of work
– Useful to:




identify when the patient’s rehabilitative progress
plateaus
clarify when a difference exists between the patient’s
reported and observed function (e.g., Waddell’s signs)
determine when vocational planning calls for an
accounting of the patient’s physical abilities
identify permanent restrictions when case closure is
indicated by judgement or statutes
Disability Determination

When return to work has not been achieved,
case settlement or disability determination
may be sought.

When discrepancies exist between physical
performance in and out of the workplace,
questions arise of symptom validation, or
differences arise between treating
practitioners, an “independent” evaluation
may be sought.
Disability Determination


Independent Medical Examination (IME): Any
examination performed for evaluation
purposes by a physician other than the
treating physician. Typically, opinions on MMI,
impairment rating, and disability
determination are rendered.
Maximum Medical Improvement (MMI): Date
after which no further significant recovery
from or lasting improvement of impairment or
disability can be anticipated based on
reasonable medical probability.
Disability Determination

Medical Possibility: An event that is likely to
occur with a probability < 50%.

Medical Probability: An event that is likely to
occur with a probability > 50%.
Disability Determination

Causality: The association between a given
cause (specifically, an event capable of
producing an effect) and effect (specifically,
one that could be produced by the cause)
within a reasonable degree of medical
probability. Causality requires the
determination that
– an event took place
– the claimant experiencing the event has the
condition
– the event could cause the condition
– the event probably did cause the condition
Disability Determination



Apportionment: The determination of
percentage of total impairment directly
attributed to pre-existing or underlying versus
resulting conditions relating to a causal or
aggravating event.
Aggravation: An event that results in
permanent worsening of a pre-existing or
underlying pathology or susceptible condition.
Exacerbation: A temporary increase in the
symptoms.
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.

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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.