Persistent Post-concussive Symptoms (PPCS): Treatment strategies
After covering introduction and imaging of persistent post-concussive symptoms (PPCS), also termed post-concussion syndrome, we continue moving forward to examine treatment strategies. The recommendations have been evolving over time and treatment for both acute and persistent concussive symptoms and has changed substantially from original strategies. Many providers will remember some advocating for waking the patient up every 1-2 hours in case there is a hemorrhage and goes unconscious. Other dated recommendations included complete physical and cognitive rest with minimal stimulation until symptoms resolved. Treatment strategies will continue to evolve as more studies are undertaken and a more comprehensive team approach is becoming more common.
Persistent symptoms related to concussion are a source of frustration for both the patient and provider. The medical community has made strides in assessing and targeting treatment for PPCS in recent years. This begins with a detailed history that includes prior migraines and their patterns, ADHD or learning disability symptoms, depression or anxiety and how these have changed since their injury. Another aspect specific to females is any changes in menstrual cycle due to increased risk of abnormal patterns (1). A thorough physical examination including a vestibular, oculomotor, neurologic (including balance assessment) and cervical examination should also be performed. Neuropsychiatric testing may also be done to monitor progress and recovery.
One of the most promising treatment strategies is submaximal exercise that does not exacerbate symptoms. Patients with PPCS were shown to have shorter exercise duration, lower heart rate at test cessation and higher rating of perceived exertion (RPE) than matched controls (2-3). Aerobic treadmill testing has been used to evaluate and treat PPCS. The test most often used is the Buffalo Concussion Treadmill Test (BCTT) in which patients walk on a treadmill at increasing speed and grade and rate their symptoms and perceived exertion, all while undergoing heart rate monitoring. This is best done by an experienced physiotherapist, physiologist or kinesiologist (5). An initial evaluation is completed and a re-evaluation is done typically every 2-3 weeks to find a new baseline (6). Initial studies showed that patients undergoing aerobic treadmill testing had a significant reduction in symptoms and athletes recovered faster than non-athletes (7). Another recent retrospective study showed that 90% of patients with PPCS treated with a tailored exercise prescription were clinically improved and 80.5% successfully returned to sporting activities (8). The average return to play was 50 days and the great majority (88%) that did not successfully complete the program had a previous or new migraine disorder. There were no serious complications in a total of 141 tests performed (8). For patients with other orthopedic conditions or other contraindications to treadmill use, a Buffalo Bike Concussion Test (BBCT) is also used with a similar protocol (5).
Image 1. Exercise therapy as demonstrated by Dr Leddy of the University of Buffalo
It has been reported that up to 60% of patients suffering from sport related concussion were shown to have either vestibular or oculomotor abnormalities or symptoms (9). Dizziness, vertigo, impaired balance, discomfort in busy environments and nausea are common symptoms associated with disruption of the vestibular system. BPPV (Benign paroxysmal positional vertigo) is commonly associated with concussion and the Dix-Hallpike maneuver should be done to evaluate for this and canalith repositioning maneuvers can be done for treatment. Vestibulo-ocular reflex (VOR) impairment, a fast-acting reflex that keeps the eyes stable and maintains eye position during head movement, is another potential target for therapy. VOR therapy requires patients to maintain visual focus on a target while moving their head and can be manipulated by varying target size and complexity, postures, duration, direction, amplitude, and velocity. One randomized controlled trial showed patients with PPCS that underwent vestibular and cervical spine rehabilitation were 3.91 times more likely to be medically cleared (return to sport) by 8 weeks (10). A 2013 study with 104 patients showed improved patient outcomes with a home vestibular rehabilitation program (11). Two other case series have shown impaired spatial memory and imbalance in adolescents with PPCS and moderate benefit to vestibular rehabilitation (12-13). The principle goal of vestibular therapy is to re-establish effective integration of the visual, vestibular, and somatosensory systems through a patient-tailored progressive vestibular exercise program (4) and there is moderate evidence to support this.
Image 2. Demonstration of vestibular therapy (courtesy of athletico.com)
Another system closely related and integrated to the vestibular system that may be involved is the visual system. It has been shown that patients with chronic vestibular abnormalities often experience dizziness related to abnormalities of the visual system (15). Abnormalities in the visual system can cause an increased sense of disorientation, dizziness or postural instability in situation with visual and vestibular conflict (14). Convergence, accommodative and eye movement disorders are most commonly seen. These patients typically become symptomatic in complex visuospatial environments such as mall, groceries stores or doing tasks such as reading from a bright screen. An evaluation should be completed by a vision therapist or optometrist, although many areas may not have a true vision therapist available for a complete evaluation. Treatment involves gradual and systematic exposure to provocative stimuli and needs to be introduced in a step-by-step progression and carefully monitored by a vision therapist or vestibular therapist trained in visual therapy. Many patients do complain of slight worsening of symptoms after initiation of vision therapy. Improved outcomes have been reported in patients with mild TBI and convergence insufficiency with vision therapy (17-18). A case-series with 218 patients with PPCS reported successful or improved outcomes in the vast majority of patient that completed treatment (around 54%). Eighty-five percent of patient with convergence insufficiency had a successful outcome and 67% of patients with accommodative insufficiency were improved after therapy (19). Another study on 83 athletes diagnosed with a “visual concussion” underwent a treatment protocol and an average of 4.5 weeks of vision therapy. The individuals that completed vision therapy had a return to play of 5.8 weeks compared to 12.3 weeks in individuals that refused vision therapy (20).
Another focus is patients suffering from PPCS should be the cervical spine, which can be a source of persistent dizziness. Pathologic abnormality creates abnormal muscle activity in the deep layers of the upper cervical spine responsible for providing proprioceptive input to the CNS. Dizziness is thought to occur because of the mismatch between aberrant cervical proprioceptive information in relation to vestibular and visual inputs (14). Clinically, these patients typically present with neck pain and stiffness, fatigue, and fogginess. Management of cervicogenic dizziness is directed toward therapies that treat the underlying cervical spine injury to normalize proprioceptive input with visual and vestibular information. This is done through manual therapy for the cervical spine, balance training and oculomotor training. The randomized controlled trial by Schneider et. al included cervical spine rehabilitation (10,16). A recent review also showed improved outcomes or fewer symptoms in patients with cervicogenic headaches undergoing mobilization or manipulation of the cervical spine (21). This rehabilitation is preferably undertaken by an experienced physiotherapist.
Image 3. Types of post-concussion headache patterns (courtesy of cognitivefx)
Migraine headache disorder, a known risk factor for prolonged recovery for concussion, is the most common primary headache disorder and affects 15-20% of the general population (4). The effect of concussion on migraine disorders is variable and most patients do describe headaches related to concussions as different. Migraines are typically unilateral, severe, and can exacerbated or provoked by stereotypical stimuli. Headaches related to concussions are typically mild to moderate in nature, global and pounding in nature. If there is concern of a migraine disorder following PPCS, the patient should be evaluated by a neurologist. There is paucity in data in regards to return to sport in patients that develop a migraine disorder following PPCS and will need to be individualized (4).
Collaborative care teams are becoming more common today and more providers are becoming comfortable treating concussions. As mentioned earlier, symptoms of anxiety and depression are a risk factor for prolonged recovery and symptoms can change when dealing with PPCS. Providers should work in conjunction with neuropsychiatrists and psychiatrists when psychological symptoms arise or worsen. Cognitive behavioral therapy (CBT) is currently recommended for adults following concussions and there is robust data supporting CBT in adolescent depression, anxiety and chronic pain (22-23). Psychopharmacologic management should also be done in close coordination between providers for these disorders. Inquiries need to be made about changes in menstrual patterns to identify patients who may develop abnormal menses. Appropriate referrals for further evaluation and treatment should be made to prevent any potential long term side effects (1,24). Sleep abnormalities may also occur as a result of a concussion. Sleep should be monitored, hygiene should be addressed and appropriate referrals should be made if necessary (25). There is limited evidence for pharmacologic management of PPCS and will be discussed in the future.
Conclusion
There have been great strides made in the last decade in regards to understanding of PPCS and management of PPCS. Treatment strategies and plans are made after a thorough history and physical examination. Aerobic treadmill testing can be used to evaluate and treat patients suffering from PPCS, especially patients with exertional headaches or headaches related to exercise. Vestibular and/or vision therapy should be recommended in patients when abnormalities related to these systems are prevalent on exam or noted in the history. The cervical spine should always be evaluated and targeted therapy can be prescribed. Collaborative care is becoming more common and providers need to be diligent to evaluate abnormalities associated with PPCS and make referrals to specialists if needed.
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