Managing Persistent Post-Concussive Symptoms: 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.
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).
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.
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.
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.
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).