> Table of Contents > Postconcussion Syndrome (Mild Traumatic Brain Injury)
Postconcussion Syndrome (Mild Traumatic Brain Injury)
Vicki R. Nelson, MD, PhD
Christopher L. Tangen, DO
image BASICS
DESCRIPTION
  • Postconcussion syndrome (PCS) is a constellation of symptoms involving physical, cognitive, and/or behavioral symptoms that persist after a concussion (mild traumatic brain injury [MTBI]) and may continue for weeks to years (1)[C].
  • It is unclear at what point postconcussive symptoms become postconcussive syndrome.
  • Symptoms of PCS can include any symptom of concussion (1,2)[C]
    • Cognitive
      • Poor focus
      • Poor organization
      • Diminished academic/intellectual performance
      • Slowed response time
    • Physical
      • Headache
      • Nausea
      • Visual changes
      • Light and noise sensitivity
      • Tinnitus
      • Dizziness and balance problems
      • Fatigue and sleep disturbance
    • Behavioral
      • Depression
      • Irritability/emotional lability
      • Apathy
      • Increased sensitivity to alcohol
  • Diagnosis is based on history and clinical symptoms.
EPIDEMIOLOGY
Incidence
The reported range of MTBI patients who develop PCS varies widely between 5% and 80%.
  • The variation is due to difficulty in differentiating postconcussion symptoms from postconcussion syndrome.
  • Consensus is that 80-90% of concussion victims recover from postconcussion symptoms within 7 to 10 days, slightly longer in children/adolescents (3)[C].
Prevalence
Predominant sex: Female > male, although female gender is not universally considered a risk factor.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Controversial; exact mechanism(s) unknown
  • It is postulated that microscopic axonal injury from shearing forces leads to inflammation that causes secondary brain injury.
  • There is conflicting data on structural brain damage and the correlation of imaging findings with physical symptoms (1,2,4,5,6)
  • Because the pathophysiology of PCS is not well understood and because of symptom overlap with other psychiatric conditions, PCS remains a difficult condition to diagnose and to manage.
    • Only some people with MTBI develop PCS; it is unclear what causes PCS symptoms to occur and to persist (5,6).
    • Psychiatric factors are commonly associated with, and may play a role in, the development of PCS. It can be a challenge to differentiate pure psychiatric dysfunction from true PCS (1,5,6)[C],(7)[B].
    • Neuropsychiatry evaluation may be helpful to differentiate PCS from psychiatric disorders.
    • Patient reported high symptom burden following MTBI is associated with increased risk of PCS (8)[B].
RISK FACTORS
  • Amnesia, migraine, self-reported cognitive decline, noise and light sensitivity developing or worsening in the first day to weeks after MTBI (1)[C],(4)[B]
  • Preexisting psychiatric disease including depression, anxiety, personality disorder, and posttraumatic stress disorder (PTSD)
  • Preexisting expectation of poor outcomes in patients following concussion/MTBI (1)[C],(4)[B]
  • Nonsport concussion
  • Unclear if previous history of concussion(s) is a risk factor for PCS (2)[C].
  • Low socioeconomic status
GENERAL PREVENTION
  • Education of players, coaches, parents, and athletic trainers about concussion, PCS, and following game safety rules designed to protect players.
  • Head injury precautions with activities are advised, but no good evidence that these decrease incidence of MTBI or PCS.
  • Early screening and intervention(s) for anxiety and depression
COMMONLY ASSOCIATED CONDITIONS
  • PTSD
  • Anxiety/depression
  • Fibromyalgia
  • Personality disorders (namely, compulsive, histrionic, and narcissistic)
  • ADHD
image DIAGNOSIS
PHYSICAL EXAM
Complete neurologic exam, including the following:
  • Glasgow Coma Scale (GCS)
  • Anxiety/depression screening
    • Patient Health Questionnaire-9 (PHQ-9)
    • GAD-7
  • Sport Concussion Assessment Tool, NFL Sideline Concussion Assessment Tool, or computerized neuropsychological (CNP) testing both pre- and post-MTBI is common practice, although data are limited on validity (3)[C]. More info regarding CNP below
DIFFERENTIAL DIAGNOSIS
  • Postconcussive symptoms
  • PTSD
  • Anxiety/depression
  • Personality disorders
  • Migraine headaches
  • Chronic fatigue syndrome, fibromyalgia
  • Evolving intracranial hemorrhage
  • Exposure to toxins, including prescription and recreational drugs
  • Endocrine/metabolic abnormality
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • If clinically warranted, consider evaluation for infection, intoxication, and endocrine/metabolic abnormality.
  • Brain imaging both on initial evaluation of MTBI and PCS is generally neither fruitful nor indicated.
  • Imaging to evaluate for bleeding may be helpful in patients with comorbid conditions or who are taking anticoagulation therapy.
  • Recommend cervical imaging when concomitant cervical spine injury is suspected.
Follow-Up Tests & Special Considerations
  • Several CNP testing programs can be used to guide decisions regarding return to play. If baseline testing is available, scores can be used as controls against scores achieved after MTBI.
  • Formal neuropsychiatric evaluations are likely superior to CNP testing when available. None of these tests should be used alone in decision making, especially if a patient is still having symptoms despite improving or “baseline” scores (1,3)[C].
  • Common neuropsychological testing programs for PCS
    • Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)
    • Axon Sports Computerized Cognitive Assessment Tool (CCAT)
    • Post Concussion Symptom Scale (PCSS)
    • Balance Error Scoring System (BESS)
    • Automated Neuropsychological Assessment Metrics (ANAM)
P.835

image TREATMENT
GENERAL MEASURES
  • Subthreshold exercise has been shown to help resolution and can start after 21 days (7)[B].
  • Consider physical therapy for coexistent cervical or vestibular injury.
  • Return to play
    • Persons with concussion or PCS should be restricted from sport activity until they are off all medications that may mask PCS symptoms and clinical symptoms have resolved (1,3)[C].
    • Return to full activity should progress according to step-wise concussion recommendations (1,3)[C].
MEDICATION
First Line
Headache/neck pain
  • Nonopioid pain control (e.g., NSAIDs)
    • Sedation may obscure cognitive evaluation.
    • Possible association with use of opiates and increased risk of anxiety/depression in PCS patients (5)[B].
    • Consider occipital nerve block.
  • Depression/sleep disorders
    • Anxiety/depression screening starting in the first week post MTBI
      • Melatonin for sleep
      • Tricyclic antidepressants, or trazodone if there is concomitant sleep disturbance, may be beneficial.
      • SSRIs
    • Consider referral to mental health specialist(s).
  • Cognitive disorders (6)
    • Evaluation by neuropsychiatrist
    • Methylphenidate may be considered (9)[A].
    • SSRIs may be considered, especially if concomitant anxiety/depression (9)[A].
ISSUES FOR REFERRAL
  • Neuropsychiatric therapy including comprehensive cognitive evaluation for potential TBI rehabilitation
  • Cognitive behavioral therapy for anxiety and depression symptoms
  • Occupational therapy for vocational rehabilitation, if needed
  • Physical therapy for vestibular rehabilitation
  • Neurology referral if primary care interventions for seizures, headache, vertigo, or cognition are unsuccessful.
  • Substance abuse counseling, if needed
COMPLEMENTARY & ALTERNATIVE MEDICINE
Massage therapy/osteopathic manipulative treatment for headache and neck pain
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Schedule regular follow-up to evaluate for persistent symptoms, efficacy of/need for neuropsychiatric evaluation, and the efficacy of/need for pharmacologic therapy.
Patient Monitoring
  • Consider serial neuropsychological testing.
  • Follow return to play guidelines (3)[C].
PATIENT EDUCATION
  • Centers for Disease Control and Prevention: http://www.cdc.gov/headsup/
  • Mayo Clinic Health Information: http://www.mayoclinic.com/health/post-concussion-syndrome/DS01020/
  • Brain Injury Association of America: http://www.biausa.org/; (800) 444-6443
PROGNOSIS
  • Prognosis generally is good.
  • Adolescents may recover more slowly than adults.
REFERENCES
1. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26.
2. Jotwani V, Harmon KG. Postconcussion syndrome in athletes. Curr Sports Med Rep. 2010;9(1):21-26.
3. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train. 2013;48(4):554-575.
4. Hou R, Moss-Morris R, Peveler R, et al. When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury. J Neurol Neurosurg Psychiatry. 2012;83(2):217-223.
5. Silverberg ND, Iverson GL. Etiology of the post-concussion syndrome: physiogenesis and psychogenesis revisited. NeuroRehabilitation. 2011;29(4):317-329.
6. Meares S, Shores EA, Batchelor J, et al. The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury. J Int Neuropsychol Soc. 2006;12(6):792-801.
7. Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370-376.
8. Meehan WP III, Mannix R, Monuteaux MC, et al. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83(24):2204-2210.
9. Lee H, Kim SW, Kim JM, et al. Comparing effects of methylphenidate, sertraline and placebo on neuropsychiatric sequelae in patients with traumatic brain injury. Hum Psychopharmacol. 2005;20(2):97-104.
Additional Reading
&NA;
  • Barlow M, Schlabach D, Peiffer J, et al. Differences in change scores and the predictive validity of three commonly used measures following concussion in the middle school and high school aged population. Int J Sports Phys Ther. 2011;6(3):150-157.
  • Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21-27.
  • Leddy JJ, Sandhu H, Sodhi V, et al. Rehabilitation of concussion and post-concussion syndrome. Sports Health. 2012;4(2):147-154.
  • Morgan CD, Zuckerman SL, Lee YM, et al. Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 2015;15(6):589-598.
See Also
&NA;
Concussion (Mild Traumatic Brain Injury)
Codes
&NA;
ICD10
  • F07.81 Postconcussional syndrome
  • S06.9X0A Unsp intracranial injury w/o loss of consciousness, init
  • S06.9X9A Unsp intracranial injury w LOC of unsp duration, init
Clinical Pearls
&NA;
  • Imaging rarely useful for PCS; head CT scan is the test of choice for acute injury to exclude intracranial bleeding.
  • Coordinate multidisciplinary treatment plans for patients with persistent symptoms.
  • Return to play/activity should not occur until symptoms return to baseline and any pre-PCS medications are optimized by the prescribing clinician.