Postconcussive Syndrome

What is Postconcussive Syndrome?

Traumatic brain injury (TBI), a condition that can happen to anyone at any age, is a major public health concern. Each year in the United States, there are about 1.5 million TBIs, with 75% of them being mild. These TBIs cost around $17 billion annually. Most people with TBIs will naturally get better, but for some, the symptoms may continue and interfere with their daily thinking abilities. Post-concussive syndrome (PCS) is a term used to describe the group of symptoms often seen in prolonged mild TBIs. However, it can also happen after moderate and severe TBIs. The official criteria for PCS is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

PCS includes a range of physical, mental, behavioral, and emotional symptoms that appear after a TBI. These symptoms can include headaches, tiredness, changes in vision, balance issues, confusion, dizziness, trouble sleeping, mental health problems, and difficulty focusing. About 90% of the symptoms following a concussion are temporary and usually resolve within 10 to 14 days. However, they may continue for several weeks. If symptoms continue past 3 months, it’s called persistent PCS. About 15% of those with a mild TBI will experience PCS, and a small portion of these people will need further evaluation and treatment because their PCS continues.

Studies show that a mild TBI that causes persistent PCS can have a long-lasting impact on thought process, memory, learning, and decision-making abilities. People who have experienced more than one brain injury are more at risk for PCS. Since there are only limited tools to diagnose these, permanent changes in decision-making abilities can go undetected. Therefore, the 15% figure is likely understating the true number of PCS cases.

What Causes Postconcussive Syndrome?

Most cases of Post-concussion Syndrome (PCS) – a condition that extends concussion symptoms – happen in people who’ve had a mild Traumatic Brain Injury (TBI), but it can also follow a brain injury of any severity. A TBI is essentially an injury to the brain that could be brought upon by events like a robbery attack, a sports injury, any blow to the head, etc.

The severity of the TBI is measured using the Glasgow coma score (GCS), a scale that assesses a person’s consciousness level. Mild TBI is defined as scoring on the 13-15 points of this scale. However, even among mild TBI cases, there could be ‘complicated’ and ‘uncomplicated’ situations.

‘Complicated’ mild TBI refers to when someone has symptoms of a concussion, and abnormal findings are present in the CT scan of their head. These abnormalities may include blood clots, bleeding under the membranes which cover the brain, a shift in the brain’s position, or fractures.

On the other hand, ‘uncomplicated’ mild TBI is when a normal CT scan comes out even though there are concussion symptoms. Those with uncomplicated mild TBI have a higher chance of seeing their symptoms disappear in under 3 months.

However, patients with complicated TBIs or those who have had more than one TBI are more likely to suffer from PCS or persistent PCS. Other risks of PCS may include being female, being of a certain age, having a history of mental health problems, or a history of chronic pain conditions.

Risk Factors and Frequency for Postconcussive Syndrome

Post-Concussion Syndrome (PCS) is often diagnosed using two different methods: The International Classification of Diseases, 10th revision (ICD-10), and the DSM-IV. Since these different methods can give different results for the same person, there is a broad range of reported occurrence, with anywhere from 30 to 80 percent of patients with mild to moderate Traumatic Brain Injury (TBI) presenting PCS symptoms.

Previous research has attempted to link the severity of the brain injury and the likelihood of PCS in patients who have suffered mild TBIs. However, the results have not shown a consistent link between the two. They looked at factors like the initial level of consciousness, how long the patient lost consciousness, memory problems after trauma, and abnormal brain scans.

Interestingly, there was at least one study suggesting that having a recent concussion or having had multiple concussions increases the risk of prolonged symptoms after a concussion.

Women have a higher risk of long-lasting PCS according to current studies.
Commonly reported symptoms in women include headaches, irritability, fatigue, and concentration problems.
Older age also tends to correspond with a higher risk of PCS.
Among younger patients, females tend to report more symptoms, while males are more likely to lose consciousness at the time of the injury and seek medical aid in an emergency department.
It is also generally believed that younger individuals are less likely to develop PCS due to their brains’ higher capacity to recover and adapt.
This information primarily comes from studies focusing on sports-related incidents, but it is expected to be the same regardless of the cause of the TBI.

Signs and Symptoms of Postconcussive Syndrome

When assessing patients who may have post-concussion syndrome (PCS), it’s important to gather a detailed history and perform a physical examination. The doctor must understand how and when the injury occurred, whether the patient lost consciousness at the time, how many similar injuries the patient has had, and what symptoms they’re experiencing. A patient’s past medical records can often identify those at a higher risk of PCS. Information about previous headaches, depression, anxiety or mood disorders, feelings of dizziness, fatigue, irritability, struggles with sleep, concentration or memory issues, sensitivity to noise, and chronic pain can all be significant.

The physical examination involves a complete neurological assessment. This includes evaluating the cranial nerves (nerves in brain), visual sharpness, reflex responses, muscle strength, understanding of body position (proprioception), and feeling of touch or pain (sensation). This thorough examination should be repeated at every patient visit.

The critical points to consider while evaluating PCS patients are:

How the injury happened
The date of injury
Whether lost consciousness occurred at the time of injury
Number of similar injuries the patient had
Reported symptoms
Previous medical history like headaches, depression, anxiety, dizziness, fatigue, irritability, sleeplessness, concentration or memory problems, sensitivity to noise, and chronic pain
A full neurological exam including cranial nerve evaluation
Visual acuity inspection
Reflex, strength, proprioception, and sensation checks

Testing for Postconcussive Syndrome

Recognizing Post-Concussion Syndrome (PCS) involves noting continuing symptoms after a traumatic brain injury (TBI). However, since these symptoms can be vague, it often takes time to diagnose PCS, which can delay treatment. The term “concussion” is used to describe a condition that gets better within 30 days of an injury. Any symptoms identified during this period are attributed to the concussion or mild TBI before diagnosing PCS.

According to the DSM-IV, a medical manual used to diagnose mental disorders, PCS is diagnosed when someone experiences cognitive deficits in attention or memory, as well as at least 3 of the following that persist for 3 months or longer: fatigue; sleep disturbance; headache; dizziness; irritability; changes in mood or personality.

The International Classification of Diseases (ICD-10) defines PCS as having these symptoms persist for longer than 3 weeks. Most patients recover in the first 7 to 10 days following an injury and most likely won’t need further evaluation.

The first step in evaluating a patient with PCS will typically involve a detailed history and physical exam. This can be done at the scene in sports-related cases, in the emergency department during a crisis, or by a primary care doctor if the patient did not immediately seek medical help at the time of injury. Key focus areas include checking the neck for injury, mental status, cranial nerves (including vision), balance, strength, body position awareness, sensation, and reflexes. Patients should also be screened with tests for their balance and eye movement, which should be repeated when the patient no longer has symptoms. Any changes in nerve function or mental status should be noted with reference to the time of injury.

Each patient will have different symptoms, so tests should be used wisely. As a result, proposed treatments should be tailored for each patient. If patients report visual symptoms, a referral to an eye specialist might be necessary. If patients present with signs of vertigo, a referral to an ear, nose, and throat specialist might be needed. Furthermore, if patients present with mental health symptoms, a referral to a psychologist or psychiatrist should be considered.

The evaluation could also include an imaging test such as a head CT scan done in an emergency setting. If the patient continues to experience symptoms more than one month post-injury, an MRI scan can be performed. Imaging helps doctors rule out other causes for the symptoms before recommending specific therapies. There are also more advanced brain imaging techniques, like functional MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, under investigation for evaluating patients with TBI.

Treatment Options for Postconcussive Syndrome

The treatment of Post-Concussion Syndrome (PCS) can vary greatly depending on each individual’s symptoms and overall experience. It’s important to note that in many cases, reassurance and time are the most effective treatments – most patients will see improvement within three months. The treatment approach often focuses on addressing the specific symptoms that each patient is experiencing.

In most cases, mild Traumatic Brain Injury (TBI) will resolve on its own and will not lead to PCS. However, in the few instances where symptoms persist beyond four weeks post-injury, it’s important to manage the physical and mental effects. Brain and body rest are advised for the first 24 to 48 hours following the injury. However, there isn’t definitive evidence to suggest that this rest improves recovery or long-term outcomes. Patients are usually advised to refrain from activities until they no longer show symptoms, to avoid the risk of a second concussion.

Various medications and interventions have been used to handle headache symptoms following trauma. Treatments might include Amitriptyline, intravenous dihydroergotamine and metoclopramide, greater occipital nerve block, propranolol, and indomethacin.

For ongoing issues with vision and balance, there are screening tools that can be used in an outpatient setting. These tools help health care providers determine the root cause of persistent post-concussion symptoms and prescribe appropriate treatments. These might include neck physical therapy, vision therapy, or therapies to help with balance issues (vestibular rehabilitation).

Patients with PCS are generally encouraged to engage in moderate exercise, as studies suggest this can help speed up recovery. The Buffalo concussion treadmill test can help to assess when patients can safely resume full physical activity. This test measures a patient’s ability to reach a targeted heart rate without experiencing symptoms or becoming excessively tired. Once a patient can reach the maximum heart rate appropriate for their age, without symptoms for at least 20 minutes over 2 to 3 consecutive days, they are considered physically recovered. Athletes may still need some time until other symptoms resolve before they can return to their sport.

There are several conditions that can display similar symptoms, and they include:

Depression
Fibromyalgia, a condition that causes widespread pain and tenderness
Posttraumatic stress disorder (PTSD), a mental health condition triggered by a traumatic event
Vertebral Artery disease, a condition that affects the arteries in the neck
Migraine, a severe, often throbbing type of headache
Tension-type headache, the most common type of headache
Cluster-type headache, severe headaches that occur in clusters or cycles
Insomnia, a sleep disorder where people have trouble sleeping

What to expect with Postconcussive Syndrome

In general terms, Post-concussion syndrome (PCS) usually has positive recovery outcomes. The worst of the symptoms and the greatest impact on daily life generally occur within the first week after injury. After a month, symptoms often improve and in many cases completely resolve. Both recurring head injuries and severe initial symptoms have been linked to symptoms lasting for more than a month. However, the vast majority of these patients get better by three months.

Unfortunately, a small number of patients (10 to 15 percent) continue to experience symptoms for more than a year. However, these numbers might be overstated due to reporting bias, and the actual rate is likely much lower. For a few patients, symptoms may persist for several months or even a year and can sometimes be more disabling than they were immediately after the injury. The ongoing symptoms often vary, but emotional symptoms can be particularly noticeable.

Research has shown that patients involved in legal or compensation claims often report persistent symptoms and disability following mild Traumatic Brain Injury (TBI). Continuous head injuries causing concussions may lead to more severe mental or intellectual deficits. More research is being conducted to further understand this association.

Patients with a score of 13 on the Glasgow Coma Scale (GCS) – a system used to assess the level of consciousness in a person following a traumatic brain injury – tend to have higher disability rates than those scoring 15. This difference may be due to other injuries unlike the TBI itself.

Patients with complicated TBI such as brain bleed (intracranial hematoma) or a fracture depressing into the brain (depressed skull fracture) might also be at risk for more long-lasting symptoms.

Possible Complications When Diagnosed with Postconcussive Syndrome

Common Problems:

Using too many painkillers
Trouble thinking or remembering things
Struggling with everyday tasks
Disruptions in sleep
Changes in thought process
Emotional changes
Acting on impulse
Feeling down or depressed
Behaving aggressively
Thinking about self-harm or suicide
Feigning illness for attention or other gains
Being unable to work
Feeling anxious or worried

Preventing Postconcussive Syndrome

It’s very important for both the patients who have post-concussion syndrome (PCS), and the people around them – like family members, caregivers, and other close relatives – to have a good understanding of the condition. PCS can cause patients to feel worried about their symptoms and how these might impact their health long-term. It’s key to reassure them that though their symptoms might feel quite intense in the first week or two after getting injured, they usually start to get better within a few weeks and often completely disappear in a few months.

Not only patients but also doctors, healthcare team members, nurses, therapists, employers, lawyers, and people who work for health insurance companies need to understand what PCS is. Getting everyone well-informed is an important part of managing PCS.

Educating the patient is one of the best ways to treat this condition. This can be done during a return visit to the doctor or in a special meeting focused on explaining the condition. Providing booklets with easy-to-understand information about PCS can be really helpful, too. Additionally, scheduled phone calls focused on education and further check-ups involving different kinds of healthcare professionals can be beneficial.

Frequently asked questions

The prognosis for Postconcussive Syndrome (PCS) is generally positive, with most symptoms improving and resolving within a month. However, a small percentage of patients (10 to 15 percent) may continue to experience symptoms for more than a year. It is important to note that these numbers may be overstated due to reporting bias, and the actual rate of long-lasting symptoms is likely much lower. Additionally, patients with complicated traumatic brain injuries or a score of 13 on the Glasgow Coma Scale may have higher disability rates.

Postconcussive Syndrome (PCS) can occur after a traumatic brain injury (TBI) of any severity, including mild TBIs. It can also follow a brain injury caused by events like a robbery attack, a sports injury, or any blow to the head.

Signs and symptoms of Postconcussive Syndrome (PCS) can vary from person to person, but some common ones include: - Headaches: Patients may experience frequent or persistent headaches following a concussion. - Depression and anxiety: PCS can lead to changes in mood, including feelings of sadness, hopelessness, or excessive worry. - Dizziness and balance problems: Some individuals with PCS may feel lightheaded or have difficulty maintaining their balance. - Fatigue: Patients may feel tired or have low energy levels, even after getting enough rest. - Irritability and mood swings: PCS can cause irritability, increased sensitivity to stress, and changes in emotional reactions. - Sleep disturbances: Many individuals with PCS have trouble falling asleep, staying asleep, or experience changes in their sleep patterns. - Problems with concentration and memory: PCS can affect a person's ability to focus, remember things, or process information. - Sensitivity to noise and light: Some individuals may become more sensitive to loud noises or bright lights. - Chronic pain: PCS can lead to ongoing pain, such as headaches, neck pain, or muscle aches. It's important to note that these symptoms may not appear immediately after a concussion and can develop over time. Additionally, not all individuals with PCS will experience all of these symptoms.

The types of tests that may be needed to diagnose Post-Concussion Syndrome (PCS) include: - Detailed history and physical exam - Tests for balance and eye movement - Imaging tests such as a head CT scan or MRI scan - Referrals to specialists such as an eye specialist, ear, nose, and throat specialist, or psychologist/psychiatrist - Advanced brain imaging techniques (under investigation) such as functional MRI, magnetic resonance spectroscopy, and diffusion tensor imaging It is important to note that the specific tests needed may vary depending on the individual patient's symptoms and overall experience.

The doctor needs to rule out the following conditions when diagnosing Postconcussive Syndrome: - Depression - Fibromyalgia - Posttraumatic stress disorder (PTSD) - Vertebral Artery disease - Migraine - Tension-type headache - Cluster-type headache - Insomnia

The side effects when treating Post-Concussion Syndrome (PCS) can vary depending on the individual, but some common problems that may arise during treatment include: - Using too many painkillers - Trouble thinking or remembering things - Struggling with everyday tasks - Disruptions in sleep - Changes in thought process - Emotional changes - Acting on impulse - Feeling down or depressed - Behaving aggressively - Thinking about self-harm or suicide - Feigning illness for attention or other gains - Being unable to work - Feeling anxious or worried

A neurologist or a primary care doctor can be consulted for Postconcussive Syndrome.

Anywhere from 30 to 80 percent of patients with mild to moderate Traumatic Brain Injury (TBI) present Post-Concussion Syndrome (PCS) symptoms.

The treatment of Post-Concussion Syndrome (PCS) can vary greatly depending on each individual's symptoms and overall experience. In many cases, reassurance and time are the most effective treatments, as most patients will see improvement within three months. The treatment approach often focuses on addressing the specific symptoms that each patient is experiencing. Various medications and interventions, such as Amitriptyline, intravenous dihydroergotamine and metoclopramide, greater occipital nerve block, propranolol, and indomethacin, can be used to handle headache symptoms. Screening tools can be used to determine the root cause of persistent post-concussion symptoms related to vision and balance, and appropriate treatments such as neck physical therapy, vision therapy, or vestibular rehabilitation can be prescribed. Moderate exercise is generally encouraged, as it can help speed up recovery, and the Buffalo concussion treadmill test can assess when patients can safely resume full physical activity.

Postconcussive Syndrome (PCS) is a term used to describe a group of symptoms that can occur after a traumatic brain injury (TBI). These symptoms can include headaches, tiredness, changes in vision, balance issues, confusion, dizziness, trouble sleeping, mental health problems, and difficulty focusing. PCS can occur after mild, moderate, or severe TBIs, and if the symptoms continue for more than 3 months, it is called persistent PCS.