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Postconcussion Syndrome (Mild Traumatic Brain Injury)

- 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

para>Avoid opiates and benzodiazepines (5)[B]. ‚

  • Depression/sleep disordersAnxiety/depression screening starting in the first week post MTBIMelatonin for sleepTricyclic antidepressants, or trazodone if there is concomitant sleep disturbance, may be beneficial.SSRIsConsider referral to mental health specialist(s).
  • Cognitive disorders (6)Evaluation by neuropsychiatristMethylphenidate 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 ‚

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.

COMPLICATIONS

  • Repeat head injury or return to play before resolution of PCS can worsen/prolong symptoms.
  • Case studies of second-impact syndrome, a rare but potentially fatal condition owing to a second head injury soon after the first, have been reported.

REFERENCES

11 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 " “26.22 Jotwani ‚ V, Harmon ‚ KG. Postconcussion syndrome in athletes. Curr Sports Med Rep. 2010;9(1):21 " “26.33 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 " “575.44 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 " “223.55 Silverberg ‚ ND, Iverson ‚ GL. Etiology of the post-concussion syndrome: physiogenesis and psychogenesis revisited. NeuroRehabilitation. 2011;29(4):317 " “329.66 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 " “801.77 Leddy ‚ JJ, Willer ‚ B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370 " “376.88 Meehan ‚ WPIII, Mannix ‚ R, Monuteaux ‚ MC, et al. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83(24):2204 " “2210.99 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

  • 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

Concussion (Mild Traumatic Brain Injury) ‚

CODES

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

ICD9

  • 310.2 Postconcussion syndrome
  • 854.01 Intracranial injury of other and unspecified nature without mention of open intracranial wound, with no loss of consciousness
  • 854.00 Intracranial injury of other and unspecified nature without mention of open intracranial wound, unspecified state of consciousness

SNOMED

  • 40425004 postconcussion syndrome (disorder)
  • 127295002 traumatic brain injury (disorder)

CLINICAL PEARLS

  • 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.