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