Virginia Commonwealth University Medical College of Virginia Hospital

Department of Physical Medicine and Rehabilitation

http://www.pmr.vcu.edu/ http://www.worksupport.com/

Post-Concussive Syndrome: Prevention and Management

David X. Cifu, M.D.

The Herman J. Flax, M.D. Professor and Chairman Department of Physical Medicine and Rehabilitation Virginia Commonwealth University

Overview

  TBI incidence – – – 1-5 million injuries/year 500,000 hospital admissions/year 50,000 rehabilitation admissions/year TBI demographics – – – 16-34 years old is most common age range >60 years is second most common age range <5 years is a close third

Overview

 Mild TBI is most common injury (by a factor of 20x). Vast majority return to pre-injury level of function and work.

 Rapid identification of mild TBI and possible sequelae (Post-concussive syndrome) is vital to effective management.

TBI Classification

 Mild TBI = Concussion  Glasgow Coma Score of 13-15  Brief loss or alteration of consciousness (“see stars”, “dazed”) for up to 30 minutes  Non-focal neurological exam by 30 minutes

TBI Classification

 No indication for imaging study if normal exam by 30 minutes. Need to be monitored for 24 hours.

 If persistent symptoms (e.g., confusion) or focal exam by 30 minutes, then CT Scan.

 Nml CT and MRI scans in >99% of mild TBI. No clinical role for PET or SPECT scans.

Post-Concussive Syndrome: Definition

 Persistent non-focal neurologic symptoms > 24 hours post-TBI = PCS • Dizziness • Headache (+/- N/V) • Cognitive deficits (attention, memory, judgement) • Behavioral changes (irritability, depression, nightmares) • Sleep disturbance

Post-Concussive Syndrome: Management

 Symptoms rapidly resolve (2-4 weeks) in >85% individuals.  5-10% may have persistent difficulties by 12 months.

 Significant medicolegal overlay common.

Post-Concussive Syndrome: Management

 Early assessment of injury (i.e., recognizing a concussion occurred), referral for comprehensive treatment, and reintegration into pre-injury life is essential to full recovery.

 Limiting treatment to professionals with good understanding of process and motivation to return patient back to maximal function is important.

Post-Concussive Syndrome: Management

 Extensive research in NCAA athletes demonstrates initial changes in cognitive testing after concussion with return to baseline by 2 weeks.

 Research in E.R.’s demonstrates that early detection of concussion and in-depth discussion of potential difficulties minimizes short and long-term symptoms.

Post-Concussive Syndrome: Management

 Treatment includes physical activity, counseling, limited medication usage, and supportive care.

 Most patients can return to full-duty in 24-72 hours. Close monitoring of performance and symptoms in first 7 days is crucial.

 Operating machinery/driving should only occur if symptom free.

Measurement Tools

 Functional Capacity Evaluation (FCE): – medical evaluative tool to assess the injured individual’s physical capacity to return to a specific job or level of work – Useful to:    identify when the patient’s rehabilitative progress plateaus clarify when a difference exists between the patient’s reported and observed function (e.g., Waddell’s signs) determine when vocational planning calls for an accounting of the patient’s physical abilities  identify permanent restrictions when case closure is indicated by judgement or statutes

Disability Determination

 When return to work has not been achieved, case settlement or disability determination may be sought.

 When discrepancies exist between physical performance in and out of the workplace, questions arise of symptom validation, or differences arise between treating practitioners, an “independent” evaluation may be sought.

Disability Determination

  Independent Medical Examination (IME): Any examination performed for evaluation purposes by a physician other than the treating physician. Typically, opinions on MMI, impairment rating, and disability determination are rendered.

Maximum Medical Improvement (MMI): Date after which no further significant recovery from or lasting improvement of impairment or disability can be anticipated based on reasonable medical probability.

Disability Determination

 Medical Possibility: An event that is likely to occur with a probability < 50% .

 Medical Probability: An event that is likely to occur with a probability > 50%.

Disability Determination

 Causality: The association between a given cause (specifically, an event capable of producing an effect) and effect (specifically, one that could be produced by the cause) within a reasonable degree of medical probability. Causality requires the determination that – an event took place – – – the claimant experiencing the event has the condition the event could cause the condition the event probably did cause the condition

Disability Determination

   Apportionment: The determination of percentage of total impairment directly attributed to pre-existing or underlying versus resulting conditions relating to a causal or aggravating event.

Aggravation: An event that results in permanent worsening of a pre-existing or underlying pathology or susceptible condition.

Exacerbation: A temporary increase in the symptoms.

Headache: Management

 Headache pain predominantly from muscle and soft-tissue injury to neck or skull.  Early use of anti-inflammatory and analgesic medications is important. Antispasmodics have little efficacy, but can assist in sleep and relaxation.

 Rapid muscle mobilization is key. Structured PT or HEP needed. Local heat or ice.

Headache: Management

 Headache specific medication may be needed if symptoms not resolving by 1 week.

– Fiorinal/Fioricet (1 tab q 4-6 hours) – Midrin (2 tabs at HA onset, repeat q1 hour x 3)  True post-traumatic migraine HA’s are rare (confirm pre-injury history). May respond to more traditional migraine treatments (refer to neurologist)

Headache: Management

 Persistent HA’s that are not resolving by 3-4 weeks may be the result of undertreatment, missed diagnosis (e.g., skull fracture), or psychological overlay.

 Psychologic intervention often helpful: – – Relaxation training Frontalis Muscle biofeedback – – Counseling Pain Management strategies

Dizziness: Etiology

 Usually resolves in 7 days.  Persistence of symptoms may be secondary to muscular injury to neck limiting full ROM. Responds to active mobilization program.

 True neurologic cause may be injury to labyrinthian mechanism of inner ear.

Dizziness: Etiology

 Contusion to semicircular canals may result in abnormal movement of otoliths, causing a delayed response to head movement. This results in: – a temporal difference in information supplied to the cerebellum by the visual, proprioceptive and labyrinthian systems.

– A feeling of dizziness  HallPike-Dix Maneuver diagnostic of labyrinthain cause.

Dizziness: Management

 Vestibular rehabilitation is effective but labor intensive. Focuses on: – – – Optimizing three components of balance   Neck ROM Visual Tracking  Proprioceptive Input Identifies positions and motions that cause dizziness and progressively exposes patient to these situations.

Rapid mobilization outside of therapy is also important (e.g., return to work).

Dizziness: Management

 Medications have limited efficacy, typically mildly sedate patient to decrease reaction to dizziness (e.g., Meclizine, Scopolamine)  Novel use of buspirone (Buspar) has been demonstrated effective in 3 case reports (5 10 mg tid).

Sleep Hygiene Disturbance

 Common following mild TBI. Often multifactorial, including pain, psychologic factors, pre-injury factors, and true alterations in arousal.

 First-line management involves appropriate sleep hygiene (e.g., eliminating caffeine, “winding down”, eliminating naps, appropriate environment).

Sleep Hygiene Disturbance

 Early (48-72 hours) use of sleep medications is appropriate. Scheduled agents for 3-7 days is preferable to prn dosing.

    Trazadone 50-300 mg qhs is preferred agent.

Sonata is second line agent.

Ambien may have cognitive side effects.

Avoid benzodiazapines (e.g., Restoril) secondary to depressive and addictive propoerties.

Deficits of Arousal and Attention

 Typical in the first 24-72 hours post-TBI. Will prevent optimal memory, concentration, and judgement. May persist to some extent in most patients for first 2 weeks.

 Optimizing sleep hygiene and eliminating sedating medications (e.g., pain medications) is important first line treatment.

 Can profoundly impair function and work.

Deficits of Arousal and Attention

 Stimulant agents an appropriate and effective intervention.

– Rapid working (24-72 hours) – – – Limited side effects or drug interactions Also assist in managing depressive symptoms.

Can be inexpensive (generic Ritalin)  Ritalin, Atteral, Cylert, and Provigil are common agents.

Deficits of Arousal and Attention

 Treat with stimulants for 4 weeks (at therapeutic dose) and then begin to wean.

 If acute condition, rarely need to restart. If chronic condition may need 6+ months treatment.

Memory and Processing Deficits

 Cognitive deficits are universal after TBI, however excellent recovery is common.

 Neuropsychological Testing best captures the spectrum of deficits. The skills of the tester and interpreter greatly influence relevance of testing.

 Depression may present as memory difficulties.

Memory and Processing Deficits

 Good evidence for utility of cognitive therapies for up to 18 months, although objective criteria for improvement are necessary.

 The use of memory aides (PDA’s, memory logs) has been highly successful.

Memory and Processing Deficits

 Similar strategies and medications as for arousal and attention deficits are employed.

 Probable role for SSRI antidepressants (e.g., Zoloft), even in absence of clinical or major depression.

 Possible role for anti-Alzheimer’s agents (e.g., Aricept and Excelon).

Depression

 Although not well studied, available data suggests 25-50% of individuals with TBI and persistent symptoms can develop clinical depression in first 12 months.

 Major depression probably less common with in post-concussive syndrome, however use of antidepressants is extremely common in this population. Post-traumatic stress disorder may also be present.

Depression

 Patients should fit criteria for major depression (at least 5 of 9 vegetative symptoms) before implementing medication treatment. Counseling therapy alone indicated if minor depression.

 Medication treatment must be treated for a minimum of 12 months, otherwise risk of relapse elevated.

Depression

 Professionals with specific training, an interest in improving the patient, and an understanding of the need for objective criteria for treatment are vital.

 Selective serotonin reuptake inhibitors are most widely used (Zoloft, Paxil, Prozac, Celexa). Appropriate durations and dosages of treatments are important.

Agitation/Irritability

 Difficulties in interpersonal relationships and stress management post-TBI may be the result of increased irritability (or behavioral dyscontrol).

 Typically resolves by 2 weeks post-concussion (when cognitive skills return to baseline)  May be a sign of depression.

Agitation/Irritability

 Normalizing sleep hygiene, controlling environmental stimulation, enriched interactions at home/work, and appropriate pain control are often highly effective.

 Psychological counseling is often necessary if there is little improvement by 2-4 weeks post injury

Agitation/Irritability

 Medications may have a role for persistent agitation: – Anxiety - Buspar 5-10 mg tid – - Paxil 10-40 mg qday Irritability - VPA 250-500 mg tid - CBZ 100-200 mg tid  Treatment usually requires 3-6 months duration.

TBI: Psychiatric

 Following mild TBI psychiatric manifestations (psychosis, OCD, hallucinations) may present without specific TBI-related cause.

 Typically, individuals had “subtle” evidence of pre-injury issues. Alcohol or drug use may have masked.

TBI: Psychiatric

 Unusual to see resolution of symptoms without treatment.

 Appropriate management with psychoactive medications and psychological therapy is necessary.