virginia commonwealth university medical college of virginia hospital department of physical...

Virginia Commonwealth Virginia Commonwealth UniversityUniversity

Medical College of Virginia HospitalMedical College of Virginia Hospital

Department of Physical Department of Physical Medicine and RehabilitationMedicine and Rehabilitation

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

Post-Concussive Post-Concussive Syndrome: Prevention and Syndrome: Prevention and

ManagementManagement

David X. Cifu, M.D.David X. Cifu, M.D.The Herman J. Flax, M.D. The Herman J. Flax, M.D. Professor and Chairman Professor and Chairman

Department of Physical Medicine and Department of Physical Medicine and RehabilitationRehabilitation

Virginia Commonwealth UniversityVirginia Commonwealth University

OverviewOverview

TBI incidenceTBI incidence– 1-5 million injuries/year1-5 million injuries/year– 500,000 hospital admissions/year500,000 hospital admissions/year– 50,000 rehabilitation admissions/year50,000 rehabilitation admissions/year

TBI demographicsTBI demographics– 16-34 years old is most common age range16-34 years old is most common age range– >60 years is second most common age >60 years is second most common age

rangerange– <5 years is a close third<5 years is a close third

OverviewOverview

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

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

TBI ClassificationTBI Classification

Mild TBI = ConcussionMild TBI = Concussion

Glasgow Coma Score of 13-15Glasgow Coma Score of 13-15

Brief loss or alteration of consciousness Brief loss or alteration of consciousness (“see stars”, “dazed”) for up to 30 minutes(“see stars”, “dazed”) for up to 30 minutes

Non-focal neurological exam by 30 minutesNon-focal neurological exam by 30 minutes

TBI ClassificationTBI Classification

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

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

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

Post-Concussive Syndrome: Post-Concussive Syndrome: DefinitionDefinition

Persistent non-focal neurologic symptoms Persistent non-focal neurologic symptoms > 24 hours post-TBI = PCS> 24 hours post-TBI = PCS• DizzinessDizziness

• Headache (+/- N/V)Headache (+/- N/V)

• Cognitive deficits (attention, memory, judgement)Cognitive deficits (attention, memory, judgement)

• Behavioral changes (irritability, depression, nightmares)Behavioral changes (irritability, depression, nightmares)

• Sleep disturbanceSleep disturbance

Post-Concussive Syndrome: Post-Concussive Syndrome: ManagementManagement

Symptoms rapidly resolve (2-4 weeks) Symptoms rapidly resolve (2-4 weeks) in >85% individuals. in >85% individuals.

5-10% may have persistent difficulties 5-10% may have persistent difficulties by 12 months.by 12 months.

Significant medicolegal overlay Significant medicolegal overlay common.common.


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

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


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

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


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

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

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

Measurement ToolsMeasurement Tools

Functional Capacity Evaluation (FCE):Functional Capacity Evaluation (FCE):– medical evaluative tool to assess the injured medical evaluative tool to assess the injured

individual’s physical capacity to return to a specific individual’s physical capacity to return to a specific job or level of workjob or level of work

– Useful to:Useful to: identify when the patient’s rehabilitative progress identify when the patient’s rehabilitative progress

plateausplateaus clarify when a difference exists between the patient’s clarify when a difference exists between the patient’s

reported and observed function (e.g., Waddell’s signs)reported and observed function (e.g., Waddell’s signs) determine when vocational planning calls for an determine when vocational planning calls for an

accounting of the patient’s physical abilitiesaccounting of the patient’s physical abilities identify permanent restrictions when case closure is identify permanent restrictions when case closure is

indicated by judgement or statutesindicated by judgement or statutes

Disability DeterminationDisability Determination

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

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


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

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


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

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

Disability DeterminationDisability Determination Causality: The association between a given Causality: The association between a given

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


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

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

Exacerbation: A temporary increase in the Exacerbation: A temporary increase in the symptoms.symptoms.

Headache: ManagementHeadache: Management

Headache pain predominantly from muscle Headache pain predominantly from muscle and soft-tissue injury to neck or skull. and soft-tissue injury to neck or skull.

Early use of anti-inflammatory and analgesic Early use of anti-inflammatory and analgesic medications is important. Antispasmodics medications is important. Antispasmodics have little efficacy, but can assist in sleep and have little efficacy, but can assist in sleep and relaxation.relaxation.

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


Headache specific medication may be Headache specific medication may be needed if symptoms not resolving by 1 needed if symptoms not resolving by 1 week.week.– Fiorinal/Fioricet (1 tab q 4-6 hours)Fiorinal/Fioricet (1 tab q 4-6 hours)– Midrin (2 tabs at HA onset, repeat q1 hour x 3)Midrin (2 tabs at HA onset, repeat q1 hour x 3)

True post-traumatic migraine HA’s are rare True post-traumatic migraine HA’s are rare (confirm pre-injury history). May respond to (confirm pre-injury history). May respond to more traditional migraine treatments (refer more traditional migraine treatments (refer to neurologist)to neurologist)


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

Psychologic intervention often helpful:Psychologic intervention often helpful:– Relaxation trainingRelaxation training– Frontalis Muscle biofeedbackFrontalis Muscle biofeedback– CounselingCounseling– Pain Management strategiesPain Management strategies

Dizziness: EtiologyDizziness: Etiology

Usually resolves in 7 days. Usually resolves in 7 days.

Persistence of symptoms may be Persistence of symptoms may be secondary to muscular injury to neck secondary to muscular injury to neck limiting full ROM. Responds to active limiting full ROM. Responds to active mobilization program.mobilization program.

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

Dizziness: EtiologyDizziness: Etiology

Contusion to semicircular canals may result Contusion to semicircular canals may result in abnormal movement of otoliths, causing a in abnormal movement of otoliths, causing a delayed response to head movement. This delayed response to head movement. This results in:results in:– a temporal difference in information supplied to a temporal difference in information supplied to

the cerebellum by the visual, proprioceptive and the cerebellum by the visual, proprioceptive and labyrinthian systems.labyrinthian systems.

– A feeling of dizzinessA feeling of dizziness

HallPike-Dix Maneuver diagnostic of HallPike-Dix Maneuver diagnostic of labyrinthain cause.labyrinthain cause.

Dizziness: ManagementDizziness: Management

Vestibular rehabilitation is effective but Vestibular rehabilitation is effective but labor intensive. Focuses on:labor intensive. Focuses on:– Optimizing three components of balanceOptimizing three components of balance

Neck ROMNeck ROM Visual TrackingVisual Tracking Proprioceptive InputProprioceptive Input

– Identifies positions and motions that cause Identifies positions and motions that cause dizziness and progressively exposes patient to dizziness and progressively exposes patient to these situations.these situations.

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

Dizziness: ManagementDizziness: Management

Medications have limited efficacy, Medications have limited efficacy, typically mildly sedate patient to typically mildly sedate patient to decrease reaction to dizziness (e.g., decrease reaction to dizziness (e.g., Meclizine, Scopolamine)Meclizine, Scopolamine)

Novel use of buspirone (Buspar) has Novel use of buspirone (Buspar) has been demonstrated effective in 3 case been demonstrated effective in 3 case reports (5-10 mg tid).reports (5-10 mg tid).

Sleep Hygiene DisturbanceSleep Hygiene Disturbance

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

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

Sleep Hygiene DisturbanceSleep Hygiene Disturbance

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

Trazadone 50-300 mg qhs is preferred agent.Trazadone 50-300 mg qhs is preferred agent. Sonata is second line agent.Sonata is second line agent. Ambien may have cognitive side effects.Ambien may have cognitive side effects. Avoid benzodiazapines (e.g., Restoril) Avoid benzodiazapines (e.g., Restoril)

secondary to depressive and addictive secondary to depressive and addictive propoerties.propoerties.

Deficits of Arousal and Deficits of Arousal and AttentionAttention

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

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

Can profoundly impair function and work.Can profoundly impair function and work.


Stimulant agents an appropriate and Stimulant agents an appropriate and effective intervention.effective intervention.– Rapid working (24-72 hours)Rapid working (24-72 hours)– Limited side effects or drug interactionsLimited side effects or drug interactions– Also assist in managing depressive symptoms.Also assist in managing depressive symptoms.– Can be inexpensive (generic Ritalin)Can be inexpensive (generic Ritalin)

Ritalin, Atteral, Cylert, and Provigil are Ritalin, Atteral, Cylert, and Provigil are common agents.common agents.


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

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

Memory and Processing Memory and Processing DeficitsDeficits

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

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

Depression may present as memory Depression may present as memory difficulties.difficulties.


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

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


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

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

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

DepressionDepression

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

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


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

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


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

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

Agitation/IrritabilityAgitation/Irritability

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

Typically resolves by 2 weeks post-Typically resolves by 2 weeks post-concussion (when cognitive skills return to concussion (when cognitive skills return to baseline)baseline)

May be a sign of depression.May be a sign of depression.


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

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


Medications may have a role for Medications may have a role for persistent agitation:persistent agitation:– Anxiety - Buspar 5-10 mg tidAnxiety - Buspar 5-10 mg tid

- Paxil 10-40 mg qday- Paxil 10-40 mg qday– Irritability - VPA 250-500 mg tidIrritability - VPA 250-500 mg tid

- CBZ 100-200 mg tid- CBZ 100-200 mg tid

Treatment usually requires 3-6 months Treatment usually requires 3-6 months duration.duration.

TBI: PsychiatricTBI: Psychiatric

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

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

TBI: PsychiatricTBI: Psychiatric

Unusual to see resolution of symptoms Unusual to see resolution of symptoms without treatment.without treatment.

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

virginia commonwealth university medical college of virginia hospital department of physical...

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