Postconcussive Syndrome Treatment & Management

Indications for hospitalization include (1) severe or fluctuating neurologic symptoms that could indicate epidural or subdural hematoma, (2) if a patient does not have someone to help and observe them should they deteriorate in the first day after trauma, and (3) for suicidal/homicidal ideation. Some studies suggested a lower incidence of postconcussive syndrome in those who were hospitalized, possibly because of greater rest after the injury or because of more intensive explanation of symptoms leading to less anxiety and stress. Current recommendations are to avoid cognitive active until the individual has healed, just as one would avoid strenuous exercise after physical injury.

Patients benefit from psychological support and, when indicated, behavioral modification, cognitive rehabilitation, psychotropic medication for specific syndromes or symptoms, family or network intervention, social services, and medical support in legal proceedings.

Therapy involves helping patients and their families be realistic about their losses and impairments, while encouraging hope and continued effort in rehabilitation. Helping patients and caregivers to interpret subtle and disruptive changes in personality in light of organic damage is particularly important to relieve guilt and blame.

• Psychological support

  • Damage to the brain impairs a person's ability to cope at a time when the need to adapt is greatest. Demoralization, depression, anger, anxiety, and irritability are likely.
  • The meaning of any injury varies in part based on the patient's prior concerns and personality. For example, narcissistic patients feel narcissistically wounded by even minor losses of function. Prior emotional lability or capacity for aggression in a patient who is borderline may worsen following a head injury.
  • Injury when a person is in transition or moving towards an important goal, such as marriage, school completion, or job performance, has a different meaning than injury occurring when someone feels stable, stagnant, or deteriorating. Injuries that occur on a job a person already dislikes or injuries that result from negligence may evoke resentment and feelings of entitlement that are absent in similar injuries in other circumstances.
  • Understanding the person's preinjury personality, stresses, and the circumstances of the injury help establish realistic goals and minimize stress during rehabilitation and reentry into life. Interpreting the person's reactions to injury in light of his or her previous state builds trust, reflecting the degree to which the patient feels understood and accepted.
  • Avoid interpreting changes in personality or behavior in light of developmental issues or conflicts without considering the impact of the injury itself. Such interpretations may produce confusion, guilt, unnecessary resentment, and fatalism. A present-oriented, problem-focussed therapy generally is best for patients after head injury, even those whose impairment appears to be driven by exaggerated emotional responses to the experience.
  • Different stages of recovery require different types of psychological support. In the first months after injury, validating symptoms, helping patients relinquish responsibilities, mourning losses of function or hopes, and counseling patience with the pace of improvement are critical. Later, patients may need encouragement to push themselves to regain self-confidence and reassume their previous roles and responsibilities.
• Behavior modification

  • Behavioral techniques may be used to discourage impulsivity, aggression, and socially inappropriate behavior. They may also encourage patients to be less apathetic or withdrawn.
  • Teaching sleep hygiene is important.
• Cognitive rehabilitation

  • The underlying principles are encouraging recovery in functions that are capable of improvement, compensation for areas of fixed deficit, and teaching substitute means of achieving particular ends. For example, gradually increasing time spent reading helps a patient both regain concentration and develop confidence in his or her ability to concentrate. Keeping lists allows a patient to compensate for decreased memory. Someone who has become dysarthric or aphasic may learn sign language as a substitute means of communication.
  • In general, cognitive rehabilitation is based on neuropsychological testing that clarifies deficits and suggests areas of preserved functioning in patients with dementia. Patients with postconcussive syndrome also have cognitive complaints, usually decreased attention and concentration. These symptoms may reflect slowly or partially reversible damage to white matter from DAI. Decreased attention and concentration seriously worsen anxiety and otherwise compromise patients' efforts to recover. When impaired concentration and attention are prominent in a patient with PCS, cognitive rehabilitation may be quite helpful.
• Family or network intervention

  • The changes in personality, especially apathy, irritability, and aggression, in patients with head injury are especially burdensome to caregivers, family, or professional care providers. Head injuries cause more family distress than bodily injuries of equivalent severity. Counseling for caregivers is essential. When the patient is demented, interpreting impairments as organic and insisting on the legitimacy of the sick role are needed to relieve blame and guilt.
  • Even when the caregiver understands the person's behavior is not within his or her control, the patient's slowness, inappropriateness, and erratic responsiveness can be exasperating or even frightening. Family members become isolated from usual support, especially when the person's impairments are severe, protracted, or fixed. Direct communication between the caregiver and the physician allows caregivers to vent their feelings and voice their concerns. Problem-solving interventions and referral to support groups for family members improve morale and enhance patient outcome. Regular staff or team meetings sustain morale in professional caregivers.
• Social services

  • Case management for patients with dementia sometimes is necessary to help patients apply for disability, locate specialized rehabilitation programs, attend to medical problems, and participate consistently in treatment.
  • When people have prominent severe problems of information procession or frontal lobe deficits manifested by impulsivity and poor judgment, they may be incompetent to make medical decisions or handle their own affairs. These 2 functions may differ. Guardianship, conservatorship, or some other protective legal arrangement may be needed. Physician evaluation typically is required, unless the person is competent enough to sign a power of attorney or designate a substitute payee.
• Medical support in legal proceedings

  • Head injuries often occur in the context of car or workplace accidents, leading to legal proceedings for damages and compensation. The prognosis of mild or moderate dementia and postconcussive syndrome remain difficult to provide with certainty. Some patients recover fully from severe injuries with prolonged coma, others remain disabled for long periods after much milder insults. Moreover, involvement in legal proceedings seems to complicate recovery. Having to repeat the story of an injury to questioners, not knowing what expenses will be incurred and which will be covered by insurance, and proving the reality of subtle impairment without visible scars increase patients' stress and anxiety. Stress seems to slow or impede recovery by both psychological and physiological mechanisms. Malingering also may occur.

• Consultations with neuropsychologists and physical and occupational therapists are helpful in designing or altering the long-term treatment plan of a patient with head injury.
• Neurologic consultation is essential to diagnose and treat seizures, subdural or epidural hematomas, or hydrocephalus. Neurologists also may help with the management of headaches, dizziness, or fatigue.
• Consult primary care physicians to ensure that concurrent medical conditions are not neglected.

• Patients with impairment in their ability to prepare food or feed themselves must have their diets monitored to be sure that they do not become malnourished or vitamin deficient.
• Otherwise, no special dietary prescriptions or restrictions apply.

• In the early phases of rehabilitation, simple, graduated physical exercises and games may improve endurance and self-confidence. Head injuries may lead to ataxia, parkinsonism, hemiparesis, or paraparesis, requiring mobility aids and monitoring. In elderly patients, altering the environment to prevent falls is important to prevent repeat injuries.
• Recommending that patients resume normal activities or responsibilities is not always simple. Patients who work night-shift jobs, work with heavy machinery, work off the ground, or who are in overstimulating environments may not be able to return to their previous positions. Returning to work when cognitive impairments are in flux may lead to failure and regression in recovery. However, patients also may be unduly reluctant to return to previous activities for fear of further injury, embarrassment about their disabilities, and underestimation of their competence. Encouraging gradual return to work or requesting temporary accommodations that allow patients to relearn or reacclimate to their jobs often is helpful, although not always possible.
• Finally, patients who play contact sports should not be allowed to return to play until their concussive symptoms have resolved completely. Failure to observe this restriction exposes these patients to the risk of sudden death from SIS.