As physical therapists, occupational therapists and speech pathologists, we often encounter clients who have symptoms of post-concussive syndrome. But what is the best course of action, and how do we manage this common- yet incredibly disruptive- condition?
What is post-concussive syndrome?
Persistent post-concussive symptoms (PPCS) is also called post-concussive syndrome, and is an area that physical, occupational and speech therapists have a valuable role to play. It technically refers to the lingering symptoms that can be experiences after a concussion/mTBI- usually including three or more signs and symptoms. PPCS is the most common neuropsychiatric consequence after sustaining a TBI– although the magnitude of the condition may differ. PPCS may also be misdiagnosed- such as in those who dismiss their persistent headaches as situational tension headaches/migraines, when they may be linked to injuries related to the concussion such as vision impairment, neck/cervical issues or sensory integration difficulties.
Symptoms may linger for 7-10 days, weeks, months or even years after injury to be qualified as PPCS. Impairments can include headache, dizziness, cognitive and/or vision difficulties, pain, and sleep disturbances. This constellation of symptoms can also occur after moderate and severe TBI, and so post-TBI syndrome may be a more accurate description.
In the first few weeks after mild TBI, the prevalence pf PPCS has reported to vary from 40-80%. 10-15% of those affected continue to report symptoms for more than a year.
Clinicians such as physical, occupational and speech therapists who work with older patients at risk of falls, as well as in settings where trauma may be common, should be well versed in how to treat post-concussive syndrome.
Risk factors: post concussive syndrome
Interestingly, the severity of the injury does not appear to be associated with the risk of developing PPCS- although there are several factors that can increase the risk of developing PPCS after a head injury.
A history of depression and anxiety or PTSD; poor or absent social supports; lack of coping skills; loss of consciousness during the event; non-sporting mechanisms of injury; female gender; more advanced age and a history of previous concussion/TBI are all factors that may pre-dispose a client to PPCS.
Symptoms of Post-Concussive Syndrome
Post concussive syndrome is a collection of various symptoms, all of which may can benefit greatly from evaluation and treatment by a physical, occupation and speech therapist. Symptoms can include:
Post Traumatic Headache
Headache is an exceedingly common symptom experienced post mTBI, and can range from migraine type headache with photo and auditory sensitivity, to a tension-type headache that may be related to neck range of motion or cervical impairment. Vision issues may contribute to post traumatic headache and can easily be confused for other issues such as migraine or dizziness.
There has been an inverse relation reported between the severity of head injury and the occurrence of chronic daily headache- this study demonstrated that of those with mTBI, 80% reported chronic daily headache whereas for moderate and severe head injury, only 17% experienced chronic headache. For clinicians, this means that we will be more likely to expect headache in those after concussion, and having means of evaluation and treating headache will serve our patients well! Addressing headache is not always an area that physical, occupational or speech therapy feel comfortable in addressing- but we can make a powerful difference, through a variety of therapeutic interventions.
Dizziness and Nausea
Dizziness is the second most common symptom reports by those who have sustained a concussion. Vertigo is often reported immediately post injury, and can persist for months and become a chronic issue for some clients. Parsing the cause of the dizziness can be tricky, as it can be experienced differently- like lightheadedness, room-spinning, sensitivity to movement, syncope, double vision, and so on.
BBPV is a common culprit of post concussive dizziness, although there are also other causes such as vestibular migraine, central nervous system dysfunction, and cervical/neck impairment. Vision issues can also cause dizziness and nausea, post mTBI. Dizziness may be triggered by movements, exercise, visual stimulation such as computer or screen work, motion sickness, or difficult tasks such as schoolwork (in younger participants).
Dizziness, like the other symptoms experienced as part of post concussive syndrome, can be incredibly disruptive and debilitating. Thorough evaluation and assessment and intervention is essential to managing this symptom.
Many cognitive domains have reported to be affected by post concussive syndrome, including executive function; memory; attention and processing speed. Even a single mTBI can result in pathophysiological changes in the brain. These impairments, as before, can also be linked to the headache, vision issues, and dizziness symptoms- which can impair concentration, attention, memory and executive function.
Research indicates that although there is a prevailing view that most symptoms of mTBI are resolved within three months, that approximately half of individuals with a single mTBI demonstrate long term cognitive impairment, which highlights once more the vital role of rehabilitation in this population.
Eye problems are a very common result of concussion- and one that has been reported to affect 69-82% of patients’ post-concussion. Vision impairment post-concussion can include abnormalities of eye movement, such as accommodation, convergence, saccades and smooth pursuits. The person may also experience blurred or double vision, ocular pain, difficulty focusing on close work. Naturally, these issues are very unsettling to the person experiencing them, and have a huge impact on their occupations and daily life.
Your patient may experience these issues as dizziness, headaches, difficulty reading, and other functional difficulties. Vision impairment in post-concussive syndrome is closed linked to body position, the balance system, and attention/focus- there is a significant role for physical, occupational and speech therapists to work together in the treatment of this issue.
Convergence insufficiency and accommodative insufficiency are among the most prevalent diagnoses and respond very well to vision therapy and vergence exercises.
Sleep wake disturbances, fatigue and insomnia are all commonly reported after mild concussions, with rates up to 50% at 6 weeks post injury. Insomnia and decreased sleep efficacy are more common in those post-concussion than more severe brain injury. Sleep problems can disrupt all areas of life and exacerbate some of the other symptoms that may present. Physical, occupational and speech therapists can educate those with post-concussive syndrome about sleep hygiene, healthful habits, energy conservation and stress management- all of which can help to contribute to better sleep and less fatigue.
What are the roles of rehab clinicians in post concussive syndrome?
The symptoms of post concussive syndrome are varied and multi dimensional, and need a collaborative effort from all rehab clinicians for best results! We have seen above how each symptom can inform the others, and for best results, physical , occupational and speech therapy work hand-in-hand to treat post concussive syndrome.
Role of Physical Therapy
Physical therapy have key roles in the treatment of post-concussive syndrome:
- Balance impairment
- Cervical issues
- Pain issues- headache, neck pain, etc.
- Visual reflex integration/Gaze stabilization/oculomotor assessment and intervention
Skilled evaluation of the cause of vestibular impairment is essential for appropriate and effective treatment. Physical therapists may find themselves presented with a patient reporting dizziness, and need to differentiate the type of dizziness, cause, and from there the most effective intervention. To learn more about rehabilitation of dizziness and other post-concussive symptoms, click here!
However, the role of the physical therapists is not limited to balance and dizziness rehabilitation post concussion- they may also examine cervical issues and ROM to see whether this may be impacting other areas of function.
Oculomotor assessment and eye movement interventions, specifically with regard to integration into movement, are also essential for a physical therapist to know- but not always routinely included in treatment! If you want to see how to do an oculomotor assessment (with included HEPs!) in ten minutes or less, check out our link below!
Role of Occupational Therapy
The role of the occupational therapist in treating post-concussive syndrome may include:
- Vision therapy
- Sleep hygiene
- Headache management
- Energy Conservation
- Return to work/school/play
- Relaxation and stress relief
Occupational therapists are in a key position to integrate the skills that a client is rehabilitating into function. Vision therapy and working on visual/perceptual skills are essential to optimal functioning, and an OT can perform a thorough vision assessment to ensure visual issues are not underlying or affecting other areas.
Sleep hygiene, efficacy, energy conservation and fatigue management are areas the OT may set goals in. As before, an OT can be instrumental in evaluating and optimizing a person’s sleep habits to ensure more effective and functional engagement in their everyday activities.
Evaluation of headache, and establishing treatments and interventions to manage triggers, such as a migraine journal, sensory diet, modalities and lifestyle changes can also fall within the OT wheelhouse. This may be the single biggest positive change for many people post-concussion, owing to the debilitating nature of chronic headache.
Role of Speech and Language Pathology
Speech therapy can be instrumental in setting a client with post concussive syndrome up for success. Through careful assessment and treatment of cognitive impairment, community re-integration and stress management techniques.
- Cognitive evaluation and intervention
- Attention and focus
- Executive function
- Memory rehabilitation
- Community re-integration
- Stress management
- Communication skills: Reading, writing and computer use
Speech and language pathologists have a vital function in the rehabilitation and treatment of those with post-concussive syndrome, particularly in cognitive rehab. Cognitive impairment, as established, is prevalent even after one concussion- but may go unnoticed if its is more subtle and masked with other issues such as vision and headache. Given the fact that about half of those who sustain an mTBI go on to have a chronic cognitve issue, skilled assessment becomes even more urgent. Speech therapy may help with practical interventions and exercises to work on cognition, and referring on to neuropsychology as indicated.
Speech therapy are also uniquely positioned to assist with communication skills and difficulties, including vision impairment that may affect reading/writing and communication.
Want to learn more about how, as a Speech Therapist, you can be more effective in post-concussive treatments? Check out Practical Approaches to Concussion Management!