Rehabilitation of Concussion and Post-concussion Syndrome

John J Leddy, Harkeet Sandhu, Vikram Sodhi, John G Baker, Barry Willer, John J Leddy, Harkeet Sandhu, Vikram Sodhi, John G Baker, Barry Willer

Abstract

Context: Prolonged symptoms after concussion are called post-concussion syndrome (PCS), which is a controversial disorder with a wide differential diagnosis.

Evidence acquisition: MEDLINE and PubMed searches were conducted for the years 1966 to 2011 using the search terms brain concussion/complications OR brain concussion/diagnosis OR brain concussion/therapy AND sports OR athletic injuries. Secondary search terms included post-concussion syndrome, trauma, symptoms, metabolic, sports medicine, cognitive behavioral therapy, treatment and rehabilitation. Additional articles were identified from the bibliographies of recent reviews.

Results: Of 564 studies that fulfilled preliminary search criteria, 119 focused on the diagnosis, pathophysiology, and treatment/rehabilitation of concussion and PCS and formed the basis of this review. Rest is the primary treatment for the acute symptoms of concussion. Ongoing symptoms are either a prolonged version of the concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual dysfunction, or some combination of conditions. The pathophysiology of ongoing symptoms from the original concussion injury may reflect multiple causes: anatomic, neurometabolic, and physiologic.

Conclusions: Treatment approaches depend on the clinician's ability to differentiate among the various conditions associated with PCS. Early education, cognitive behavioral therapy, and aerobic exercise therapy have shown efficacy in certain patients but have limitations of study design. An algorithm is presented to aid clinicians in the evaluation and treatment of concussion and PCS and in the return-to-activity decision.

Keywords: cognitive behavioral therapy; concussion; physiology; post-concussion syndrome; rehabilitation.

Figures

Figure 1.
Figure 1.
Neurometabolic cascade following concussion. K+, potassium; CMRglucose, cerebral metabolic rate of glucose utilization; Ca2+, calcium; CBF, cerebral blood flow. With permission (adapted from Hovda et al).
Figure 2.
Figure 2.
Return-to-activity algorithm for concussion and postconcussion syndrome. *Time for symptom resolution will vary depending on clinical circumstances. Most athletes recover within 1 to 3 weeks. **Treadmill testing in patients with persistent symptoms should not be performed before 3 weeks after injury. Neuropsychological testing is not indicated, because the patient is still symptomatic. ¶If neuropsychological testing has been used, assume that there is a baseline preinjury test or valid normative data for the particular patient. †Exercise to exhaustion without exacerbation of symptoms. ‡Exercise stopped at a submaximal effort level because of symptom exacerbation. §Repeat testing interval will vary depending on clinical circumstances; it may be several days to several weeks. If athlete is not recovering, consider aerobic exercise rehabilitation. If computerized neuropsychological testing has been used and remains abnormal, continue exercise treatment and consider consultation with a neuropsychologist to evaluate for a specific cognitive deficit. RTA, return to activity; PCS: postconcussion syndrome; NP, neuropsychological.

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