Rehabilitation of Concussion and Post-concussion Syndrome
Leddy JL, Sandhu VS, Baker JG., Willer B. Sports Health. 2012:4;147-154.
The majority of athletes recover from a concussion within 10 days, however, at least 10% of athletes continue to have signs and symptoms (s/s) beyond 14 days. Post-concussion syndrome (PCS) occurs when patients display persistent s/s beyond normal recovery period (> 14 days). This systematic review found 564 studies that fulfilled their search criteria and utilized 119 articles that focused on pathophysiology, diagnosis, and treatment/rehabilitation of concussions and PCS. Acceleration-deceleration forces are the most common mechanisms that strain the neuron by causing the brain to move within the skull. The stretch of the neuron results in a neurometabolic cascade that causes an array of problems (e.g., hyperglycolosis, mitochondrial dysfunction, decreased blood flow) within neuronal tissue, which can last for 7-10 days. Researchers have described this period of time as a window of vulnerability that a second insult prior to healing could lead to a more severe injury. Magnetic resonance spectroscopy (MRS) can determine the concentration of brain metabolites such as lactate, which can characterize the state of the central nervous system. MRS imaging studies have shown that even after s/s subsided there is still an ionic imbalance (e.g., levels of calcium, sodium, and potassium are not within homeostatic levels in the neuronal cells) leaving the brain vulnerable for a secondary injury. Depression and migraine differential diagnosis is also important to evaluate because of the overlapping s/s. This review also notes that researchers found other physiological changes that can occur following a concussion are increased heart rate, autonomic dysfunction, and cerebral infarction, which can be exacerbated with exercise.
The differential diagnosis of PCS include depression, somatization, chronic fatigue, visual dysfunction, or a combination of these illnesses. The challenge is to determine whether the prolonged s/s implicate a concussion pathology or one of these secondary processes (e.g., migraine, depression). Initial concussion assessment should include concentration exam (e.g., counting down from 100 in 3’s), memory recall, cranial nerve exam, and vestibular-ocular exam including balance testing. An exertion test can help determine a concussion from psychological illness. If s/s occur during exertion but are alleviated with rest it is likely a concussion, however, if s/s are not relieved with rest it could indicate a psychological disorder. Another more broad definition used to define PCS is having 3 or more of the following s/s: headache, dizziness, fatigue, irritability, insomnia, difficulty concentrating, or memory difficulty. After diagnosis the clinician should provide treatment and rehabilitation for the concussion or PCS. There still is no therapeutic agent to accelerate recovery. Treatment includes primarily rest, however some therapeutic agents can be utilized. The most commonly prescribed medications for PCS are antidepressants. These therapeutic agents block serotonin from being taken up and can improve depression symptoms and cognition. In addition, glutamate blockers such as NMDA antagonists are used to help alleviate concussion s/s by preventing or limiting the ionic imbalance. Rest is necessary, however, prolonged rest especially for athletes can lead to physical deconditioning, metabolic disturbances, fatigue, and depression so implementing a gradual return to play after the concussive s/s have dissipated should be executed. Rehabilitation includes a gradual return to play. That is, starting when the athlete has been s/s free they can begin a treadmill test. If s/s develop during or following the treadmill test patients must return to the previous phase, and if no s/s are experienced patients progress through each of the phases of the return to play criteria. In children it has also been suggested that an information booklet on strategies for dealing with concussion s/s resulted in less behavioral changes and s/s. Other rehabilitation techniques include a neurocognitive portion that uses cognitive tasks to improve aspects of cognition such as attention, memory, and executive functioning. What have you done for athletes with prolonged s/s of concussions? Have any of your athletes developed an illness due to a prolonged concussion?
Written by: Jane McDevitt MS, ATC, CSCS
Reviewed by: Stephen Thomas
Related Posts:Leddy, J., Sandhu, H., Sodhi, V., Baker, J., & Willer, B. (2012). Rehabilitation of Concussion and Post-concussion Syndrome Sports Health: A Multidisciplinary Approach, 4 (2), 147-154 DOI: 10.1177/1941738111433673