Each year an estimated 1.7 million traumatic brain injuries occur in the United States. Nearly 80% of these are treated and released from an emergency department (ED), and 75% of traumatic brain injuries are diagnosed as concussion. These concussions are often a result of falls, motor vehicle accidents, and sports injuries. While many patients completely recover, others have lingering symptoms that may impact their life for weeks, months, or even years. Those patients suffer from post-concussive syndrome (PCS).

Case study: A patient with PCS

Charles is a 44-year-old man who slipped on an ice-covered sidewalk and fell backwards, hitting his head on concrete. He lost consciousness for a few seconds. Within minutes he had a severe headache, started repeating himself, and became very forgetful. His wife drove him to the ED.

After several hours of observation in the ED and a normal computed tomography (CT) scan, Charles was diagnosed with a concussion and released to go home. He and his wife were not given any instructions on what might be expected following a concussion, except that the physician thought he would be able to return to work 2 days later.

Charles had a constant headache, nausea, dizziness, ringing in his ears and slept most of the day. He discomfort persisted for almost a week, so he was unable to return to work as expected. His wife noticed he wasn’t thinking clearly, so she took him to a larger hospital where a repeat CT was conducted. The repeat CT showed no abnormalities and no changes from the first CT. The physician diagnosed Charles with post-concussive syndrome and talked with him and his wife about the symptoms and what could be expected. He also referred Charles to a neuropsychologist for evaluation and testing. Testing showed deficits in his short-term memory and concentration.

During the next several weeks, Charles realized he had a hard time being around groups of people and was more irritable. He also continued to have problems with dizziness, tiredness, balance, and memory. He wasn’t able to return to work for 6 weeks. For the next several months Charles had frequent headaches, noise bothered him, and he felt easily distracted and had a difficult time concentrating. A year later his wife noticed Charles had significant mood changes so he returned to the neuropsychologist who referred him to a psychologist. Charles was diagnosed with depression and was prescribed citalopram. Two and a half years after his fall, Charles says he feels he continues to have a lack of patience and intolerance of people. He feels he isn’t depressed but just doesn’t deal with stress well.

Defining PCS

A concussion is a mild traumatic brain injury caused by a bump, blow, or jolt to the head that may change how the brain functions. Concussions also can occur from a blow to the body that causes the head and brain to move quickly back and forth. Loss of consciousness isn’t required for a diagnosis of concussion. Signs and symptoms of concussion usually fall into four categories: cognitive, physical, emotional, and sleep. Difficulty thinking clearly, headache, nausea, balance problems, irritability, sadness, and sleeping more or less than usual are some of the symptoms that may be present with concussion. Some of these symptoms may appear right away and go away within a few days. However, for some patients, these symptoms may last longer.

PCS refers to persistent, concussive-like symptoms that develop after a traumatic brain injury. About 30% to 80% of patients with mild to moderate brain injury experience some symptoms of PCS. Symptoms typically start within a few days after the head injury and may persist for several months; 15% of patients will have symptoms 1 year later, and possibly beyond. Typically, patients don’t have neurologic deficits on examination, but report headache, fatigue, dizziness, impaired memory, difficulty concentrating, insomnia, and irritability, as well as lowered tolerance of stress or alcohol. At least three of those symptoms are needed to meet International Classification of Diseases ICD-10 criteria for PCS. Several other associated symptoms are known to exist in patients with PCS (See Symptoms of PCS.)

Pathophysiology

On autopsy, it’s been found that patients with PCS have damage in the white matter of the brain. White matter is located in the inner part of the brain and consists of the axons of neurons that make the connections within the brain. These neural cells require precise balance and distance to process and transmit messages between cells. With concussion, there is damage to these neurons along with tiny hemorrhages and swelling in the brain. This damage may cause problems in how the brain processes information, which possibly leads to the clinical signs and symptoms of PCS. The degree of severity of PCS after minor head injury has been shown to be significantly correlated with the degree of damage to white matter. Unfortunately, common tests in the clinical setting typically do not identify this physical damage.

Diagnosis

In patients with symptoms of concussion and PCS, brain imaging scans, such as CT scan and magnetic resonance imaging (MRI), often are normal. These brain imaging technologies can detect more serious problems like major bleeding, but often cannot detect the microscopic brain damage in concussions. Newer, more sophisticated imaging technologies are more effective in capturing the damage that occurs in concussion. In some patients with cognitive symptoms of PCS, a significant reduction in brain activity has been evident in functional MRI exams. Unfortunately, this equipment often isn’t readily available and is quite expensive.

A patient with PCS usually has a normal neurological exam, but reports more subjective symptoms. Neuropsychological testing may reveal difficulties in concentration, memory, language, and executive tasks. The British Columbia Post Concussion Symptoms Inventory, the Post Concussion Syndrome Checklist, the Post Concussion Syndrome Symptoms Scale, and the Rivermead Post Concussion Symptoms Questionnaire are known to be reliable tools that consistently identify the symptoms of PCS.

Both Automated Neuropsychological Assessment Metrics (ANAM) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test cognitive function before injury and compares it with function after injury.

ANAM is used in the military setting and is a proven computer-based cognitive assessment tool designed to detect the speed and accuracy of attention, memory, and thinking ability. It records every service member’s performance through responses provided on a computer. ANAM testing is conducted before deployment and can be used to identify and monitor changes in function before and after an injury. It does not diagnose any medical condition.

ImPACT is the first, most-widely used, and most scientifically validated computerized concussion evaluation system. It provides neurocognitive assessment tools and services that are used by medical doctors, psychologists, athletic trainers, and other licensed healthcare professionals to assist them in determining an athlete’s ability to return to play after suffering a concussion. It involves assessment of the athlete before the athletic playing season begins (pre-injury) as well as after injury.

Risk factors and predictors

Concussions resulting from car collisions, falls, assaults, and sports injuries are commonly associated with PCS. The severity of the type of injury does not predict whether a person will develop PCS, but there are other factors that may influence the likelihood:

• Female gender
• Older age
• Low socioeconomic status
• History of headaches or prior traumatic brain injury
• History of psychiatric illness such as depression or anxiety

Patients who had strong concerns about their injury, had a more difficult time coping with their injury, and those who reported earlier complaints of symptoms are also known to be at greater risk for a slow recovery and development of PCS.

Screening patients in the ED for immediate memory problems, delayed memory, and severity of injury-related headache may help identify patients at risk for PCS.

Management

Treatment in the ED may include prescriptions for pain medications and anti-nausea medications. However, no medication prescribed at discharge from the ED has been proven to change the course of PCS. At follow-up visits, providers typically develop an individualized treatment plan to alleviate the patient’s ongoing symptoms. Treatment plans often include prescriptions for antidepressants. For example, amitriptyline may be prescribed for post-trauma headaches as well as for symptoms such as irritability, dizziness, insomnia, and depression.

Nonpharmacologic therapy may include early psychological intervention and cognitive rehabilitation as well as physical and occupational therapy. Tips to aid recovery following a concussion include:

• Get plenty of sleep at night
• Rest during the day
• Avoid physically demanding activities or activities that require a lot of concentration
• Do not drink alcohol or use other non-prescribed drugs.

Adequate rest is vitally important because it helps the brain to heal. Slowly and gradually returning to work or school is advised. If symptoms return or a patient develops new symptoms as activity increases, it is a sign that the patient needs to cut back on his or her activity level.

Suggestions for nurses

Patients diagnosed with concussion have varying degrees and types of PCS symptoms. Though a concussion and PCS may slow a person down, it’s usually not life-threatening. However, this injury can have serious and long-term impact on a person’s physical, cognitive, and psychological function. That’s why early diagnosis, referral, and patient and family education are critical to achieve the best possible recovery.

It’s important to tell family members of those with a concussion about the symptoms of PCS before the patient is discharged from the ED. Written as well as thorough verbal instructions should be provided to the patient as well as family members. Patients should be encouraged to self-monitor for new symptoms, pace themselves, and seek medical attention if there are concerns.

The Centers for Disease Control and Prevention (CDC) have developed an educational program called Heads Up that provides concussion and mild traumatic brain injury information to aid in the diagnosis and management of patients with concussion. This program includes tool kits, fact sheets, and pocket cards that make it easy for clinicians, patients, and family members to learn about concussions and their effects. These materials are also appropriate for coaches, athletic trainers, school nurses, teachers, counselors, and student athletes. The educational materials for patients include a discharge instruction sheet and wallet card to learn about PCS symptoms and when to return to the ED.

The newest addition to the program is an online course for clinicians that was developed with support from the National Football League. The program, Addressing Concussion in Sports Among Kids and Teens, offers free continuing education credits and provides valuable information that is critical for helping young athletes achieve the best recovery possible. All materials are available online at https://www.cdc.gov/headsup/index.html.

Multifaceted approach

Preventing and managing PCS requires a multifaceted approach. Better diagnostic testing in the clinical setting is warranted, and more technologically advanced brain imaging equipment needs to be readily available and affordable.

Education of medical personnel should include instruction on how to effectively communicate the potential for persistent symptoms of concussion. Patients need to know that recovery from concussion is not always quick and that lingering symptoms may be present for an unknown amount of time.

Use of the post-concussive assessment tools and/or neuropsychological testing should be completed at follow-up appointments for all patients with concussion, whether or not they lose consciousness at the point of injury. Medication management, referral to specialists, and ongoing follow-up should be considered until patients are symptom free or at a level of effective management of the PCS symptoms.

Through these efforts, outcomes for patients with PCS can be improved.

Amy Lavin is a family health nurse practitioner at the Ministry Medical Group Clinic in Woodruff, Wisconsin.

Selected references

Automated Neuropsychological Assessment Metrics (ANAM). U.S. Army Medical Department Web site. http://armymedicine.mil/Documents/R2D-ANAM_Info_Brochure.pdf. Accessed March 1, 2013.

Bay E, Strong CA. Cognitive-representational approach to patient education after mild traumatic brain injury. Adv Emerg Nurs J. 2010;32(3): 247-257.

Centers for Disease Control (CDC). How many people have TBI? http://www.cdc.gov/TraumaticBrainInjury/statistics.html Accessed on March 1, 2013.

Centers for Disease Control (CDC). What are the signs and symptoms of concussion?
http://www.cdc.gov/concussion/signs_symptoms.html Accessed on March 1, 2013.

Centers for Disease Control (CDC). What can I do to feel better after a concussion? http://www.cdc.gov/concussion/feel_better.html. Accessed on March 1, 2013.

ImPACT-Testing and Neurocognitive Assessment Tools. ImPACT Web site. http://www.impacttest.com. Accessed March 1, 2013.

Jotwani V, Harmon KG. Postconcussion syndrome in athletes. Curr Sports Med Rep. 2010;9(1):21-6.

Ryan PB, Lee-Wilk T, Kok BC, Wilk JE. Interdisciplinary rehabilitation of mild TBI and PTSD: a case report. Brain Inj. 2011;25(10):1019-25.

Sheedy J, Harvey E, Faux S, Geffen G, Shores EA. Emergency department assessment of mild traumatic brain injury and the prediction of postconcussive symptoms: a 3-month prospective study. J Head Trauma Rehabil. 2009;24(5):333-43.

Smits M, Houston GC, Dippel DWJ, Wielopolski PA, Vernooij MW, et al. Microstructural brain injury in post-concussion syndrome after minor head injury. Neuroradiology. 2011;53(8):553-63.

Snell DL, Siegert RJ, Hay-Smith EJC, Surgenor LJ. Associations between illness perceptions, coping styles and outcome after mild traumatic brain injury: preliminary results from a cohort study. Brain Inj. 2011;25(11):1126-38.

Sullivan K, Garden NA. Comparison of the psychometric properties of 4 postconcussion syndrome measures in a nonclinical sample. J Head Trauma Rehabil. 2011;26(2):170-6.

Wu-Chen WY, Brady MF. Postconcussive syndrome. In: Ferri’s Clinical Advisor,
2012. Philadelphia, PA: Mosby; 2011:815.