Virginia Commonwealth University Medical College of Virginia Hospital

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Virginia Commonwealth University Medical
College of Virginia Hospital

• Department of Physical Medicine and
  Rehabilitation

http//www.pmr.vcu.edu/
http//www.worksupport.com/
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Post-Concussive Syndrome Prevention and
Management

• David X. Cifu, M.D.
• The Herman J. Flax, M.D. Professor and Chairman
• Department of Physical Medicine and
  Rehabilitation
• Virginia Commonwealth University

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Overview

• TBI incidence
• 1-5 million injuries/year
• 500,000 hospital admissions/year
• 50,000 rehabilitation admissions/year
• TBI demographics
• 16-34 years old is most common age range
• gt60 years is second most common age range
• lt5 years is a close third

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Overview

• Mild TBI is most common injury (by a factor of
  20x). Vast majority return to pre-injury level of
  function and work.
• Rapid identification of mild TBI and possible
  sequelae (Post-concussive syndrome) is vital to
  effective management.

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TBI Classification

• Mild TBI Concussion
• Glasgow Coma Score of 13-15
• Brief loss or alteration of consciousness (see
  stars, dazed) for up to 30 minutes
• Non-focal neurological exam by 30 minutes

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TBI Classification

• No indication for imaging study if normal exam by
  30 minutes. Need to be monitored for 24 hours.
• If persistent symptoms (e.g., confusion) or focal
  exam by 30 minutes, then CT Scan.
• Nml CT and MRI scans in gt99 of mild TBI. No
  clinical role for PET or SPECT scans.

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Post-Concussive Syndrome Definition

• Persistent non-focal neurologic symptoms gt 24
  hours post-TBI PCS
• Dizziness
• Headache (/- N/V)
• Cognitive deficits (attention, memory, judgement)
• Behavioral changes (irritability, depression,
  nightmares)
• Sleep disturbance

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Post-Concussive Syndrome Management

• Symptoms rapidly resolve (2-4 weeks) in gt85
  individuals.
• 5-10 may have persistent difficulties by 12
  months.
• Significant medicolegal overlay common.

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Post-Concussive Syndrome Management

• Early assessment of injury (i.e., recognizing a
  concussion occurred), referral for comprehensive
  treatment, and reintegration into pre-injury life
  is essential to full recovery.
• Limiting treatment to professionals with good
  understanding of process and motivation to return
  patient back to maximal function is important.

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Post-Concussive Syndrome Management

• Extensive research in NCAA athletes demonstrates
  initial changes in cognitive testing after
  concussion with return to baseline by 2 weeks.
• Research in E.R.s demonstrates that early
  detection of concussion and in-depth discussion
  of potential difficulties minimizes short and
  long-term symptoms.

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Post-Concussive Syndrome Management

• Treatment includes physical activity, counseling,
  limited medication usage, and supportive care.
• Most patients can return to full-duty in 24-72
  hours. Close monitoring of performance and
  symptoms in first 7 days is crucial.
• Operating machinery/driving should only occur if
  symptom free.

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Measurement Tools

• Functional Capacity Evaluation (FCE)
• medical evaluative tool to assess the injured
  individuals physical capacity to return to a
  specific job or level of work
• Useful to
• identify when the patients rehabilitative
  progress plateaus
• clarify when a difference exists between the
  patients reported and observed function (e.g.,
  Waddells signs)
• determine when vocational planning calls for an
  accounting of the patients physical abilities
• identify permanent restrictions when case closure
  is indicated by judgement or statutes

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Disability Determination

• When return to work has not been achieved, case
  settlement or disability determination may be
  sought.
• When discrepancies exist between physical
  performance in and out of the workplace,
  questions arise of symptom validation, or
  differences arise between treating practitioners,
  an independent evaluation may be sought.

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Disability Determination

• Independent Medical Examination (IME) Any
  examination performed for evaluation purposes by
  a physician other than the treating physician.
  Typically, opinions on MMI, impairment rating,
  and disability determination are rendered.
• Maximum Medical Improvement (MMI) Date after
  which no further significant recovery from or
  lasting improvement of impairment or disability
  can be anticipated based on reasonable medical
  probability.

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Disability Determination

• Medical Possibility An event that is likely to
  occur with a probability lt 50.
• Medical Probability An event that is likely to
  occur with a probability gt 50.

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Disability Determination

• Causality The association between a given cause
  (specifically, an event capable of producing an
  effect) and effect (specifically, one that could
  be produced by the cause) within a reasonable
  degree of medical probability. Causality requires
  the determination that
• an event took place
• the claimant experiencing the event has the
  condition
• the event could cause the condition
• the event probably did cause the condition

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Disability Determination

• Apportionment The determination of percentage of
  total impairment directly attributed to
  pre-existing or underlying versus resulting
  conditions relating to a causal or aggravating
  event.
• Aggravation An event that results in permanent
  worsening of a pre-existing or underlying
  pathology or susceptible condition.
• Exacerbation A temporary increase in the
  symptoms.

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Headache Management

• Headache pain predominantly from muscle and
  soft-tissue injury to neck or skull.
• Early use of anti-inflammatory and analgesic
  medications is important. Antispasmodics have
  little efficacy, but can assist in sleep and
  relaxation.
• Rapid muscle mobilization is key. Structured PT
  or HEP needed. Local heat or ice.

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Headache Management

• Headache specific medication may be needed if
  symptoms not resolving by 1 week.
• Fiorinal/Fioricet (1 tab q 4-6 hours)
• Midrin (2 tabs at HA onset, repeat q1 hour x 3)
• True post-traumatic migraine HAs are rare
  (confirm pre-injury history). May respond to more
  traditional migraine treatments (refer to
  neurologist)

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Headache Management

• Persistent HAs that are not resolving by 3-4
  weeks may be the result of undertreatment, missed
  diagnosis (e.g., skull fracture), or
  psychological overlay.
• Psychologic intervention often helpful
• Relaxation training
• Frontalis Muscle biofeedback
• Counseling
• Pain Management strategies

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Dizziness Etiology

• Usually resolves in 7 days.
• Persistence of symptoms may be secondary to
  muscular injury to neck limiting full ROM.
  Responds to active mobilization program.
• True neurologic cause may be injury to
  labyrinthian mechanism of inner ear.

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Dizziness Etiology

• Contusion to semicircular canals may result in
  abnormal movement of otoliths, causing a delayed
  response to head movement. This results in
• a temporal difference in information supplied to
  the cerebellum by the visual, proprioceptive and
  labyrinthian systems.
• A feeling of dizziness
• HallPike-Dix Maneuver diagnostic of labyrinthain
  cause.

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Dizziness Management

• Vestibular rehabilitation is effective but labor
  intensive. Focuses on
• Optimizing three components of balance
• Neck ROM
• Visual Tracking
• Proprioceptive Input
• Identifies positions and motions that cause
  dizziness and progressively exposes patient to
  these situations.
• Rapid mobilization outside of therapy is also
  important (e.g., return to work).

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Dizziness Management

• Medications have limited efficacy, typically
  mildly sedate patient to decrease reaction to
  dizziness (e.g., Meclizine, Scopolamine)
• Novel use of buspirone (Buspar) has been
  demonstrated effective in 3 case reports (5-10 mg
  tid).

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Sleep Hygiene Disturbance

• Common following mild TBI. Often multifactorial,
  including pain, psychologic factors, pre-injury
  factors, and true alterations in arousal.
• First-line management involves appropriate sleep
  hygiene (e.g., eliminating caffeine, winding
  down, eliminating naps, appropriate environment).

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Sleep Hygiene Disturbance

• Early (48-72 hours) use of sleep medications is
  appropriate. Scheduled agents for 3-7 days is
  preferable to prn dosing.
• Trazadone 50-300 mg qhs is preferred agent.
• Sonata is second line agent.
• Ambien may have cognitive side effects.
• Avoid benzodiazapines (e.g., Restoril) secondary
  to depressive and addictive propoerties.

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Deficits of Arousal and Attention

• Typical in the first 24-72 hours post-TBI. Will
  prevent optimal memory, concentration, and
  judgement. May persist to some extent in most
  patients for first 2 weeks.
• Optimizing sleep hygiene and eliminating sedating
  medications (e.g., pain medications) is important
  first line treatment.
• Can profoundly impair function and work.

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Deficits of Arousal and Attention

• Stimulant agents an appropriate and effective
  intervention.
• Rapid working (24-72 hours)
• Limited side effects or drug interactions
• Also assist in managing depressive symptoms.
• Can be inexpensive (generic Ritalin)
• Ritalin, Atteral, Cylert, and Provigil are common
  agents.

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Deficits of Arousal and Attention

• Treat with stimulants for 4 weeks (at therapeutic
  dose) and then begin to wean.
• If acute condition, rarely need to restart. If
  chronic condition may need 6 months treatment.

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Memory and Processing Deficits

• Cognitive deficits are universal after TBI,
  however excellent recovery is common.
• Neuropsychological Testing best captures the
  spectrum of deficits. The skills of the tester
  and interpreter greatly influence relevance of
  testing.
• Depression may present as memory difficulties.

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Memory and Processing Deficits

• Good evidence for utility of cognitive therapies
  for up to 18 months, although objective criteria
  for improvement are necessary.
• The use of memory aides (PDAs, memory logs) has
  been highly successful.

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Memory and Processing Deficits

• Similar strategies and medications as for arousal
  and attention deficits are employed.
• Probable role for SSRI antidepressants (e.g.,
  Zoloft), even in absence of clinical or major
  depression.
• Possible role for anti-Alzheimers agents (e.g.,
  Aricept and Excelon).

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Depression

• Although not well studied, available data
  suggests 25-50 of individuals with TBI and
  persistent symptoms can develop clinical
  depression in first 12 months.
• Major depression probably less common with in
  post-concussive syndrome, however use of
  antidepressants is extremely common in this
  population. Post-traumatic stress disorder may
  also be present.

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Depression

• Patients should fit criteria for major depression
  (at least 5 of 9 vegetative symptoms) before
  implementing medication treatment. Counseling
  therapy alone indicated if minor depression.
• Medication treatment must be treated for a
  minimum of 12 months, otherwise risk of relapse
  elevated.

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Depression

• Professionals with specific training, an interest
  in improving the patient, and an understanding of
  the need for objective criteria for treatment are
  vital.
• Selective serotonin reuptake inhibitors are most
  widely used (Zoloft, Paxil, Prozac, Celexa).
  Appropriate durations and dosages of treatments
  are important.

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Agitation/Irritability

• Difficulties in interpersonal relationships and
  stress management post-TBI may be the result of
  increased irritability (or behavioral
  dyscontrol).
• Typically resolves by 2 weeks post-concussion
  (when cognitive skills return to baseline)
• May be a sign of depression.

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Agitation/Irritability

• Normalizing sleep hygiene, controlling
  environmental stimulation, enriched interactions
  at home/work, and appropriate pain control are
  often highly effective.
• Psychological counseling is often necessary if
  there is little improvement by 2-4 weeks
  post-injury

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Agitation/Irritability

• Medications may have a role for persistent
  agitation
• Anxiety - Buspar 5-10 mg tid
• - Paxil 10-40 mg qday
• Irritability - VPA 250-500 mg tid
• - CBZ 100-200 mg tid
• Treatment usually requires 3-6 months duration.

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TBI Psychiatric

• Following mild TBI psychiatric manifestations
  (psychosis, OCD, hallucinations) may present
  without specific TBI-related cause.
• Typically, individuals had subtle evidence of
  pre-injury issues. Alcohol or drug use may have
  masked.

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TBI Psychiatric

• Unusual to see resolution of symptoms without
  treatment.
• Appropriate management with psychoactive
  medications and psychological therapy is
  necessary.