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Post Concussive Syndrome

In the days and first weeks after a mild traumatic brain injury, almost every individual has some worrisome symptoms that fall into one of three general areas-somatic (physical), cognitive (brain function), and emotional (psychological). This set of symptoms, lasting days to a few weeks, is the anticipated consequence of concussion. For most people, these symptoms decrease over time. Recovery is most rapid in the first few weeks after the injury, but continues for many months after the injury. Most patients recover completely in three to six months. Individuals who are older than 40, as well as individuals who have had a concussion before (especially if they had not fully recovered before sustaining another concussion), take longer to recover.

As time passes, the relationship of symptom severity and the medical measures of brain injury becomes less certain. Many of the problems caused by the injury appear to persist even when brain recovery has taken place. Individuals who continue to report symptoms months after their injuries also commonly report emotional distress and poor physical functioning. The persistence of symptoms similar to the acute symptoms of concussion is called the post-concussion syndrome (PCS).

Because the symptoms after concussion are very similar to the symptoms that persist long after the injury, the distinction between concussion symptoms and PCS symptoms is often uncertain. The factors that extend symptoms - not just the injury severity - may need to be identified for proper treatment.

The most common symptoms of concussion or post-concussive syndrome are:

Physical (somatic) symptoms

Headaches and neck pain

Headaches are common in the first few days after a mild traumatic brain injury. If headaches are improving, you do not have to worry or seek urgent care. Headaches have several potential causes, and simply referring to all headaches after trauma as "post traumatic headaches" does not identify cause or treatment. In many cases, they are due to a whiplash neck injury (a strain of the neck muscles) or muscle tension that often is made worse by worry and poor sleep. If you had migraine headaches before your injury, they may get worse for a while. In some cases, people with no prior history of migraines will develop them for a few weeks or longer. Headaches and neck pain can be treated in a number of ways, depending on the type of headaches and their severity. Treatments may include physical therapy, medications, behavioral interventions and referrals to a specialized pain/headache clinic.

Dizziness

Dizziness is a very common symptom after a mild traumatic brain injury, but it is important to clarify exactly what a person means by "dizzy." A mild sense of poor equilibrium, or being off balance, is very common. It will often come and go and be worse during activities. Poor equilibrium may require caution and some limitations during work, athletic or leisure activities. The best treatment is to gradually increase activity as you become more able to tolerate it. Vertigo is a less common symptom after a mild brain injury. Vertigo is a sense of spinning or rotation, similar to the feeling after getting off of a carnival ride. Vertigo may require a careful assessment to make a diagnosis. In almost all cases, it is a very brief feeling that often occurs after movement, especially bending or rolling over. The most common cause of vertigo is an injury to the inner ear. This type of vertigo is called benign positional vertigo. Although it can be very distressing, it is not serious and the treatment is easy and straightforward.

Nausea and motion sickness

Nausea and motion sickness are fairly common after a head injury. They are sometimes related to headaches, especially migraines, and are sometimes related to issues with equilibrium or vertigo. Nausea and motion sickness are not signs of brain damage. Their treatment is incorporated into the treatment of headaches or equilibrium issues.

Photosensitivity

Increased sensitivity to bright light or loud noise following a mild traumatic brain injury usually is associated with headaches. It is not a symptom of brain damage and will typically go away in time.

Insomnia and fatigue

Many individuals experience disrupted sleep for a few days following a mild injury. Some are exhausted and sleep excessively. Others are hurting or stressed and cannot sleep at all. Fatigue - both mental and physical - is normal for a few days after injury. It takes time to regain energy after a trauma. Patients often feel tired when they first return to work or school and have to balance getting nighttime sleep, daytime rest and increasing activity.

Cognitive symptoms

Poor concentration and action lapses

Individuals who have had a mild traumatic brain injury may be easily distracted. In the middle of one activity, another activity or distraction pops up - the phone rings, someone walks into the office, etc. You lose track of your thoughts or actions; you may have to back up on the activity until you recover your intention.

Memory problems, poor recall and mental fatigue

A person's name will not come to you; you need to keep appointments written down; the content of something you read or a movie you watch slips away immediately. To remember something, you have to pay attention first. Very often, you really were not paying as much attention as you thought.

And no one's memory is perfect. Worrying about and focusing on each lapse will only make your memory seem worse. Memory "problems" are actually quite common.

One of the primary goals when we assess individuals with mild traumatic brain injury - those patients seen soon after injury and especially the ones seen late after injury - is to establish the real causes of cognitive symptoms, not to simply assume that they are due to the brain injury. It may take time, thought and discussion with your doctor to identify exactly what is causing your symptoms (and it may be more than one cause).

Although there is no one known direct treatment for the cognitive issues that often follow a brain injury, identifying the symptoms and their causes helps you, your doctor and your family as you learn what things you can do to compensate until the symptoms resolve.

Your doctor may recommend making accommodations while you are recovering such as getting enough sleep, lightening your schedule, taking on one only project at a time, building rest into your routines, using a calendar or PDA, asking teachers for temporary accommodations or employers for gradual return to activity. There are no particular medications that a doctor can prescribe to help. In some cases, stimulants such as coffee or energy drinks are helpful and can be used temporarily while you recover.

Emotional (psychological) symptoms

Anxiety

Individuals who have had a mild traumatic brain injury may have disturbing memories of their accidents - the car veering, the truck cutting them off, the scaffolding cracking, the slip on the ice, etc. Reliving parts of the experience, seeing pictures of your car or your face in the emergency department, reading the accident report, and even nightmares about injury or loss may be troublesome. For some time after the injury, you may be fearful of riding in a car, being on a particular road or being in crowds. Some anxiety is normal, but when it affects functioning, sleep or concentration it may actually become a problem. Event-related anxiety can become severe enough to qualify as Acute Stress Disorder. The physical and cognitive symptoms common after mild traumatic brain injury may also cause worry: Why am I dizzy? Why can't I remember where I left my keys? Early return to managing everyday activities at home, work or school may be a struggle leading to more worry about "what's wrong with me?"

Depression

People often become depressed when unpleasant things happen to them, and a traumatic brain injury is unpleasant. There may also be depressing complications after an injury such a loss of work, legal problems, guilt about an accident, financial obligations, function loss and so on. Depression can become a problem in and of itself. Individuals who are depressed are encouraged to seek help if it is interfering with their recovery.

Irritability

Irritability is not a symptom of a brain injury, but in the aftermath of an accident or injury there are many reasons for short-tempered behaviors, including cognitive difficulties, worry, fatigue, pain and disrupted sleep. Being irritable becomes a problem when it interferes with your ability to get along with people around you.
The psychological symptoms that often appear after a mild brain injury are very much like the signs of normal daily stress. After an injury, it is easy to forget how common stress-related symptoms are in everyday life. Stress on its own can produce many of the physical and cognitive symptoms that you may think are caused by your injury.

For individuals who have had a mild traumatic brain injury and continue to experience symptoms long after the injury, it is very important to establish the extent to which emotional or psychological symptoms are contributing to other symptoms and disability. Many non-brain-injured people who are depressed or who have chronic pain report the same symptoms as patients recovering from concussion. Once emotional or somatic factors contributing to or causing disability are accurately identified, they can be treated effectively with medications and behavioral therapies.


Contact Information

Traumatic Brain Injury Clinic
Department of Neurology
Beth Israel Deaconess Medical Center
330 Brookline Avenue
Boston, MA 02215
617-667-4824