Treatment in Postconcussional Syndrome

Abstract

Postconcussional syndrome is characterized by somatic, cognitive and psychiatric (emotional, behavioral) symptoms that occur after mild traumatic brain injury. These symptoms usually recover fully within 3-6 months almost in 90% of patients. Persistent post-concussion symptoms could occur in 10% of patients. Diagnosis is based on the subjective complaints and the treatment of the syndrome is mainly of palliative nature. The patient should be educated about the nature and outcome of the syndrome and reassured that almost all symptoms recover fully within 3-6 months. Multifaceted rehabilitation programs and cognitive behavioral therapy could be beneficial. Pharmacotherapy and somatic therapy are other options for persistent symptoms.

Keywords

• Postconcussional syndrome, treatment

Postkontüzyonel Sendromda Tedavi

Öz

Postkontüzyonel sendrom hafif şiddette kafa travması sonrası gelişen fiziksel, bilişsel ve psikiyatrik (duygusal, davranışsal) belirtilerle karakterizedir. Belirtilerin 3-6 ay içerisinde, kişilerin yaklaşık %90'ında tamamen düzeldiği bilinmektedir. Geriye kalan %10'luk kesimde kalıcı post-kontüzyon belirtileri görülür. Tanısı öznel yakınmalara dayanan bu durumun tedavisi genellikle bildirilen belirtilere yöneliktir. Kişi erken dönemde hastalığın doğası ve seyri konusunda bilgilendirilmeli, belirtilerin çoğunlukla 3-6 ay içerisinde düzeldiği vurgulanmalıdır. Çok yönlü rehabilitasyon programları ve özellikle son zamanlarda etkinliğine dair umut verici çalışmalar olan bilişsel davranışçı tedavi faydalı olabilir. Kalıcı belirtiler için farmakoterapi ve somatik tedaviler kullanılabilir.

Anahtar Kelimeler

• Postkontüzyonel sendrom, tedavi

References

1. Evans RW.The postconcussion syndrome and the sequelae of mild head injury. Neurol Clin 1992; 10:815-847.
2. Ryan LM, Warden DL. Post concussion syndrome. Int Rev Psychiatry 2003;15:3103
3. Prigatano GP, Gale SD. The current status of postconcussion syndrome. Curr Opin Psychiatry 2011; 24:243-250.
4. Reddy CC. Postconcussion syndrome: a physiatrist's approach.PM R 2011; 3:39640
5. Hall Ryan CV, Hall Richard C.W, Chapman MJ. Definition, diagnosis and forensic implications of postconcussional syndrome, Psychosomatics 2005; 46:195-202.
6. Silverberg ND, Iverson GL.Etiology of the post-concussion syndrome, physiogenesis and psychogenesis revisited. NeuroRehabilitation 2011; 29:317-329.
7. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343:100-105.
8. Jagoda AS, Bazarian JJ, Bruns JJ, Cantrill SV, Gean AD, Howard PK et al. Clinical policy: neuroimaging and desicion making in adult mild traumatic brain injury in the acute setting. J Emerg Nurs 2009; 35:5-40.

9. Belanger HG, Vanderploeg RD, Curtiss G, Warden DLRecent neuroimaging techniques in mild traumatic brain ınjury. J Neuropsychiatry Clin Neurosci 2007; 19:5Hofman PAM, Stapert SZ, van KroonenburghMJPG, Jolles a J, de KruijkJ, WilminkJT. MR imaging, single-photon emission CT, and neurocognitive performance after mild traumatic brain injury. AJNR Am J Neuroradiol 2001; 22:441-449.
10. Rostami E, Davidsson J, Ng KC, Lu J, Gyorgy A, Walker Jet al. A model for mild traumatic brain injury that induces limited transient memory impairment and increased levels of axon related serum biomarkers. Front Neurol 2012; 3:115.
11. Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of post-concussion syndrome following mild head injury. J Clin Exp Neuropsychol 2001; 23:829-836.
12. Paniak C, Toller-Lobe G, Reynolds S, Melnyk A, Nagy J. A randomized trial of two treatments for mild traumatic brain injury: 1 year follow-up. Brain Inj 2000; 14:2192
13. King NS. Mild head injury: neuropathology, sequelae, measurement and recovery. a literature review. Br J Clin Psychol 1997; 36:161-184.
14. King NS. The post concussion syndrome: clarity amid the controversy? Br J Psychiatry 2003; 183:276-278.
15. Wade D, King N, Wenden F, Crawford S, Caldwell F. Routine follow up after head injury: a second randomised controlled trial. J Neurol Neurosurg Psychiatry 1998;65:177-183.
16. Ponsford J, Willmott C, Rothwell A, Cameron P, Kelly A, Nelms R et al. Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry 2002; 73:330-332.
17. Ghaffar O, McCullagh S, Ouchterlony D, Feinstein A. Randomized treatment trial in mild traumatic brain injury. J Psychosom Res 2006; 61:153-160.
18. Elgmark Andersson E, Emanuelson I, Bjorklund R, Stålhammar DA. Mild traumatic brain injuries: the impact of early intervention on late sequelae. a randomized controlled trial. Acta Neurochir (Wien) 2007; 149:151-160.
19. Heskestad B, Waterloo K, Baardsen R, Helseth E, Romner B, Ingebrigtsen T. No impact of early intervention on late outcome after minimal, mild and moderate head injury. Scand J Trauma Resusc Emerg Med 2010; 18:10.
20. Elgmark Andersson E, Bedics BK, Falkmer T. Mild traumatic brain injuries: a 10 year follow-up. J Rehabil Med 2011; 43:323-329.
21. Al Sayegh A, Sandford D, Carson AJ. Psychological approaches to treatment of postconcussion syndrome: a systematic review. J Neurol Neurosurg Psychiatry 2010; 81:1128-1134.
22. Hanna-Pladdy B, Berry ZM, Bennett T, Phillips HL, Gouvier WD. Stress as a diagnostic challenge forpostconcussive symptoms: sequelae of mild traumatic brain injury or physiological stress response. Clin Neuropsychol 2001; 15:289-304.
23. McMillan T, Robertson IH, Brock D, Chorlton L. Brief mindfulness training for attentionalproblems after traumatic brain injury: a randomised control treatment trial. Neuropsychol Rehabil 2002; 12:117-125.
24. Bédard M, Felteau M, Mazmanian D, Fedyk K, Klein R, Richardson J et al. Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disabil Rehabil 2003; 25:7227
25. Azulay J, Smart CM, Mott T, Cicerone KD. A pilot study examining the effect of mindfulness-based stress reduction on symptoms of chronic mild traumatic brain injury/postconcussive syndrome. J Head Trauma Rehabil 2012, doi: 1097/HTR.0b013e318250ebda.
26. Rath JF, Simon D, Langenbahn DM, Sherr RL, Diller L. Group treatment of problem-solving deficits in outpatients with traumatic brain injury: a randomised outcome study. Neuropsychol Rehabil 2003; 13:461-488.
27. Ownsworth T, Fleming J, Shum D, Kuipers P, Strong J. Comparison of individual, group and combined intervention formats in a randomized controlled trial for facilitating goal attainment and improving psychosocial function following acquired brain injury. J Rehabil Med 2008; 40:81-88.
28. Stejskal TM. Removing barriers to rehabilitation: theory-based family intervention in community settings after brain injury. NeuroRehabilitation 2012; 31:75-83.
29. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA 2012; 307:173617
30. Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010; 34:87-93.
31. Register-Mihalik JK, Mihalik JP, Guskiewicz KM. Balance deficits after sports-related concussion in individuals reporting posttraumatic headache. Neurosurgery 2008; 63:76-80.
32. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep-maintenance and sleep-onset insomnia. Pharmacotherapy 2007; 27:89-110.
33. Silver JM, McAllister TW, Arciniegas DB. Depression and cognitive complaints following mild traumatic brain ınjury. Am J Psychiatry 2009; 166:653-661.
34. Rapoport MJ, Chan F, Lanctot K, Herrmann N, McCullagh S, Feinstein A. An open-label study of citalopram for major depression following traumatic brain injury. J Psychopharmacol 2008; 22:860-864.
35. Fann JR, Uomoto JM, Katon WJ. Sertraline in the treatment of major depression following mild traumatic brain injury. J Neuropsychiatry Clin Neurosci 2000; 12:226-232
36. Dinan TG, Mobayed M. Treatment resistance of depression after head injury: a preliminary study of amitriptyline response. Acta Psychiatr Scand 1992; 85:292-294. Saran AS. Depression after minor closed head injury: role of dexamethasone suppression test and antidepressants. J Clin Psychiatry 1985; 46:335-338.
37. Kanetani K, Kimura M, Endo S. Therapeutic effects of milnacipran (serotonin noradrenaline reuptake inhibitor) on depression following mild and moderate traumatic brain injury. J Nippon Med Sch 2003; 70:313-320.
38. Lee H, Kim SW, Kim JM, Shin IS, Yang SJ, Yoon JS. Comparing effects of methylphenidate, sertraline, and placebo on neuropsychiatric sequelae in patients with traumatic brain injury. Hum Psychopharmacol 2005; 20:97-104.
39. Neurobehavioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW, Silver JM, Barth JT et al. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J Neurotrauma 2006; 23:1468150
40. Halbauer JD, Ashford JW, Zeitzer JM, Adamson MM, Lew HL, Yesavage JA. Neuropsychiatric diagnosis and management of chronic sequelae of war-related mild to moderate traumatic brain injury. J Rehabil Res Dev 2009; 46:757-796.
41. Rao V, Lyketsos CG. Psychiatric aspects of traumatic brain injury, Psychiatr Clin North Am 2002; 25:43-69.
42. Levin HS. Treatment of postconcussional symptoms with CDP-choline. J Neurol Sci 1991; 103:39-42.
43. Aniruddha TJ, Shibu P, Indira Devi B, Sampath S, Chandramouli BA. Role of citicoline in the management of mild head injury. Indian Journal of Neurotrauma 2009; 6:49-52.
44. Kant R, Coffey CE, Bogyi AM. Safety and efficacy of ECT in patients with head injury a case series. J Neuropsychiatry Clin Neurosci 1999; 11:32-37.
45. Baker-Price LA, Persinger MA. Weak, but complex pulsed magnetic fields may reduce depression following traumatic brain injury. Percept Mot Skills 1996; 83:4914
46. Schoenberger NE, Shif SC, Esty ML, Ochs L, Matheis RJ. Flexyx Neurotherapy System in the treatment of traumatic brain injury: an initial evaluation. J Head Trauma Rehabil 2001; 16:260-274.
47. Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR. Cognitive-behavioral prevention of postconcussion syndrome. Arch Clin Neuropsychol 1996; 11:139-145. Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, Schwartz T et al. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Arch Phys Med Rehabil 2005; 86:1565-1574.
48. Harch PG, Andrews SR, Fogarty EF, Amen D, Pezzullo JC, Lucarini J et al. A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma 2012; 29:168-185.
49. Wright JK, Zant E, Groom K, Schlegel RE, Gilliland K. Case report: Treatment of mild traumatic brain injury with hyperbaric oxygen. Undersea Hyperb Med 2009; 36:391-399.
50. Milman A, Zohar O, Maayan R, Weizman R, Pick CG. DHEAS repeated treatment improves cognitive and behavioral deficits after mild traumatic brain injury. Eur Neuropsychopharmacol 2008; 18:181-187.
51. Hecht JS. Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. J Head Trauma Rehabil 2004; 19:58-71.
52. Erken DD, Okay Tİ, Dilbaz N. Psikiyatride beyin sarsılması sonrası sendromu. Klinik Psikofarmakoloji Bülteni 2008; 18:130-139. Necla Keskin, Dr., Çukurova Üniversitesi Tıp Fakültesi Psikiyatri ABD, Adana; Lut Tamam, Prof. Dr., Çukurova Üniversitesi Tıp Fakültesi Psikiyatri ABD, Adana. Yazışma Adresi/Correspondence: Necla Keskin, Çukurova Üniversitesi Tıp Fakültesi Psikiyatri ABD, Adana, Turkey. E-mail: [e-mail] Yazarlar bu makale ile ilgili herhangi bir çıkar çatışması bildirmemişlerdir. The authors reported no conflict of interest related to this article. Çevrimiçi adresi / Available online at: www.cappsy.org/archives/vol5/no1/ Çevrimiçi yayım / Published online 10 Kasım/November 10, 2012; doi:10.5455/cap.20130507