Post-Concussive Syndrome

[Guest UVAPAC]

I was just looking for others thoughts on Post-Concussive Syndrome.

Over the past few years I have seen an explosion of patients who sustain a "Mild TBI" and months/years later continue to have post-concussive symptoms including headaches, photosensitivity, nausea, mood-swings, dizziness, etc.  

This is a diagnosis that is 100% subjective.  Patients will have a negative CT Scan of the head, followed by a negative MRI.  I have seen patients trial amitriptyline/nortriptyline and Topamax with minimal efficacy.  Typically Neuropsychiatric testing is next, but patients can very easily manipulate these results (IE: very simple to fail a mini mental status examination).  

I have had patients who are out of work for weeks, months, and even a year + with these symptoms.  I find any attempt to return these patients to some form of light duty often results in them returning a day or two later stating their symptoms have been exacerbated by activity, and they must be placed out of work again.  

As a clinician I have a difficult time with these cases, and at times feel frustrated that seemingly nothing I can do/offer helps.  (Tylenol, NSAIDs, TCA's, neurovestibular therapy/rehab).  I have generally been referring these cases to Neurology after 6-8 weeks with no patient improvement.

I have read on UpToDate, as well as any other medical literature I can get my hands on, and it seems no one has a good answer/solution to the above.  

Does anyone else see a lot of these cases?  Has anyone had success in  treating these patients?  

[lkth487]

I have seen some of these patients in pediatrics - like after a sports concussion that was initially thought to be mild but the kids are having significant symptoms months and sometimes years down the line (headaches, no concentration, poor grades).  Like you, I have very little to offer them, unfortunately. 

https://www.cdc.gov/injury/pdfs/bsc/systematicreviewcompilation_august_2016.pdf

Ive read through this document more than once and I still can't tell you anything specific that I can say with confidence will work.  If you look at their quality of evidence in the guidelienes, it's "low" and "very low" for a whole lot of it.  

Wish I had something profound to say. All I know is my kids are never playing football under any circumstance haha. 

[thinkertdm]

As with most pain, there is always a strong psychiatric overlay onto the symptoms.  However, for some, the connections between the gray and white matter is now disrupted.  I explain it like this: the brain is like a parfait of jello and whipped cream; start sliding it across the table then stop it.  Are the layers still lined up?  When layers of differing densities start moving, they don't stay in line.  Unfortunately, in between those layers, are trillions of connections that can't stretch.  Gonna take some time, and if something shows up on Ct, that's even worse.

when they say "why me", I bring up Kevin Ware, who jumped for a layup, came back down and had a compound fracture of his tibia.  Google it.  Basketball player, top notch shape, and the right amount of force was applied.  In most of the head injuries, there is very little cognitive reserve- people are so used to not using their brains that it is even more noticeable when it is lost.

the thing that makes the symptoms worst by far is frustration.  

 

[Boatswain2PA]

Depends...if it's TBI from something that of an IED from a 155mm shell (like this: http://www.submarineboat.com/blown_up.htm), then it's legit and we should do everything we can for them.

Iff not, tell them they have a boo-boo and need to suck it up and get back to work.

 

[sas5814]

You are suffering a syndrome I myself have. It's called "I can't see it or test for it or touch it so it's probably BS" syndrome. I don't have any real way to sort the real from the malingerers and I, because of a lot of different life experiences, tends to be a suspicious doubter. When I had to deal with them I took the "you need someone smarter than me" approach. Let the high dollar help deal with them whether their problem is real or imagined. That's right...I kicked the can right down the road.

[lkth487]

2 hours ago, Boatswain2PA said:

Depends...if it's TBI from something that of an IED from a 155mm shell (like this: http://www.submarineboat.com/blown_up.htm), then it's legit and we should do everything we can for them.

Iff not, tell them they have a boo-boo and need to suck it up and get back to work.

 

I have to disagree here.  I do think the syndrome and the symptoms are real.  All these kids who've had a drastic, immediate, and objective drop in their academics, ability to focus, physical sx etc - it can't all be made up.  It's too linear and can be traced back to a very clear incident. 

I see these kids in neuro clinic, in concussion clinic, in my normal outpatient primary care office.  It sucks. 

[Boatswain2PA]

1 hour ago, sas5814 said:

When I had to deal with them I took the "you need someone smarter than me" approach.

I do the same thing...tell them to follow up with their PCM!

42 minutes ago, lkth487 said:

I have to disagree here.  I do think the syndrome and the symptoms are real.  All these kids who've had a drastic, immediate, and objective drop in their academics, ability to focus, physical sx etc - it can't all be made up.  It's too linear and can be traced back to a very clear incident. 

I was, of course, being overly callous, and generally talking about the folks who want a "work note".

Brain injuries suck.  But on the other hand, so does back pain, doesn't mean you get a life-time work note.  

[MedicinePower]

There is a comprehensive discussion of PCS here:

 

[thinkertdm]

Prior to PA school, I administered a six hour battery to soldiers at Reed who had not only blast injuries, but numerous other kinds as well... This was around 98-02ish.  

No point to this fact except sometimes a seemingly minor knock to the head has far reaching effects.  But like things we can't see, sometimes there's other forces at play.

[Cideous]

The simple fact is the human neck and brain were never meant to sustain the kind of trauma that we subject it to now.  Sports like football (which I played a lot of) and soccer not to mention the explosion of MMA even for kids, has opened up a whole new set of issues humans were never meant to deal with.  Actually the movie "concussion" with Will Smith is pretty darn good at explaining the micro-trauma and subsequent protein build up (scaring).  Good movie, and terrifying for those of us who played the game.

[Guest UVAPAC]

Fortunately, none of my patients have been blown up by IED's.  The vast majority of them are injured "getting assaulted" at mental health facilities or prisons, hitting their head on various objects such as piping, ceilings, etc, falls from flat ground where they strike their head.

It is hard not to be suspicious of malingering in many of these cases where symptoms persist for months.  

As someone mentioned above, generally I will "kick the can" after a month, however I notice that a lot of the neurologic experts continue to keep these patients out of work for months/years/etc.  I have never performed neuropsychiatric testing, but can imagine it is not difficult to skew the results if there is incentive.  

[Joelseff]

You are suffering a syndrome I myself have. It's called "I can't see it or test for it or touch it so it's probably BS" syndrome. I don't have any real way to sort the real from the malingerers and I, because of a lot of different life experiences, tends to be a suspicious doubter. When I had to deal with them I took the "you need someone smarter than me" approach. Let the high dollar help deal with them whether their problem is real or imagined. That's right...I kicked the can right down the road.

I have a few... One had a VERY minor head injury and has been out for almost a year. Can't get them to do anything remotely close to light duty "everything makes me nauseous..." referred to Neuro. On F/U's I just simply ask "how'd it go with Neuro on your last appt?" and it's always "oh they're keeping me off for x amount of months and re-evaluate" I'm like "ok" see you in x amount of months."

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