Persistent Post-Concussion Symptoms

Persistent Post-Concussion Symptoms (PPCS) – also called post-concussion syndrome- occurs when concussion (mild traumatic brain injury) symptoms last longer than expected after an injury. Most people recover from concussion uneventfully.

Persistent Post-Concussion Symptoms

Persistent Post-Concussion Symptoms (PPCS) – also called post-concussion syndrome- occurs when concussion (mild traumatic brain injury) symptoms last longer than expected after an injury. Most people recover from concussion uneventfully. However, some individuals will experience a prolonged recovery. PPCS can have significant impacts on a person’s life, including their ability to participate in daily activities, school and/or work. Healthcare professionals can help to treat and manage ongoing symptoms.

What are Persistent Post-Concussion Symptoms?

PPCS is a condition where a child, adolescent or adult continues to experience concussion (mild traumatic brain injury) symptoms for more than 4 weeks. It is not clear how many people suffer from PPCS after concussion, though some research indicates that it could be as high as 53%. PPCS can be subtle, and sometimes people do not realise that they are experiencing PPCS until they go back to their normal daily activities, or return to school, work or playing sport.

What causes PPCS?

More research is needed to better understand how and why some people develop PPCS and others do not. A range of biological, psychological, and social factors are likely to play a role in the development of this condition. It’s important to remember that each person’s experience and concussion recovery speed is unique to them. 

Risk factors

Risk factors that may contribute to a person experiencing PPCS include:

  • Age. Research indicates that the risk of PPCS may change with age, with adolescents and older adults being more likely to experience poor outcome following concussion injury.
  • Sex. Females are more likely to be diagnosed with PPCS relative to males. Researchers are only beginning to understand the unique effects of concussion in females, including why they are at a greater risk of experiencing PPCS. Differences in brain anatomy, neck strength, and hormone cycles as well as a greater willingness to report concussion symptoms are amongst some of the reasons that have been suggested.
  • Previous history of mental health disorder. People with a history of mental health disorders have been found to be more likely to experience PPCS.

Prevention

The only way to lower the risk of experiencing PPCS is to avoid head injury in the first place. Things you can do to help prevent a concussion include:

  • Fastening your seat belt whenever you’re travelling in a car.
  • Making sure children are secured in age-appropriate safety seats. Children aged under 7 years are generally not permitted to sit in the front seat. Check with your State Government for more information.
  • Taking action to prevent falls such as avoiding standing on unstable surfaces, removing or securing small area rugs, improving lighting, and installing handrails.
  • Enforcing rules and policies that penalise head contact, rough play, or impact with the ground in contact sports at all levels of play.

Reducing the risk of Persistent Post-Concussion Symptoms

Always seek medical attention as soon as possible if you or someone you know have had a concussion (or suspect one may have occurred) and follow instructions given to you by your healthcare practitioner. Click here to learn more about the signs and symptoms of concussion.

Additional things to help your concussion recovery include:

The first 24-48 hours: A period of relative (not strict) rest

Physical and mental activity should be reduced (but not completely avoided) immediately and for up to 48 hours following a concussion injury. Its ok for a person to participate in light physical (e.g. walking, stationary cycling) and cognitive activity during this time, though screen time should be limited. Complete rest until concussion symptoms resolve is no longer recommended and may be even detrimental to recovery.

Increasing activity levels gradually

It is understandable that many people are eager to resume their normal lives following a concussion. However, returning to activity too quickly can trigger or worsen concussion symptoms, and potentially lengthen the recovery process. After a concussion, it is best to return to activities of daily living, school, work, and sport in a graduated (step-by-step) manner.

A person can start to go back to these different areas of life at the same time, and gradually (not all at once) increase the level of activity/difficulty over time. If an activity that you are doing triggers your concussions symptoms, stop what you are doing and take a break. You may need to return to a lower level of activity until your symptoms improve. Your healthcare provider will provide you with instructions on how to safely return to daily activities, school, work and/or sport, or you can view Connectivity’s range of return to activity Fact Sheets here.

Avoiding anything that might cause another concussion

Individuals who experience multiple concussions/repeated head injury may be more likely to experience PPCS, though research findings on this are mixed. However, it is generally a good idea to avoid any activities that could result in you falling and hitting their head or body (e.g., contact sports) until you are symptom-free. Second Impact Syndrome is a rare and potentially fatal condition that can occur if a second concussion happens soon after the first concussion. A person who has experienced a concussion from playing sport or participating in recreational activities should never be allowed to return to play the same day. To learn more about Sport-related concussion, enrol in our free online short course here.

Treatment and management options

A range of healthcare professionals can assist with persistent post-concussion symptoms. Speaking to your GP is a good place to start. They can help identify if there are any factors that could be contributing to your PPCS or making your symptoms worse (e.g., poor sleeping patterns, stress, mental health challenges, substance abuse), and can provide referrals to other medical specialists and/or allied healthcare professional/s that can help treat or manage your symptoms. Your symptoms will guide what healthcare professional/s to see. Examples of healthcare professionals that individuals with PPCS may be referred to include:

  • Neurologist (e.g. for help with persistent headaches)
  • Physiotherapist (e.g. for help with neck pain or stiffness, balance problems, dizziness)
  • Psychologist (e.g. for help with anxiety, depression, irritability, relationship problems)
  • Neuropsychologist or Occupational Therapist (e.g. for help with difficulties with cognition (thinking skills))

To learn more about these and other healthcare professionals that can help, click here.

Regular follow-up appointments with your GP will help them monitor your recovery journey and determine if any changes need to be made to your treatment plan. Keeping a note of your symptoms, including their severity, how often they occur, and whether they are triggered by anything (e.g. loud noises, bright lighting, sudden movements) can also be helpful.

Return to Activity 

Speak to your school or workplace about how they can help support you through your concussion recovery process. They may have a policy for dealing with concussion injuries, so it’s worth asking. Actions you may consider to help manage persistent post-concussion symptoms include:

  • Returning to school or work part-time.
  • Rescheduling tests or extending project deadlines.
  • Taking breaks to help keep work manageable.

 

PPCS References
  1. Patricios, J. S. et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med 57, 695–711 (2023).
  2. Nelson, L. D. et al. Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study. JAMA Neurol 76, 1049–1059 (2019).
  3. Silverberg, N. D. et al. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma 32, 517–526 (2015).
  4. Solomito, M. J., Reuman, H. & Wang, D. H. Sex differences in concussion: a review of brain anatomy, function, and biomechanical response to impact. Brain Inj 33, 105–110 (2019).
  5. Merritt, V. C., Padgett, C. R. & Jak, A. J. A systematic review of sex differences in concussion outcome: What do we know? Clin Neuropsychol 33, 1016–1043 (2019).
  6. Rizzone, K. H. & Ackerman, K. E. Female Athlete and Sports-Related Concussions. Clinics in Sports Medicine vol. 40 133–145 Preprint at https://doi.org/10.1016/j.csm.2020.08.006 (2021).
  7. Gallagher, V. et al. The Effects of Sex Differences and Hormonal Contraception on Outcomes after Collegiate Sports-Related Concussion. J Neurotrauma 35, 1242–1247 (2018).
  8. Wunderle, K., Hoeger, K. M., Wasserman, E. & Bazarian, J. J. Menstrual phase as predictor of outcome after mild traumatic brain injury in women. Journal of Head Trauma Rehabilitation 29, E1–E8 (2014).
  9. Wallace, J., Covassin, T. & Beidler, E. Sex Differences in High School Athletes’ Knowledge of Sport-Related Concussion Symptoms and Reporting Behaviors. J Athl Train 52, 682–688 (2017).
  10. Yue, J. K. et al. Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol 10, 343 (2019).
  11. Lingsma, H. F. et al. Outcome prediction after mild and complicated mild traumatic brain injury: External validation of existing models and identification of new predictors using the TRACK-TBI pilot study. J Neurotrauma 32, 83–94 (2015).
  12. Government of South Australia & Department for Infrastructure and Transport. Seatbelts and child restraints. https://www.mylicence.sa.gov.au/roadrules/seatbelts-and-child-restraints#:~:text=Children%20aged%20seven%20and%20over,appropriately%20restrained%20for%20their%20size.
  13. NSW Government. Child car seats. https://www.nsw.gov.au/driving-boating-and-transport/roads-safety-and-rules/safe-driving/child-seats.
  14. VicRoads & Victoria State Government. Seat belts & child restraints. https://www.vicroads.vic.gov.au/safety-and-road-rules/road-rules/a-to-z-of-road-rules/seat-belts-and-child-restraints#:~:text=Children%20aged%207%20years%20and,travelling%20in%20the%20back%20seat.
  15. Tasmanian Government. Child restraints – a guide to car seats. https://www.transport.tas.gov.au/road_safety_and_rules/road_rules/child_restraints_-_a_guide_to_car_seats#:~:text=A%20child%20that%20is%20over,legally%20sit%20in%20the%20front.
  16. Queensland Government. Child restraints. https://www.qld.gov.au/transport/safety/rules/children/where-to-sit#:~:text=Babies%20and%20children%20up%20to,children%20under%207%20years%20old.
  17. Australian Capital Territory Government & Access Canberra. Child restraints in vehicles.
  18. Northern Territory Government & Department of Infrastructure, P. and L. Child car restraints Frequently Asked Questions. Preprint at https://roadsafety.nt.gov.au/__data/assets/pdf_file/0003/485364/Child-Car-Restraints-FAQ.pdf.
  19. Government of Western Australia Department of Transport. Seats and seatbelts. https://www.transport.wa.gov.au/licensing/seats-and-seat-belts.asp (2023).
  20. Leddy, J. J. et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Br J Sports Med 57, 762–770 (2023).
  21. Cnossen, M. C. et al. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma 34, 2396–2409 (2017).
  22. Nelson, L. D. et al. Acute clinical predictors of symptom recovery in emergency department patients with uncomplicated mild traumatic brain injury (mTBI) or non-TBI Injuries. J Neurotrauma 35, 249–259 (2018).
  23. Wojcik, S. M. Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department. Brain Inj 28, 422–430 (2014).

 

 

July 2023