The post-concussion syndrome , also known as postconcussive syndrome or PCS , is a series of symptoms that can persist for weeks, months, or a year or more after a concussion - a mild form of traumatic brain injury (TBI). PCS rates vary, but most studies report that about 15% of individuals with a single concussion history develop persistent symptoms associated with injury. Diagnosis can be made when symptoms of a concussion last for more than three months after injury. Loss of consciousness is not necessary for the diagnosis of a concussion or post-concussion syndrome.
Although there is no treatment for PCS, symptoms can be treated; drugs and physical and behavioral therapy can be used, and individuals can be educated about symptoms and given in the hope of recovery. The majority of cases of PCS heal after a period of time.
Video Post-concussion syndrome
Signs and symptoms
In the past, the term PCS was also used to refer to immediate physical symptoms or post-concussive symptoms after minor TBI or concussion. The severity of these symptoms usually decreases rapidly. In addition, the nature of the symptoms may change over time: acute symptoms are generally physical, while persistent symptoms tend to be more psychological. Symptoms such as voice sensitivity, concentration and memory problems, irritability, depression, and anxiety can be called 'late symptoms' because they generally do not occur immediately after injury, but more on days or weeks after injury. Nausea and drowsiness usually occur acutely after a concussion. Headaches and dizziness occur immediately after injury, but can also last a long time.
This condition is related to various symptoms: physical, such as headache; cognitive, such as difficulty concentrating; and emotional and behavioral, such as irritability. Many symptoms associated with PCS often occur or may be aggravated by other disorders, so there is a risk of incorrect diagnosis. Headaches that occur after a concussion may feel like a migraine headache or tension-type headache. Most headaches are tension-type headaches, which may be associated with neck injuries that occur at the same time as head injury.
Physical
The general condition associated with PCS is a headache. While most people experience headaches of the same kind as they did before the injury, people diagnosed with PCS often report headaches that are more frequent or more lasting. Between 30% and 90% of people treated for PCS reports experienced more frequent headaches and between 8% and 32% still reported it a year after the injury.
Dizziness is another common symptom reported in about half of people diagnosed with PCS and still exists up to a quarter of them a year after the injury. Older people are at high risk for dizziness, which may contribute to subsequent injuries and higher mortality rates due to falls.
About 10% of people with PCS develop a sensitivity to light or noise, about 5% experience a decrease in taste or odor, and about 14% report blurred vision. People may also have double vision or ringing in the ear, also called tinnitus. PCS can cause insomnia, fatigue, or other problems with sleep.
Psychological and behavioral
Psychological conditions, which exist in about half of people with PCS, may include irritability, anxiety, depression, and personality changes. Other emotional and behavioral symptoms include anxiety, aggression, and mood swings. Some common symptoms, such as apathy, insomnia, irritability, or lack of motivation, can occur due to other conditions that occur together, such as depression.
Higher mental function
Common symptoms associated with PCS diagnosis are related to cognition, attention, and memory, especially short-term memory, which can also exacerbate other problems such as forgetting appointments or difficulties in the workplace. In one study, one in four people diagnosed with PCS continued to report memory problems a year after the injury, but most experts agree that cognitive symptoms are apparent within six months to one year after injury to most individuals.
Maps Post-concussion syndrome
Cause
The question of the cause or cause of PCS has been much debated for years and remains controversial. It is not known exactly what degree of symptoms is due to physiological changes or other factors, such as pre-existing psychiatric disorders or factors related to secondary gain or disability compensation. The subjectivity of the complaint makes it difficult to assess and makes it difficult to determine whether the symptoms are exaggerated or falsified.
While the cause of the symptoms occurs immediately after concussion tends to be physiological, it is less clear that persistent post-concussive symptoms have a fully organic base, and inorganic factors tend to engage in symptoms lasting more than three months. PCS can also be exacerbated by psychosocial factors, chronic pain, or some or all of these interactions. The majority of experts believe that PCS results come from a mixture of factors, including pre-existing psychological factors and which are directly related to physical injury.
It is not known what caused PCS to occur and settled, or why some people who suffered minor traumatic brain injuries later developed PCS while others did not. The nature of the syndrome and the diagnosis itself has been the subject of intense debate since the 19th century. However, certain risk factors have been identified; for example, pre-existing medical or psychological conditions, disability expectations, being female, and older age all increase the likelihood that a person will suffer from PCS. Physiological and psychological factors that exist before, during, and after injury are considered to be involved in PCS development.
Some experts believe the post-concussion symptoms are caused by structural damage to the brain or disorders of the neurotransmitter system, resulting from the effects that cause concussions. Others believe that post-concussion symptoms are associated with general psychological factors. The most common symptoms such as headaches, dizziness, and sleep problems are similar to those experienced by individuals who are diagnosed with depression, anxiety, or post traumatic stress disorder. In many cases, the two physiological effects of brain trauma and emotional reactions to these events play a role in the development of symptoms.
Physiological
The study of conventional neuroimaging of the brain after concussion is usually normal. However, research has found some subtle physiological changes associated with PCS using more new imaging modalities. Studies using positron emission tomography have linked PCS with reduced glucose utilization by the brain. Changes in brain blood flow have also been observed for three years after concussion in the study using single photon emission tomography (SPECT). At least one study with functional magnetic resonance imaging (fMRI) has shown differences in brain function during tasks involving memory after mild traumatic brain injury (mTBI) even though they did not examine PCS specifically. Additional studies have shown, using various MRI techniques (such as Diffuse Tensor Imaging (DTI) MRI), that individuals with PCS have various abnormalities in their brain structures. Similar findings have recently been reported in the army with mTBI/PCS explosion-induced.
Not everyone with PCS has an abnormality in imaging, however, and abnormalities found in studies such as fMRI, PET, and SPECT may result from other comorbid conditions such as depression, chronic pain, or post-traumatic stress disorder (PTSD). Proponents of the view that PCS has a physiological basis show findings that children show deficits on standard tests of cognitive function after mild TBI. Some studies have shown that people with PCS scores are lower than controls on neuropsychological tests that measure attention, verbal learning, reasoning, and information processing, but problems related to secondary efforts and advantages can not be ruled out as contributing to these differences. Recovery as measured by scores on cognitive tests is often not correlated with symptomatic resolution; individuals diagnosed with PCS may still report subjective symptoms after their performance on cognitive function tests has returned to normal. Another study found that although children with PCS had worse scores on cognitive function tests after injury, they also had worse behavior adjustments before injury than those without persistent symptoms; These findings support the idea that PCS can be produced from a combination of factors such as brain dysfunction due to a head injury and pre-existing psychological or social problems. Different symptoms can be predicted by various factors; for example, one study found that cognitive and physical symptoms were not predicted in a way in which parents and family members overcame injuries and adjusted for their effects, but psychological and behavioral symptoms.
Inflammation of the brain is suggested to play a role in post-concussive syndrome.
Psychological
It has been argued that psychological factors play an important role in the presence of post-concussion symptoms. The development of PCS may be due to a combination of factors such as adjustment to the effects of injury, pre-existing vulnerability, and brain dysfunction. The setbacks associated with injuries, such as problems at work or with physical or social functions, can act as stressors that interact with pre-existing factors such as personality and mental state to cause and perpetuate PCS. In one study, daily stress levels were found to correlate with PCS symptoms in both subjects and control concussions, but in others, stress was not significantly associated with symptoms.
Iatrogenic effects (caused by medical intervention) can also occur when individuals are given misleading or incorrect information related to symptom recovery. This information can cause people to focus and think about the idea that their brains are permanently damaged. It seems that even symptom expectations may contribute to the development of PCS by causing individuals with mTBI to focus on the symptoms and therefore see them become more intense, to attribute symptoms that occur for other reasons for injury, and underestimate the symptom tariffs before the injury.
Diagnosis
The International Statistical Classification of Diseases and Health Problems Related (ICD-10) and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder have set criteria for post-concussion syndrome ( PCS ) and post-concussional interruptions ( PCD ), respectively.
The ICD-10 established a set of diagnostic criteria for PCS in 1992. To meet this criterion, a patient suffered a head injury "is usually severe enough to result in a loss of consciousness" and then develops at least three of the eight symptoms marked with a tick on the table just below "ICD-10" within four weeks. Approximately 38% of people who suffered head injuries with symptoms of concussion and no radiological evidence of brain lesions that meet these criteria. In addition to these symptoms, people who meet the ICD-10 criteria for PCS may fear that they will have permanent brain damage, which can worsen the original symptoms. Preoccupation with injury can be accompanied by the assumption of "the role of pain" and hypochondriasis. The criteria focus on subjective symptoms and mention that neuropsychological evidence of significant disturbances does not exist. With their focus on psychological factors, the ICD-10 criterion supports the idea that the causes of PCS function. Like ICD-10, ICD-9-CM defines PCS in terms of subjective symptoms and discusses the greater frequency of PCS in people with a history of mental disorders or financial incentives for diagnosis.
The DSM-IV lists the criteria for the diagnosis of PCD in people who suffer head trauma with persistent post-traumatic amnesia, loss of consciousness, or post-traumatic seizures. In addition, for the diagnosis of PCD, patients should have neuropsychological disorders as well as at least three symptoms marked with a check mark under the table under "DSM-IV". These symptoms should be present for three months after the injury and must be none or less severe before the injury. In addition, patients should experience social problems as a result, and should not meet the criteria for other disorders that explain the symptoms better.
Neuropsychological tests exist to measure deficits in cognitive function that can result from PCS. The Stroop Color Test and 2 & amp; 7 Processing Speed ​​Test (which both detect deficits in mental processing speed) can predict the development of cognitive problems from PCS. A test called the Rivermead Post-Earthquake Symptom Questionnaire, a series of questions that measure the severity of 16 different post-concussion symptoms, can be managed independently or managed by the interviewer. Other tests that can predict PCS development include the Hopkins Verbal Learning (HVLA) test and Digit Span Forward examination. HVLA tests verbal and memory learning by presenting a set of words and assigning points based on the sum called, and the digit range measures the efficiency of attention by asking the test participants to repeat the digits spoken by the testers in the same order as presented. In addition, neuropsychological tests can be performed to detect malingering (exaggeration or symptom).
Differential diagnosis
PCS, which shares symptoms with other conditions, is likely to be misdiagnosed in people with this condition. Cognitive and affective symptoms that occur after traumatic injury can be attributed to mTBI, but in fact due to other factors such as post-traumatic stress disorder, which is easily misdiagnosed as PCS and vice versa. Affective disorders such as depression have some symptoms that may resemble the symptoms of PCS and lead to a false diagnosis of the latter; These include problems of concentration, emotion, anxiety, and sleep problems. Depression, which is very common in persistent PCS, may aggravate other PCS symptoms, such as headaches and problems with concentration, memory, and sleep. PCS also shares symptoms with chronic fatigue syndrome, fibromyalgia, and certain toxic exposures. Traumatic brain injury can cause damage to the hypothalamus or pituitary gland, and pituitary hormonal deficiency (hypopituitarism) can cause symptoms similar to post-concussion syndrome; in this case, the symptoms can be treated by replacing any less hormones.
Treatment
Management of post-concussion syndrome usually involves treatments that deal with specific symptoms; For example, people can take pain relievers for headaches and medications to reduce depression or insomnia. Rest is recommended, but only somewhat effective. Physical and behavioral therapy can also be prescribed for problems such as loss of balance and difficulty with attention, respectively.
Medication
Although there is no pharmacological treatment for PCS, doctors may prescribe drugs used for symptoms that also occur in other conditions; for example, antidepressants are used for depression that often follows mTBI. Drug side-effects can affect people suffering from mTBI consequences more severely than others, and it is therefore recommended that treatment be avoided where possible; there may be benefits to avoiding narcotic drugs. In addition, some pain medications prescribed for headaches may cause rebound headaches when stopped.
Psychotherapy
Psychological treatments, of which about 40% of PCS patients are referred for consultation, have been shown to reduce the problem. Ongoing disabilities can be treated with therapy to improve workplace function, or in a social or other context. Therapy aims to assist in the gradual return of work and other preinjury activities, as symptoms are permitted. A protocol for the treatment of PCS has been designed based on the principle behind Cognitive behavioral therapy (CBT), a psychotherapy that aims to influence disturbed emotions by improving mind and behavior. CBT can help prevent the persistence of iatrogenic symptoms - which occur because healthcare providers create hope that they will do so. There is a risk that "power of suggestion" may aggravate symptoms and cause long-term disability; Therefore, when counseling is indicated, the therapist should consider the origins of psychological symptoms and do not assume that all symptoms are a direct result of neurological damage due to injury.
In situations such as motor vehicle accidents or after violent attacks, post-concussion syndrome can be accompanied by post-traumatic stress disorder, which is important to recognize and treat in its own right. People with PTSD, depression, and anxiety can be treated with drugs and psychotherapy.
Education
Education about their usual symptoms and time is part of psychological therapy, and most effective when given immediately after injury. Because stress exacerbates post-concussion symptoms, and vice versa, an important part of treatment is the certainty that PCS symptoms are normal, and education about how to deal with disorders. One study found that patients with PCS who were trained to return to the activity gradually, said what symptoms were expected, and trained how to manage them had a reduction in symptoms compared to the control group of uninjured people. Early education has been found to reduce symptoms in children as well.
Neurotherapy
Neurotherapy is an operant conditioning test in which the patient is given a conditional audio/visual award after producing certain types of brainwave activity. Recent neurotherapy improvements in QEEG can identify specific brain wave patterns that need to be corrected. Studies have shown that neurotherapy is effective in the treatment of post-concussion syndrome and other disorders with similar symptoms.
Prognosis
The prognosis for PCS is generally considered positive, with total resolution of symptoms in many, but not all, cases. For 50% of people, symptoms of post-concussion disappear within a few days to several weeks after the original injury occurred. In others, symptoms may remain for three to six months, but evidence suggests that many cases are actually resolved within 6 months. Most of the symptoms are mostly lost in about half the people with a concussion one month after the injury, and about two thirds of people with mild head trauma are nearly symptom-free within three months. Persistent, often severe, headaches are the longest-running symptoms in most cases and are the symptoms that are most likely never fully resolved. This is often stated in the literature and is considered to be common knowledge that 15-30% of people with PCS have not recovered one year after the injury, but this estimate is not appropriate because it is based on research of hospitalized people, a methodology that has been criticized. In about 15% of people, symptoms can persist for years or permanently. If symptoms can not be resolved within a year, it is likely to become permanent, although repairs may occur even after two or three years, or may suddenly occur after a long time without much improvement. Older people and those with previous head injuries tend to take longer to recover.
The way in which children cope with injuries after they occur may have more impact than the factors that existed before the injury. The mechanisms of children to deal with their injuries may have an effect on the duration of symptoms, and ineffective parents handling anxiety about the functioning of post-injury children may be less able to help their children recover.
If another blow to the head occurs after a concussion but before the symptoms disappear, there is little risk of developing a serious second-impact syndrome (SIS). In SIS, the brain swells rapidly, greatly increasing intracranial pressure. People who repeat minor head injuries during prolonged periods, such as boxers and Gridiron football players, are at risk for chronic traumatic encephalopathy (or variant dementia pugilistica), a chronic severe disorder involving decreased mental and physical abilities.
Epidemiology
It is not known exactly how common PCS are. Estimates of prevalence at 3 months post-injury were between 24 and 84%, variations that may be due to different populations or study methodologies. The estimated incidence of PPCS (persistent postconcussive syndrome) is about 10% of mTBI cases. Because PCS by definition only exists in people suffering from head injuries, demographics and risk factors similar to head injury; for example, young adults are at higher risk than others because they receive head injuries, and, consequently, develop PCS.
The existence of PCS in controversial children. It is possible that the brains of children have sufficient plasticity so that they are unaffected by the long-term consequences of concussion (although the consequences are known to originate in moderate and severe head trauma). On the other hand, children's brains may be more vulnerable to injury, as they are still developing and have fewer skills that can compensate for deficits. Clinical studies have found a higher rate of post-concussion symptoms in children with TBI than in those injured in other parts of the body, and that symptoms are more common in restless children. Symptoms in children are similar to those in adults, but children show fewer of them. Evidence from clinical studies found that high school age athletes had a slower recovery than concussion as measured by neuropsychological tests than older adults and adults. PCS is rare in young children.
Risk factors
Various factors have been identified as PCS predictive, including low socioeconomic status, previous mTBI, seriously related injuries, headaches, ongoing court cases, and female sex. Being older than 40 and being female has also been identified as a predictive diagnosis of PCS, and women tend to report more severe symptoms. In addition, the development of PCS can be predicted by having a history of alcohol abuse, low cognitive abilities before injury, personality disorder, or medical illnesses unrelated to injury. PCS is also more common in people with a history of psychiatric conditions such as clinical depression or anxiety before injury.
Factors associated with mild brain injury that increase the risk for maintaining post-concussion symptoms include injuries associated with acute headaches, dizziness, or nausea; Glasgow Coma Acute Score 13 or 14; and suffered another head injury before recovering from the first. The risk for developing PCS also seems to be increasing in people who have traumatic memories of injury or hope to be disabled by injury.
History
The symptoms that occur after a concussion have been described in various reports and writings for hundreds of years. The idea that these sequences of phenomena formed different entities began to gain greater recognition in the later part of the nineteenth century. John Erichsen, a surgeon from London, played an important role in developing the study of PCS. The controversy surrounding the cause of PCS began in 1866 when Erichsen published a paper on surviving symptoms after mild head trauma. He suggested that the condition was due to "molecular chaos" to the spine. This condition was originally called the "railroad spine" because most of the injuries being investigated occurred in railroad workers. While some of his contemporaries agree that the syndrome has an organic basis, others associate those symptoms with psychological factors or directly pretend. In 1879, the notion that physical problems were responsible for the symptoms was challenged by Rigler, stating that the cause of persisting symptoms is actually "compensatory neurosis": the practice of trains to compensate injured workers has led to complaints.. Then, the notion that hysteria is responsible for symptoms after mild head injury is suggested by Charcot. Controversy about the syndrome continued into the 20th century. During World War I many soldiers suffered from confusing symptoms after close proximity to the explosion but without any evidence of head injury. The disease is called shock shell, and psychological explanations are finally favored. In 1934, the current concept of PCS has replaced the notion of hysteria as the cause of post-concussion symptoms. British authorities prohibited the term "shock shell" during World War II to avoid a case epidemic, and the term "posttrauma concussion state" was created in 1939 to describe "a disorder of consciousness without direct or obvious pathological changes in the brain". The term postconcussion syndrome was used in 1941.
In 1961, H. Miller first used the term "accident neurosis" to refer to the syndrome now called PCS and confirmed that the condition only occurs in situations where people stand to be compensated for injury. The real cause of this condition is still unclear.
Controversy
Although there is no universally accepted definition of postconcussive syndrome, most literature defines this syndrome as developing at least 3 of the following symptoms: headache, dizziness, tiredness, irritability, memory and concentration disorders, insomnia, and lower tolerance for noise and light. One complication in diagnosis is that PCS symptoms also occur in people who have no history of head injury, but who have other medical and psychological complaints. In one study, 64% of people with TBI, 11% of those with brain injury, and 7% of those with other injuries met the DSM-IV criteria for post-concussion syndrome. Many of these PCS patients were misdiagnosed to have other unrelated conditions due to symptom similarity. (see diagnosis, below).
Headache is one of the criteria for PCS, but it is mainly not determined where the headache originates. Couch, Lipton, Stewart and Scher (2007) argue that headache, one of the hallmarks of PCS, occurs in a variety of head and neck injuries. Furthermore, Lew et al. (2006) reviewed many studies comparing headaches with post-traumatic headache and found that there is a wide heterogeneity in the source and causes of headaches. They point out that the International Headache Society mentions 14 known causes of headaches as well. In addition, headaches may be better taken into account by mechanical causes, such as whiplash, which is often mistaken for PCS. An additional possibility is that Post-traumatic Stress Disorder may explain some cases that are diagnosed as PCS, but for emotional regulation as well.
Depression, post-traumatic stress disorder, and chronic pain share symptoms similar to PCS. One study found that while people with chronic pain without TBI reported many symptoms similar to post-concussion syndrome, they reported fewer symptoms related to memory, slowed thinking, and sensitivity to noise and light than people with mTBI. In addition, it has been found that neuroendocrinology may explain the symptoms of depression and stress management due to irregularities in the regulation of cortisol, and thyroid hormone regulation. Finally, there is evidence that major depression following TBI is fairly common, but it may be better noted with the diagnosis of dysexecutive syndrome.
In a syndrome, a series of symptoms are consistently present, and symptoms are linked in such a way that the presence of one symptom indicates that of another person. Because PCS symptoms vary widely and many can be attributed to a large number of other conditions, doubts about whether the term "syndrome" is appropriate for the constellation of symptoms found after concussion. The fact that the persistence of one symptom is not always related to other symptoms has led to doubts about whether "syndrome" is the right term.
The old controversy surrounding PCS concerns the nature of etiology - that is, the cause behind it - and the extent to which psychological factors and organic factors involving brain dysfunction are responsible. The debate has been referred to as 'psychogenesis versus physiogenesis' (psychogenesis refers to the psychological origin for the condition, physiogenesis to physique).
See also
- Daniel Amen, a post-concussionist for the National Football League
References
External links
Source of the article : Wikipedia
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