How to Treat Post Concussion Syndrome

Living with post-concussion syndrome (PCS) can be incredibly challenging, and if you're experiencing it, you're not alone. Millions of people each year will sustain traumatic brain injuries (TBIs). Approximately 30% of those individuals will develop PCS. 

Dealing with PCS can disrupt various aspects of your life, from work and school to relationships and hobbies. However, understanding that effective treatment and support are available can provide hope and guidance on the journey toward recovery.

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What Is Post Concussion Syndrome (PCS)?

A traumatic brain injury (TBI) is damage to the brain caused by a sudden impact, blow, or jolt to the head or body. TBIs can vary in severity and are classified as mild, moderate, or severe based on the Glasgow Coma Scale (GCS) grading system. 

Mild TBI, or concussion, is the least severe form of TBI, correlating to a GCS score of 13-15. PCS is the constellation of symptoms that persist after sustaining a TBI. 

Concussions affect how people feel, think, learn, act, and sleep. Concussion symptoms may appear up to 10 days after sustaining a brain injury but typically resolve spontaneously within two to six weeks. PCS is diagnosed when symptoms persist longer than expected. (39, 40) 

There are four categories of concussion symptoms:

• Physical: headaches, balance problems, fatigue, nausea, clumsiness, sleeping too little or too much
• Sensory: light and sound sensitivity, seeing stars, blurred and double vision, dizziness and vertigo, sound, trouble seeing at night, difficulty reading and tracking objects with the eyes, difficulty seeing things up close
• Mental: memory loss, brain fog, difficulty concentrating, slowed thinking
• Emotional/Behavioral: irritability, depression, anxiety, agitation, mood swings, restlessness, thoughts of self-harm or suicide

Two sets of diagnostic criteria are established for diagnosing PCS: DSM-IV and ICD-10. Per the DSM-IV criteria, PCS is diagnosed when at least three symptoms are present for at least three months. ICD-10 criteria define PCS as symptoms persisting longer than three weeks.

Identifying Root Causes and Triggers of PCS

While it's not entirely understood why some people who suffer a concussion will experience PCS and others will not, it appears that a combination of factors increases the likelihood of it occurring. 

Neurovascular Coupling Dysfunction

Neurovascular coupling (NVC) is the process that links brain cells (called neurons) to blood flow in the brain, ensuring that active portions of the brain receive the oxygen and nutrients they need to function appropriately. 

When the brain sustains an injury, the immune system mounts an inflammatory response, recruiting immune cells to the area to support healing and clear cellular debris from the area. This inflammation can cause a temporary breakdown of neurological and vascular structures, disrupting the NVC mechanism. This is called NVC dysfunction. NVC dysfunction is responsible for the lingering symptoms of PCS because it impairs the ability of the impacted areas of the brain to perform efficiently. (17) 

Hormonal Imbalance

If the pituitary gland is injured during a brain injury, the endocrine (hormonal) system can be compromised. 

The pituitary gland is located in the brain and is responsible for producing hormones including thyroid-stimulating hormone (TSH), adrenocorticotropin hormone (ACTH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH).

• TSH signals the thyroid gland to produce thyroid hormones
• ACTH signals the adrenal glands to produce cortisol
• LH and FSH signal the ovaries and testes to produce estrogen and testosterone

An underactive pituitary can lead to greater hormonal deficiencies, which can mimic and exacerbate PCS symptoms. For example, an underactive thyroid (hypothyroidism) leads to fatigue, depression, and sleep disturbances. 

Nutritional Deficiencies

Adequate nutrition supports various aspects of brain function, including energy metabolism, neurotransmitter synthesis, and the repair of brain tissue. Certain vitamins and minerals are essential in neurological function, and deficiencies can lead to neurological symptoms. For example, a common symptom of vitamin B12 deficiency is peripheral neuropathy (numbness, pain, and weakness that results from nerve injury). 

Certain nutritional deficiencies may exacerbate TBI symptoms. Particular attention has been placed on the importance of vitamin D status and TBI recovery. Vitamin D is strongly neuroprotective and anti-inflammatory. According to one study, vitamin D insufficiency and deficiency are common in patients with TBI. The severity of deficiency correlates to more substantial cognitive impairment and symptomatology in patients after sustaining TBI. (16, 23)  

Stress

Autonomic dysfunction, which involves dysregulation of the autonomic nervous system (ANS), is also common after TBI. The ANS controls involuntary bodily functions such as heart rate, blood pressure, digestion, and breathing. Many post-concussive symptoms can be attributed to autonomic dysfunction, such as headache, changes in heart rate variability, abnormal blood pressure, and digestive issues. (31) 

Following a TBI, individuals often experience heightened stress levels due to the challenges associated with the injury. Stress can contribute ANS dysregulation, leading to increased sympathetic ("fight or flight") and decreased parasympathetic ("rest and digest") activity. This imbalance exacerbates symptoms of autonomic dysfunction and hinders recovery. (54) 

Treatment Strategies for Managing PCS

Factors like the severity of TBI and a history of past head trauma influence PCS prognosis. While most patients are expected to fully recover in three months, an estimated 10-15% will have symptoms that persist for one year or longer. (38) 

The brain needs time for full recovery. Treatment approaches for PCS involve strategies to address specific symptoms, facilitate brain recovery, and support neurological function. (40) 

Nutrition

A healthy diet that meets the brain's nutritional requirements elevates levels of molecules, such as brain-derived neurotrophic factor (BDNF), that are important for daily brain function and injury recovery. 

The Mediterranean diet has been extensively studied for its brain benefits. The Mediterranean diet is centered around high consumption of fruits, vegetables, whole grains, legumes, nuts, seeds, fish, and olive oil. 

Fatty fish are rich in omega-3 fatty polyunsaturated acids, which comprise 35% of the brain's weight. In particular, the omega-3 fatty acid called docosahexaenoic acid (DHA) makes up approximately 40% of the brain's total fatty acids. Omega-3s are anti-inflammatory and preserve the health of brain cells. (14) 

The brain is 75% water. Dehydration restricts blood flow to the brain, leading to symptoms of cognitive deficits. Staying well hydrated by drinking enough water can help alleviate PCS symptoms. While not everyone needs the same amount of water, general guidelines recommend drinking half your body weight in ounces daily. 

Most Americans eat too little protein. Dietary protein is broken down into amino acids, which support the repair of damaged brain tissue and act as the building blocks for neurotransmitters. Meat, fish, eggs, beans, nuts, and seeds are good protein sources.  

Antioxidants fight inflammation. Eating the rainbow is a great way to ensure you consume adequate antioxidants. Herbs and spices also are highly antioxidant. Turmeric, in particular, has been studied for its anti-inflammatory and neuroprotective properties. 

Lifestyle Modifications

Sleep is essential for healing, cognitive function, memory consolidation, and overall brain health. Studies indicate that long-term sleep disturbances are a consequence of TBI. Sleep disturbances are correlated to impaired functionality and reduced quality of life in those who have sustained brain injuries. 

Therefore, addressing sleep habits and quality is important to PCS recovery. Patients should be encouraged to establish healthy sleep hygiene habits. Supplemental or pharmaceutical sleep aids may also be of benefit during recovery. For example, 1-3 mg of melatonin two hours before bedtime can reduce the time it takes to fall asleep.

Research suggests that exercise promotes neuroplasticity, enhances BDNF levels, and reduces inflammation, all of which benefit brain recovery. Patients recovering from TBI should focus on low-intensity exercise to facilitate healing. Examples include riding a stationary bike and walking slowly for up to 30 minutes daily. If exercise worsens PCS symptoms, patients should be advised to take breaks and reduce activity intensity/duration. (40)  

Mind-body therapies combat stress and balance the ANS by activating the vagus nerve, the primary nerve of the parasympathetic nervous system. Research has demonstrated that stress reduction interventions, such as mindfulness-based stress reduction (MBSR), can improve psychological well-being and reduce symptom severity in individuals with TBI.

Detoxification Support

Minimizing exposure to environmental toxins may benefit individuals with PCS, as toxins can exacerbate neuroinflammation. Sources of toxins include air pollution, pesticides, heavy metals, and chemicals found in food, water, and household products. Adopting simple lifestyle changes, such as consuming organic foods, using non-toxic household cleaners, and drinking filtered water, can reduce toxic exposure and burden, potentially alleviating PCS symptoms. 

Neuroplasticity and Brain Rehabilitation

Neuroplasticity refers to the brain's ability to adapt and change throughout life by forming new neural connections and pathways and modifying existing ones.

Brain rehabilitation recruits a variety of therapies to address the cognitive, physical, emotional, and functional challenges associated with concussion to harness the power of neuroplasticity. Different therapies can be employed, including physical therapy, occupational therapy, speech therapy, vestibular rehabilitation, vision therapy, and psychotherapy. 

Studies have demonstrated that these targeted interventions can significantly improve concussion symptoms, functional abilities, and quality of life for individuals recovering from TBI. Early initiation of rehabilitation results in the most significant functional recovery; however, even patients who start rehab later after injury can still reap its benefits. 

Complementary and Integrative Medicine

Massage is a complementary therapy that involves manual manipulation of soft tissues. Evidence supports its use in treating musculoskeletal pain and headaches. Published case reports also suggest massage can effectively reduce other TBI-related symptoms, including dizziness and nausea. 

Research suggests that acupuncture may alleviate pain by modulating pain perception. Acupuncture exhibits neuroprotective effects by reducing inflammation, oxidative stress, and neuronal damage while enhancing neurotrophic factor expression and promoting neurogenesis in animal studies. Other potential benefits of acupuncture for PCS recovery include its ability to regulate pain-modulating neurotransmitter release, improve cerebral blood flow, and modulate autonomic function.

Building a Supportive Care Team

As you can infer, treating PCS necessitates an interdisciplinary approach that integrates various medical specialties and therapeutic modalities to address the multifaceted nature of the condition. Multidisciplinary teams include neurologists, endocrinologists, physical therapists, and psychologists, allowing for a holistic assessment (considering physical, cognitive, and emotional aspects) of the patient's needs. Studies have shown that combining multimodal interventions can significantly improve symptom severity, functional outcomes, and quality of life for individuals recovering from TBI.

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Key Takeaways

• Post-concussion syndrome (PCS) is characterized by persistent symptoms that can last for weeks to years after a concussion.
• Symptoms of PCS may include headaches, dizziness, fatigue, difficulty concentrating, memory problems, mood changes, and sleep disturbances.
• Therapeutic nutrition, lifestyle modifications, rehabilitation, and complementary and integrative modalities help meet the goals of PCS treatment: managing symptoms and promoting brain healing.
• The collaboration between healthcare professionals, including physicians, neuropsychologists, physical therapists, and occupational therapists, can enhance health outcomes for individuals with PCS.