Understanding Post-Concussion Syndrome: A Case Study

[Melissa Mills, BSN]

Post-Concussion Syndrome is difficult to recognize. Would you know the symptoms? Let's meet Mr. Jones and learn about his symptoms of post-concussion syndrome.

Case Study: Mr. Jones is a school teacher. While walking down the hall, he slipped in water on the floor near the water fountain. He fractured his left wrist during the fall and reports that he hit his head. He did not lose consciousness.

He was treated in the emergency room on the day of the injury. An MRI of the head showed no acute changes. His wrist was reduced in the ER and he was discharged home with instructions to follow-up with an Occupational Health Clinic and orthopedic clinic.

Four weeks go by, Mr. Jones returns to the occupational health clinic where you work. He reports that his wrist is doing better and he has started Physical Therapy for mobility and strength training. During his appointment with the Occupational Health physician, it is noted that he is irritable and has difficulty finding certain words. The doctor asks him if he has any other symptoms. He reports intermittent headaches, dizziness, anxiety, and feeling more irritable than normal. He tells the doctor he is confused by these symptoms because the MRI was normal.

The occupational health physician tells him that he has post-concussion syndrome and that his symptoms could last months or even years. He gives him an order for vestibular rehab, some written education on post-concussion syndrome, and sends him on his way. You try to provide education, but Mr. Jones is irritable and says he just wants to leave.

As he starts to leave the clinic, he comes back to the desk where you are sitting. He is angry, yet tearful. He does not understand this diagnosis, treatment plan, or why this is happening since he bumped his head a month ago. He asks you to help explain this to him further. Can you help?

What is Post-Concussion Syndrome?

According to Mayo Clinic, post-concussion syndrome is a complex disorder that can last for weeks, months, or even years after a mild traumatic brain injury. It can be caused by a blow to the head or violent shaking or movement of the head or body. You don't have to lose consciousness to have a concussion or post-concussion syndrome. The severity of the head injury is not an indicator of the risk of developing post-concussion syndrome.

What Causes Post-Concussion Syndrome?

There are several different theories behind the true cause of post-concussion syndrome. One theory is that the symptoms are caused by structural damage to the brain and/or messaging system within the nerves. Another theory is that these symptoms are related to pre-existing psychological factors, such as a history of the following:

• Depression
• Anxiety
• Post-traumatic stress disorders
• Life stressors
• Poor social support system
• Lack of coping skills

Signs and Symptoms of Post-Concussion Syndrome

• Headache
• Dizziness
• Fatigue
• Irritability
• Anxiety
• Insomnia
• Loss of concentration and memory
• Ringing in the ears
• Blurry vision
• Noise and light sensitivity
• Changes in taste and smell

Treatment

Treatment of post-concussion syndrome focuses on symptom control. A treatment plan that includes symptom management coupled by time is the best way to assist the patient to learn to control the symptoms they experience.

Medications - The patient may be given medications to treat the headaches, depression, or anxiety felt after a mild concussion.

Psychotherapy - The patient may need to speak to a therapist to understand that there is a cause for their symptoms. They will need to learn coping mechanisms that help to control the severity of depression and anxiety related to the injury.

Vestibular Rehabilitation - One study defines vestibular rehabilitation as a form of physical therapy that uses specialized exercises that result in gaze and gait stabilization. It is an effective treatment for central balance system issues, such as post-concussion syndrome. The goals of vestibular rehab include improved balance, minimizing falls risks, decreased feelings of dizziness, and decreased anxiety.

Nursing Goals and Interventions

Our main focus for patients with post-concussion syndrome is education and self-management. Mr. Jones is frightened, frustrated and probably a bit confused by his diagnosis. You know that you will be seeing him every week when he comes back for his check-ups with the doctor. You can also stop by while he is receiving vestibular rehab in the clinic's physical therapy department.

What should you use for nursing goals and interventions? Below are a few nursing goals and interventions that may appropriate for post-concussion syndrome patients:

Goal: Patient will report decreased severity and frequency of headaches.

Interventions may include:

• Education on medication management
• Education on non-pharmacologic interventions to decrease the severity of headaches such decreased activity, noise and light control, and rest

Goal: Patient will be free of intervening injuries, including falls, while experiencing dizziness.

Interventions may include:

• Education on clear pathways in the home
• Education on use of any ordered durable medical equipment
• Education on energy conservation
• Education on the use of slow position changes to decrease the severity of dizziness
• Education on the importance of compliance with Vestibular Rehab and home exercise program

Goal: Patient will report a decrease in symptoms of anxiety and depression.

Interventions may include:

• Education on the importance of attending all psychotherapy appointments
• Education on the proper use of prescribed medications

Post-Concussion Syndrome can be a difficult to treat problem. Patients need support and understanding as they receive treatment. Do you have a story about a post-concussion syndrome patient? Other ideas of nursing goals and interventions? We would love to hear your stories and thoughts. Just comment below and get the conversation started.

[debrasimons]

I am acquainted with someone who had a severe fractured skull but yet has syringomyelia and charcot-marie-tooth all of which can cause headaches and all of that combined makes it really difficult on this patient. She is suffering from headaches 2 years out so it is hard to know what exactly is causing them since she has underlying issues

[Melissa Mills, BSN]

Hi debrasimons - Thanks for the comment. Yes, the differential diagnoses seem to clump together, which only makes the symptoms that much harder to treat. Has she tried Vestibular Therapy? Might be worth a shot. Best of luck.

Melissa

[Farawyn]

I've never heard of vestibular therapy. We usually suggest a pediatric neuro and follow up with very strict return to play.

My son had a bad concussion playing football 2 years ago. He couldn't read music for a month or 2 after, everything else was fine.

He now seems fully recovered, but it is scary.