Post-Concussion Syndrome Management

Initial Workup

The American Academy of Neurology recommends evaluating the collective burden of postconcussion symptoms, including physical, cognitive, and emotional symptoms 1
Vestibular evaluation is recommended to assess for persistent vestibular dysfunction that may contribute to dizziness, balance problems, and visual disturbances 2, 3
Visual/Oculomotor Assessment is recommended to screen for vergence, accommodative, or eye movement dysfunction that may cause headache, visual symptoms, and concentration difficulties 2, 4
Cervical Spine Assessment is recommended to evaluate for cervicogenic contributions to headache and neck pain 5, 3
Psychological Assessment is recommended to screen for emotional symptoms, including depression, anxiety, and post-traumatic stress 1

Patient Education is recommended to provide systematic information and advice regarding symptom management, expected recovery course, and self-care strategies 6, 3
Patient Education has shown positive effects on reducing overall symptom burden and preventing memory problems 3

Graded Physical Exercise is recommended to implement sub-symptom threshold aerobic exercise with gradual increase in intensity/complexity 7, 6
Graded Physical Exercise has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 3
Vestibular Rehabilitation is recommended for patients with persistent vestibular symptoms 2, 3
Vestibular Rehabilitation has demonstrated positive effects on physical functioning and return to sport/activities 2
Manual Therapy is recommended to consider spinal mobilization/manipulation for patients with neck pain 5, 3
Manual Therapy has shown positive effects on pain reduction and readiness to return to activities 5

Oculomotor Vision Treatment is recommended for patients with persistent visual symptoms 2, 4
Oculomotor Vision Treatment includes vergence training, accommodative training, and eye movement exercises 4
Clinical experience suggests improvements in visual symptoms, headache, and fatigue with Oculomotor Vision Treatment 4

Psychological Treatment is recommended to offer individual or group therapy for emotional symptoms 1, 8
Psychological Treatment is associated with positive effects on overall symptom burden, emotional symptoms, and quality of life 1

Interdisciplinary Coordinated Rehabilitation is recommended to implement treatment from at least two different healthcare disciplines 9, 8
Interdisciplinary Coordinated Rehabilitation has shown positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life 9

The evidence supporting these interventions ranges from very low to low certainty 7, 10
Recommendations for most interventions are weak but consistent across guidelines 10
The recommendation for oculomotor vision treatment is based primarily on clinical consensus rather than controlled trials 4

For patients with anxiety and sleep disturbances following concussion, the American Medical Association recommends initiating psychological treatment, such as cognitive behavioral therapy, as first-line for anxiety, and implementing sleep hygiene education with consideration of melatonin for sleep problems, while simultaneously addressing these symptoms within a graded physical exercise program 11, 12

Psychological treatment should be offered as individual or group therapy administered at least 1 hour per week for a minimum of 4 weeks, demonstrating positive effects on emotional symptoms, overall symptom burden, and quality of life at longest follow-up 12
The treatment should be provided by psychologists or clinicians with similar professional backgrounds 12

If symptoms persist beyond 4 weeks or are severe, coordinate treatment from at least two healthcare disciplines, such as psychology and physical therapy, demonstrating positive effects on overall symptom burden, emotional symptoms, physical functioning, and quality of life 12
This approach should include at least 2 interventions administered minimally once weekly for 4 weeks 12

Recognize that 15-20% of patients develop persistent symptoms requiring more intensive intervention 13