When Concussion Symptoms Persist: What Doctors Need to Know

Each year, an estimated 1.6% of Canadians aged 12 years or older sustain one or more concussions, according to data from Statistics Canada. Many of these patients face lingering symptoms long after the initial injury.“Concussions are extremely common, especially in Canada,” said Charles Tator, MD, PhD, professor of neurosurgery at the University of Toronto. “There’s rough terrain here, people frequently play contact sports, they may drive too fast or fall off a ladder while working, et cetera. We also have the problem of intimate partner violence, which looms large as a cause of concussion.”Risk Factors for Persisting Symptoms“While most patients recover within 4 weeks following a concussion, [many] experience persisting symptoms,” said Shelina Babul, PhD, clinical professor of pediatrics at The University of British Columbia in Vancouver.A 2018 study estimated that 11.4%-38.7% of patients with concussion will experience persisting symptoms after concussion (PSaC) — a newer term for postconcussion syndrome — while a 2022 study found that the rate was higher than 50%.“We don’t have a way of telling at the beginning how long symptoms are going to last,” pointed out Tator.Nevertheless, two “of the strongest predictors for persisting symptoms and prolonged recovery are the number of symptoms and the severity of those symptoms in the early period following the injury,” said Babul.Other factors associated with an increased risk for concussion, PSaC, or both include the following:Certain age groups, such as children, adolescents, and older adultsFemale sexPrevious concussionsPreexisting learning disabilities and attention-deficit/hyperactivity disorderHistory of migraineHistory of mental health diagnosesType of sport and position played“Social determinants of health — for example, education level, household size, income, insurance, and access to care — also influence the patient’s recovery,” said Babul.In addition, “older people are at high risk of concussion because they have many falls,” said Carmela Tartaglia, MD, associate professor in the Tanz Centre for Research in Neurodegenerative Diseases at the University of Toronto. “Yet many times, they are not assessed for concussion, such as when they have a fall that results in a broken limb. Older people with dementia can also have events that are not remembered or noticed by anyone, so their concussion may go completely undiagnosed, or the symptoms may be mistaken for worsening dementia.”Early Treatment Essential“Concussion, although a mild brain injury, is still a brain injury and thus should be treated as such,” emphasized Tartaglia.Symptoms of PSaC fall into the following four categories:Physical: headache, sensitivity to light or sound, blurry vision, dizziness, balance problems, etc.Cognitive: difficulty with memory, attention, or thinking; confusion; mental “fog;” etc.Sleep: sleeping less or more than usual, difficulty falling or staying asleep, daytime drowsiness, etc.Mood or behavioral: increased irritability, depression, or anxiety; crying more easily; feeling overwhelmed; etc.During the initial visit with a primary care physician or emergency department physician, “patients should be provided with evidence-based education and guidance on management and recovery, and a follow-up visit should be booked,” said Babul.If symptoms persist for longer than 2-4 weeks, she recommends targeted treatment with multidisciplinary care, aimed at managing specific symptoms. “Patients with an increased number of risk factors for prolonged recovery should be referred earlier in the recovery period,” she emphasized.For example, headache may be treated with certain medications, while low mood, depression, or anxiety may be treated with a selective serotonin reuptake inhibitor or other medication along with cognitive-behavioral therapy.In the past, patients were asked to rest until symptoms resolved. But beyond the initial 24-48 hours — during which strenuous activity should be avoided — “rest, both physical and cognitive, is not recommended,” said Babul, “and current evidence suggests that it hinders recovery.”Specialty Care for PSaCGiven the large number of new concussions each year in Canada, it’s not possible for specialized concussion clinics to treat all of them, Tator said. “So the emphasis is on having primary care physicians look after the majority of patients.”“Many of the persisting symptoms of concussion — such as headache, sleep issues, low mood or anxiety, vertigo — can be managed in primary care practices,” emphasized Tartaglia. “But physicians should refer to specialists if patients fail first-line therapies.”One challenge of treating concussions in Canada is that access to specialized care varies throughout the country, with limited availability in rural areas, said Babul, and even long wait times to see a family physician in certain places. “This represents a gap in timely and equitable access to concussion care.”The science of concussion prevention, diagnosis, and management is rapidly changing. Babul recommends that physicians and the public be aware of the latest evidence-based guidelines on how to recognize and manage a concussion, such as through the Concussion Awareness Training Tool.Babul, Tartaglia, and Tator reported no relevant financial relationships.