An approach to treating postconcussion symptoms is given further on. It has also been reported that military personnel who experience head injuries of any degree have a higher incidence of posttraumatic stress disorder (PTSD) than those with other somatic injuries but again, the disorder is not easily predicated on psychologic factors. The same disorder can be detected in civilians after injury and it then blends clearly into the earlier-described postconcussion syndrome.
Hysterical symptoms that develop after head injury, both cognitive and somatic, appear to be more common than those following injury to other parts of the body. These symptoms are discussed in Chap. 47. They may be immediate or delayed and vary from amnesia to blindness, paralysis, stuttering, inability to stand, and even to catatonia.
Patients with an uncomplicated concussive injury who have already regained consciousness by the time they are seen in a hospital and have a normal neurologic examination pose few difficulties in management. They should not be discharged until a decision is made about appropriate examinations (CT scans, skull films), if necessary and the results prove to be negative. Also, the patient should probably not be released until the capacity for consecutive memories has been regained and arrangements have been made for observation by the family of signs of possible, although unlikely, delayed complications (subdural and epidural hemorrhage, intracerebral bleeding, and edema). A program instituted by Mittenberg and colleagues (2001) has shown that reassurance and explanation of the concussive injury and anticipated aftereffects reduce the incidence of postconcussive symptoms at 6 months. Most such patients become mentally clear, have mild or no headache, and are found to have a normal neurologic examination. They do not require hospitalization or special testing, but in the current litigious climate of the United States, some form of brain imaging is nonetheless often performed as discussed in an earlier section.
Concussion from athletic injury currently mandates removal from play, a formal assessment of some sort and a graduated program of activity as mentioned earlier. Many testing methods and rehabilitation programs have been introduced, many of which are proprietary and not profitably recounted here.
Patients with persistent complaints of headache, dizziness, and nervousness, are the most difficult to manage. The main approach is to counsel patients while the symptoms resolve, coupled with a reduction in mental and physical effort that is commensurate with the patient’s level of endurance. A program must be planned in accordance with the basic problem. The notion of “cognitive rest” has been introduced but its effectiveness is difficult to gauge. Certainly youngsters and teens have difficulty concentrating on homework and other tasks and there seems to be little virtue in pressing them to perform. The range of time to recover and severity as symptoms such as “mental fog” and sleepiness is wide. If work or school work precipitate headaches, for example, plans should be made to have them curtailed. Half-time work may be suitable for some individuals but not for others. Similarly, some physical activity is to be encouraged but exertion that causes headaches or mental confusion to occur or worsen should be reduced. At the same time, a bedbound or homebound state is discouraged and the patient may walk, use the Internet, watch television, or read up to the level of causing fatigue. Each of these activities is then increased at a gradual rate. In all instances, reassurance that these symptoms improve over weeks or more should be offered in order not to allow the individual to internalize the notions of chronic dementia after head injury that pervade the popular press. Some hard-driving patients return to work, only to find headache, confusion, and fatigue recur in a disabling way and must start the cycle of reduced effort over again.
If there is mainly an anxious depression, antidepressant medications are sometimes prescribed but this is not our usual practice—their effects are often disappointing. Simple analgesics, such as acetaminophen or nonsteroidal antiinflammatory drugs, should be prescribed for the headache. Any increase in headache, vomiting, or difficulty arousing the patient should prompt a return to the emergency department. A written instruction sheet with symptoms to be expected and clear advice about returning for examination is very helpful.