1. Introduction
In Denmark approximately 25.000 cases of mTBI are diagnosed each
year1 with an additional estimated 25%
undiagnosed,2 bringing the national incidence rate up
to 545 pr. 100.000. This is in line with the international rate where
incidents of mTBI, including diagnosed and undiagnosed, are estimated to
be about 600 per 100.000 worldwide, or around 45 million a
year.3 Of these, roughly 75-90% experience gradual
remission of symptoms within 14 days, whereas 10-25% continue having
symptoms, which may then devolve into Post-Concussion Syndrome
(PCS).4,5 While no consensus on the timeframe exists,
PCS can be defined as experiencing persistent symptoms of a mTBI for
longer than 3 months, as by the DSM-5 criteria, with additional
psychosocial sequelae.6,7 Patients often experience
difficulties in maintaining their social, professional and physical
levels of activity, and may be at risk of not participating in and
contributing to the financial state of society. A Danish survey found
that 19% of all mTBI patients were on sick leave for more than a month
and that 2% had still not returned a year after the initial
trauma.8 In the U.S., a report from the Agency for
Health Research and Quality found that TBI patients across all levels of
severity had a higher prevalence of long term depression at 30%, which
is more than three times the national average at 8-10%, as well as
higher rates of anxiety and PTSD.9
An increasing amount of evidence shows that an active approach, contrary
to earlier beliefs about a ”wait and see approach”, can improve outcomes
and long term prognosis.10–12 The international
consensus statement on Concussion in Sports from 2016 in Berlin
recommends a period of 24-48 hours of physical and cognitive rest after
the initial trauma, followed by a progressively active
rehabilitation.13 It is well established that PCS
patients can experience barriers towards physical and cognitive
activity, with higher levels of cognitive exertion associated with
longer duration of symptoms in some,14 and that
adequate management between rest and activity is a central yet complex
part of the recovery process.15–17 These barriers
often manifest as exercise intolerance, cervicogenic headaches, rapid
eye exhaustion, dizziness, nausea, excessive fatigue, and a low
threshold for managing sensory input.18–22 Therefore,
it is important to clarify the parameters of an active approach to
treatment in a rehabilitation setting. In this context, an active
approach can be both an up or downregulation of physical and mental
stimulation, as well as providing education and tools to promote patient
self-efficacy.
One of the major challenges in dealing with PCS is categorizing the
underlying pathologies and understanding their effect on the
symptomatology, to which the evidence suggests a multitude of
neurophysiological and psychosomatic mechanisms. These mechanisms
include disruptions in cerebral blood flow (CBF),23,24changes in brain metabolism,25 axon
damage,26 changes in autonomic and neuroendocrine
function,27–30 cervical injury and postural
weakness,31 disturbances in the vestibular and
oculomotor system,32,33 and neuropsychological
dysfunctions.34,35 These myriad of components and
overlapping comorbidities adds to the complexity of PCS, and highlights
the difficulties of having a single treatment regimen. It may also
explain the varying responses to clinical
assessment.36
A useful tool in organizing and providing the most relevant care is the
evidence-based practice (EBP) model originally coined by
Sackett37 and further developed through
Straus38 and Howick.39 While
different iterations exists, the model formulates three dimensions of
best practice: Best Research Evidence which is the highest graded and
most appropriate evidence in the scientific literature, Clinical
Expertise which is the clinical experience and knowledge, and Patient
Preferences which is the individual patient preferences, their values or
larger group characteristics. Using the EBP model practitioners can more
easily stratify the individual variables and formulate a cohesive plan
of action to target the multifaceted nature of PCS.
By applying two distinct interventions, this paper will examine how an
active and individualized approach can be used in the treatment of PCS.
The empirical data will be derived from two case studies, each
consisting of two cases with separate protocols, highlighting the
aspects of overcoming symptoms of PCS with insight from the cases, as
well as an inclusion of the relevant literature. This will be viewed
through the lens of a modified EBP model and ultimately summarized in a
visual presentation, to more appropriately transfer knowledge to the
clinical practice.