Post-concussion syndrome - what is it, what influences it?
It is estimated that 42 million head injuries occur globally each year. In countries such as the United States, it is estimated that up to 1.5 million head injuries occur annually, but statistics for other nations are not as well-documented.
Post-concussion syndrome (PCS) is the clustering of symptoms that persists beyond 3 months after trauma, and often results in debilitating symptoms such as persistent headaches, fatigue, and difficulty engaging in employment and social roles.
This study investigated the prevalence of PCS, specifically in a rural country such as Ethiopia, and the impact of on-going concussion symptoms and PCS in this area. This study also sought to establish if the factors impacting the criteria for PCS were similar in Ethiopia as compared to other countries with documented PCS input, such as the United States and New Zealand.
For this study, 275 cases were sampled from a hospital setting, where individuals were assessed following their head injury. The cases were reviewed over the course of 5 months, with over half of the subjects being in the age range of 25-34 years old.
The Rivermead Questionnaire (a validated subjective measurement tool used to predict the likelihood of the development of PCS) was used to assess their symptoms. The Rivermead Questionnaire asks questions in relation to headaches, fatigue and overall subjective feelings of recovery from the head injury.
A persistent headache was the main on-going symptom, and based on the Rivermead scores, 41.5% of the cases met the criteria for PCS, due to the length of time and number of symptoms beyond 3 months. This number is significantly higher than other countries, such as New Zealand (which has an estimated 30% rates of progression to PCS) and Malaysian and Swedish studies (which have a rate of 8% and 34% progression to PCS, respectively).
The aim of this study was to investigate the incidence of PCS and the factors that could be contributing to the development of PCS. Interestingly, this study also found a difference in prevalence of PCS between different types of occupation, with a significantly lower rate of PCS in students as opposed to employed staff, and government workers having high rates of PCS development.
Lastly, this article also found that the type of accident (i.e., motor bike accidents etc.) had a higher rate of PCS development, as did the location of the head injury, with right lateral head impacts having higher rates of PCS.
While this study has several limitations, such as a lack of controls or blinding, it is interesting to see that external factors may play a role in the risk of development of PCS. Societal differences and cultural beliefs may potentially explain the variations between different countries and the rates at which PCS is reported.
Additionally, the differences in students vs. other employed workers may raise questions for further research, such as how socioeconomic status impacts head injury recovery and personal coping strategies, and the likelihood of the developing PCS.
Expert opinion by Jessica Povall
As said, this article has certain limitations, but it does raise some interesting questions on the potential factors that contribute to PCS.
In a clinical setting, PCS is sometimes incorrectly diagnosed, there is no valid basis for naming it PCS vs. concussion. However, with the definition of multiple symptoms lasting longer than 3 months, and by using the validated Rivermead Questionnaire, specific criteria for PCS are available.
Finally, no 2 injuries are the same. Concussion therapy should do more than just addressing the injury, and multidisciplinary treatment has to be considered. In addition to physiotherapy, occupational therapy, psychological and medical support may be needed to achieve resolution of the concussion and limit the risk of progression to PCS.
> From: Bedaso et al., J Headache Pain 19 (2018) 1-6. All rights reserved to The Journal of Headache and Pain. Click here for the online summary.