Managing Persistent Post-Concussion Syndrome: 6 Strategies for Cognitive Recovery
Persistent post-concussion syndrome (PPCS) is characterized by a constellation of symptoms associated with a mild traumatic brain injury (mTBI). Common symptoms often include headaches, dizziness, fatigue, sensitivity to light and noise, difficulty concentrating, memory problems, irritability, and mood changes. These symptoms can disrupt work, relationships, and various aspects of daily life, making recovery challenging.
While most people recover from concussions within a few weeks, some survivors experience debilitating symptoms that can last for months or even years. PPCS often manifests as an invisible disability, making it misunderstood by those around the patient and requiring a thoughtful, multidisciplinary approach to manage, combining medical interventions and cognitive rehabilitation therapies.
As speech-language pathologists, we work closely with patients to assess and treat communication issues, memory challenges, and executive function difficulties that can impede social interaction and daily activities. The complex interaction of sensory, physical, emotional, and cognitive symptoms calls for a comprehensive approach to managing PPCS, focusing on helping individuals restore their cognitive-communication abilities and fully participate in daily life.
To achieve this, we must employ a range of therapeutic strategies. Here are key components of the therapeutic process to support mitigation of cognitive-communication symptoms and return to functional life participation:
1. Thoughtful use of assessment tools
When evaluating PPCS, a range of assessment tools is used to gather comprehensive diagnostic information. Unlike other neurogenic cognitive communication disorders that can rely solely on standardized tests, PPCS requires a more nuanced and tailored approach. Below are some common tools we can use:
Non-standardized tools
- In-depth clinical interviews: These interviews allow us to gain a detailed understanding of the patient’s history, lifestyle, and personal challenges. For example, asking patients to describe specific situations where they struggle with communication or memory can reveal subtle cognitive difficulties that standardized tests might miss.
- Functional task observation: This method involves observing patients while they perform everyday tasks, such as managing a phone call or organizing a shopping list. It provides insight into how cognitive and communication difficulties affect real-world activities. For instance, a patient may struggle to maintain focus during multitasking or have trouble recalling important details in conversations.
Standardized tools
- Patient-reported outcome measures (PROMs): PROMs are questionnaires designed to capture the patient’s perception of the severity and frequency of their symptoms. These questionnaires can help patients rate symptoms like headaches or concentration problems, giving us a clearer picture of how these issues impact their daily lives.
- Discourse analysis: This assessment evaluates language and communication issues, such as word-finding difficulties or disorganized speech. A discourse analysis might reveal that a patient struggles to find the right words during conversation or has difficulty maintaining the flow of their speech, impacting verbal communication competence.
Together, these assessment tools provide a comprehensive and individualized view of PPCS symptoms. The findings from these evaluations can also help us identify when referrals to other specialists—such as occupational therapists, physical therapists, or mental health professionals—are necessary to address related symptoms.
2. Biopsychosocial education
One of the first steps in managing cognitive-communication symptoms in PPCS is to help patients understand their experience as a clinically defined syndrome resulting from mTBI.
Patient education that is accessible and tailored for individual health literacy and learning ability needs is a powerful strategy for demystifying the nature of PPCS. This approach can help raise awareness of situations and activities that may exacerbate symptoms. By empowering patients with evidence-based knowledge, we can actively involve them in their recovery process.
For PPCS, we need to use a comprehensive educational approach that includes biopsychosocial education, addressing the interconnected biological, psychological, and social factors contributing to symptom persistence.
Biopsychosocial education is based on the multifaceted aspects of a PPCS diagnosis, describing the known factors in a patient’s history—such as repeated or recent concussions, mental health history, prior coping strategies, and the nature of their support system—that may contribute to the persistence of symptoms. A biopsychosocial model offers clarity on risk factors, as well as precipitating and perpetuating elements that may require intervention.
3. Motivational interviewing and collaborative goal setting
Managing cognitive-communication difficulties requires a person-centered approach built upon a strong clinical understanding of PPCS and adept active listening skills. Below, you can watch as I explain active listening, straight from the Creative Approaches to Delivering Skilled, Person-Centered Rehabilitation recorded webinar.
Active listening lays the foundation for motivational interviewing by creating a supportive and open environment where patients feel heard and understood. With this trust in place, motivational interviewing becomes a conversational approach that encourages open and non-judgmental dialogue.
Motivational interviewing helps patients reflect on their experiences, identify their priorities, and set meaningful goals in collaboration with their speech-language pathologist, who brings clinical observations and knowledge of treatment options. By empowering patients to take an active role in shaping their treatment, motivational interviewing enhances adherence to the treatment plan and increases overall satisfaction with the treatment experience.
4. Cognitive-communication strategy training
Because of the often-reported overwhelm and frustration associated with living with PPCS, patients frequently respond well to practical cognitive strategy training to address cognitive communication challenges.
Cognitive strategy training starts with foundational skills to support attention, information processing, and memory. It typically focuses on executive functions that are critical for navigating daily life. Incorporating strategies like attention process training and compensatory methods for memory is essential for improving cognitive-communication impairments in patients with traumatic brain injuries.1
Strategy training for communication considers deficits noted across all affected communication modalities, including verbal and written expression, as well as necessary skills for listening and reading.
Adapting strategies to fit each individual’s lifestyle is essential, and incorporating cognitive strategy training into daily activities is key. Our role as speech-language pathologists is to identify strategies, promote guided practice, and fine-tune their use for effective application in real-world situations. This approach not only improves cognitive-communication function, but also supports long-term independence, self-sufficiency, and confidence.
5. Goal attainment scaling for personalized progress tracking
One of the gold standards in brain injury rehabilitation is the use of goal attainment scaling (GAS). This method offers a structured and personalized way to measure progress on individual therapy goals over time. Each goal is rated, ranging from expected outcomes to more ambitious achievements, allowing for a flexible and meaningful assessment of success. When used in tailored, person-centered interventions, GAS can lead to high levels of goal achievement across various functional domains, including cognitive, emotional, and social areas.2
GAS enables patients to establish their baseline using personally selected metrics to assess their progress. For example, a patient may determine their baseline perception of cognitive endurance during the workday is a 5 out of 10 on a self-anchored rating scale. They can then aim for consistent improvements along this scale as they acquire and learn to implement new strategies.
Other patients may use frequency as a meaningful metric, which could apply to how often they can participate in a desired activity. Tracking improvements in cognitive-communication abilities through this personalized approach can be highly motivating and provide patients with a clear and measurable view of their recovery progress.
6. Dynamic coaching and self-evaluation
As with other acquired brain injuries, PPCS recovery is not a linear process. Patients often face delays of months or even years before being referred for cognitive rehabilitation. During this waiting period, they may continue to experience the effects of this invisible disability, which is often misunderstood or even disbelieved by those around them. Until they receive the necessary and appropriate care, their challenges may go largely unrecognized.
Once therapy begins, patients with PPCS benefit from a dynamic coaching model that validates their experience, meets them where they are, and adapts as they progress. This research-based approach, grounded in patient-centered care and self-evaluation techniques, emphasizes therapy sessions driven by the patient’s self-reported progress and ongoing assessment of their own challenges.3
Regularly reviewing what is working and identifying ongoing challenges helps us partner with patients to adjust strategies and interventions effectively. By allowing them to guide the focus of each session, this dynamic coaching model promotes empowerment, self-efficacy, and long-term resilience.
A patient-centered path to recovery
Managing cognitive-communication symptoms in persistent post-concussion syndrome requires a multifaceted, patient-centered approach due to the complexity of this diagnosis. By integrating principles of biopsychosocial education, motivational interviewing, cognitive strategy training, and dynamic coaching, we can provide personalized, impactful interventions that empower patients to take control of their recovery.
As speech-language pathologists, we are uniquely qualified to guide clients and their families through the challenges of PPCS, advocate for effective and meaningful treatment of symptoms, improve quality of life, and promote meaningful participation.
Resources
- Barman, A., Chatterjee, A., & Bhide, R. (2016). Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury. Indian journal of psychological medicine, 38(3), 172–181. https://doi.org/10.4103/0253-7176.183086
- Borgen, I. M. H., Hauger, S. L., Forslund, M. V., Kleffelgård, I., Brunborg, C., Andelic, N., Sveen, U., Søberg, H. L., Sigurdardottir, S., Røe, C., & Løvstad, M. (2022). Goal Attainment in an Individually Tailored and Home-Based Intervention in the Chronic Phase after Traumatic Brain Injury. Journal of clinical medicine, 11(4), 958. https://doi.org/10.3390/jcm11040958
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Wright, J., & Sohlberg, M. M. (2021). The implementation of a personalized dynamic approach for the management of prolonged concussion symptoms. American journal of speech-language pathology, 30(4), 1611-1624.
