Background:

Five - 15 % of patients with concussion continue to experience impairing physical, cognitive and emotional symptoms longer than 3 months post-injury. Currently, no standardised treatment is available for patients with persistent post-concussional symptoms (PCS) and systematic treatment studies remain limited.

Aim:

1. to develop an early intervention programme based on principles from cognitive-behavioural therapy and graded exercise for young patients with PCS lasting more than 3 months, and
2. to evaluate the efficacy of this intervention on PCS in a randomised, controlled trial.

Methods:

Patients aged 15 - 30 years diagnosed with concussion at hospitals in Central Denmark Region will be screened for persistent symptoms two months post-injury. Those with impairing symptoms will be invited to participate in a randomised controlled trial comparing the early intervention programme with enhanced usual care. We expect to include 120 patients from 2015-2016. Treatment will be interdisciplinary and will begin approximately 3 - 5 months after concussion. All patients will complete self-report measures at baseline and 3, 6 and 15 months after randomisation. The primary outcome is severity of PCS.

Background Concussion is an important public health concern. Debilitating and persistent post-concussional symptoms are associated with considerable long-term sickness and markedly reduced health-related quality of life in industrialized countries. In Denmark, approximately 25000 people are diagnosed with concussion each year. Although complete resolution of typical post-concussional symptoms such as headaches, dizziness and fatigue normally occur within the first days or weeks after a concussion, a significant proportion corresponding to five to15 % of patients continue to experience symptoms longer than 3 months post-injury. These patients are at risk of long-term sickness, reduced health-related quality of life as well as permanently reduced working ability, which is particularly disastrous for adolescents and young adults. Currently, no standardised treatment is available for patients with persistent post-concussional symptoms.

The aetiology of persistent post-concussional symptoms is only partly elicited, and no consensus exists whether post-concussional symptoms constitute a true syndrome linked to neurobiological disturbances caused by accident or head trauma. Nevertheless, the term post-concussional syndrome is widely used to describe a set of persistent somatic and emotional symptoms often observed in concussed individuals. We use the abbreviation 'PCS' as a purely descriptive term for post-concussional symptoms. The literature suggest, that PCS are best understood in a complex, multifactorial model, where both biological and psychological factors contribute to persistent symptoms and associated disability. Moreover, PCS overlap considerably with symptoms of other trauma-related conditions such as whiplash-associated disorders and post-traumatic stress disorder. On this background, a number of trials have tested the effect of various psychosocial interventions, including cognitive behavioural therapy (CBT), on persistent PCS. Although preliminary, there is some promising evidence that treatment based on the cognitive-behavioural model may be effective in treating PCS and prevent permanent suffering and disability.

Some of the cognitive - behavioural mechanisms that have been found to play an important role in the maintenance of PCS are unhelpful illness perceptions, maladaptive coping strategies and all-or-nothing behaviour. The all-or-nothing behaviour refers to a behavioural response, where patients overdo things when they believe symptoms are abating and then spend prolonged periods recovering when symptoms reappear. Other patients report a gradual restriction of activity over time, because they fear worsening of symptoms. A promising avenue for treatment seems to be focusing on making sustainable, gradual increases in levels of activity (in intensity and / or duration) over time, and to avoid extreme oscillations. This is often referred to as Graded Exercise Therapy (GET), a treatment that can effectively reduce impairment and suffering in chronic fatigue and persistent pain and that can be provided by physiotherapists and hence delivered in a primary care or municipality setting.

Currently, systematic studies of psychosocial interventions for patients with persistent PCS remain limited. A recent review concludes that more rigorous, large-scale randomised controlled trials (RCT) evaluating the effectiveness of CBT for persistent PCS are needed.

Aim:

1. to develop an early intervention programme based on CBT and GET principles for young patients aged 15 - 30 years with PCS lasting more than three months, and
2. to evaluate the efficacy of this intervention programme on PCS in a RCT.

Hypotheses Primary hypothesis Patients in the early intervention group will 6 months after randomisation report a statistically and clinically significantly greater reduction of post-concussional symptoms compared to patients who receive enhanced usual care.

Secondary hypotheses

1. Patients in the early intervention group will 6 months after randomisation report a statistically and clinically significantly higher health related quality of life and overall daily functioning compared to patients who receive enhanced usual care.
2. Patients in the early intervention group will during the 12 months after treatment have less consumption of health care (based on register-data) and less illness-related absence from school or work (based on self-reported data) compared to patients, who receive enhanced usual care.

Inclusion Criteria:

1. Concussion caused by a head trauma according to the diagnostic criteria recommended by the Danish Consensus Report on Commotio Cerebri 5 within the last 2 - 6 months. The criteria is based on the diagnostic criteria recommended by the WHO Task Force 1, but with the amendment, that there must have been a direct contact between the head and an object in order to rule out acceleration - deceleration traumas.
2. Age between 15 and 30 years at the time of the head trauma.
3. Able to understand, speak and read Danish.
4. A score of 20 or more on the Rivermead Post Concussion Symptoms Questionnaire (RPQ).

Exclusion Criteria:

1. Objective neurological findings from neurological examination and / or acute trauma CT scan, indicating neurological disease or brain damage.
2. Previous concussion leading to persistent post-concussional symptoms within the last two years.
3. Severe misuse of alcohol, prescription drugs and / or illegal drugs.
4. Multiorgan Bodily Distress Syndrome (multiple somatic symptoms from various body sites and organ systems not related to the accident).
5. Psychiatric morbidity (Bipolar Disorder, severe Attention Deficit Hyperactivity Disorder, autism, psychotic disorder (life time)), or other psychiatric illness that impedes participation in the treatment.
6. Severe neurological disease and / or other medical disease that impedes participation in the treatment programme.
7. Significant learning and / or reading difficulties or mental retardation.