these conditions. cognitive and affective symptoms that occur following a traumatic injury may be attributed to mtbi, but in fact be due to another factor such as posttraumatic stress disorder, which is easily misdiagnosed as pcs and vice versa. affective disorders such as depression have some symptoms that can mimic those of pcs and lead to a wrongful diagnosis of the latter; these include problems with concentration, emotional lability, anxiety, and sleep problems. depression, which is highly common in persistent pcs, can worsen other pcs symptoms, such as headaches and problems with concentration, memory, and sleep. pcs also shares symptoms with chronic fatigue syndrome, fibromyalgia, and exposure to certain toxins. traumatic brain injury may cause damage to the hypothalamus or the pituitary gland, and deficiencies of pituitary hormones (hypopituitarism) can cause similar symptoms to post-concussion syndrome; in these cases, symptoms can be treated by replacing any hormones that are deficient. treatment management of post-concussion syndrome typically involves treatments addressing specific symptoms; for example, people can take over the counter pain relievers for headaches and medicine to relieve depression or insomnia. participation in low-risk physical activities that raise the heart rate and mental activities is advised, at a level that does not worsen symptoms. prolonged rest is not suggested. physical and behavioral therapy may also be prescribed for problems such as loss of balance and difficulties with attention, respectively. medication though no pharmacological treatments exist for pcs, doctors may prescribe medications used for symptoms that also occur in other conditions; for example, antidepressants are used for the depression that frequently follows mtbi. side effects of medications may affect people with mtbi more severely than they do others, and thus it is recommended that medications be avoided if possible; there may be a benefit to avoiding narcotic medications. in addition, some pain medications prescribed for headaches can cause rebound headaches when they are discontinued. psychotherapy psychological treatment, to which about 40% of pcs patients are referred for consultation, has been shown to reduce problems. ongoing disabilities may be treated with therapy to improve function at work, or in social or other contexts. therapy aims to aid in the gradual return to work and other preinjury activities, as symptoms permit. a protocol for pcs treatment has been designed based on the principles behind cognitive behavioral therapy (cbt), a psychotherapy aimed at influencing disturbed emotions by improving thoughts and behaviors. cbt may help prevent persistence of iatrogenic symptoms – those that occur because health care providers create the expectation that they will. a risk exists that the power of suggestion may worsen symptoms and cause long-term disabilities; therefore, when counseling is indicated, the therapist must take a psychological origin of symptoms into account and not assume that all symptoms are a direct result of neurological damage from the injury. in situations such as motor vehicle accidents or following a violent attack, the post-concussion syndrome may be accompanied by posttraumatic stress disorder, which is important to recognize and treat in its own right. people with ptsd, depression, and anxiety can be treated with medication and psychotherapy. physical therapy concussion protocols are continuously changing, with the common recommendation remaining both physical and cognitive rest. exercise should be implemented as soon as possible after the initial rest period as this lowers the risk of post concussion syndrome (pcs) and overall symptoms. moderate intensity aerobic exercise will provide therapeutic benefits and reintroduce the body to movement. patients should begin with 20 minutes of brisk walking or an exercise bike set with mild resistance. if this exacerbates any symptoms, like headache or dizziness, the individual should stop exercising and try again the following day. upper cervical care post-concussion syndrome can sometimes be the result of a misalignment in the upper cervical spine (neck) specifically the c1 (atlas) or c2 (axis) which surround the brain stem. some individuals have found relief through upper cervical care. an upper cervical chiropractor is a specialist who uses x-rays to identify misalignments in the upper cervical spine then gently repositions the top two bones of the neck. there are currently approximately seven different chiropractic methods of repositioning the c1 bone, however the three most popular techniques are nucca (adjustment done by hand), blair technique (adjustment done by hand), and atlas orthogonal (adjustment done by a machine). education education about symptoms and their usual time course is a part of psychological therapy, and is most effective when provided soon after the injury. since stress exacerbates post-concussion symptoms, and vice versa, an important part of treatment is reassurance that pcs symptoms are normal, and education about how to deal with impairments. one study found that pcs patients who were coached to return to activities gradually, told what symptoms to expect, and trained how to manage them had a reduction in symptoms compared to a control group of uninjured people. early education has been found to reduce symptoms in children as well. post concussion patients will benefit most from a multidisciplinary approach. education is crucial for concussion patients to stress the importance of being active by engaging in light aerobic exercise, improving sleep habits and reducing stressors as much as possible. additional treatments include manual therapy, like massage, and deep neck flexor retraining. interventions should target specific muscular deficits, which commonly include weakness in the rhomboids, mid and lower trapezius and neck flexor muscles neurotherapy neurotherapy is an operant conditioning test where patients are given conditional audio/visual rewards after producing particular types of brainwave activity. recent neurotherapy improvements in quantitative electroencephalography can identify the specific brainwave patterns that need to be corrected. studies have shown that neurotherapy is effective in the treatment of post-concussion syndrome and other disorders with similar symptoms. transcranial low-frequency pulsating electromagnetic fields (t-pemf) has shown some positive results in treating pcs patients. the tolerability was assessed in a 2020 study, which resulted in 61% of patients reporting decreased symptoms based on the rivermead post-concussion symptoms questionnaire. multimodal multimodal physical therapy has been shown to improve pcs symptoms. the therapy is most effective when it is symptom-specific. dizziness and unsteady gait were treated with exercises such as gaze stabilization and static and dynamic balance exercises. decreased range of motion and cervical instability (known specifically as cervicogenic pcs) are best treated with cervical soft tissue and joint mobilization, deep cervical flexor strengthening exercises and stretching. symptoms indicative of physiologic pcs (symptoms exacerbated by cardiovascular exercise) seem to improve with light cardio exercises like walking and using a stationary bike while the pt carefully monitors hr. overall, a patient-specific pt plan of care has proven significantly effective in reducing pcs symptoms. prognosis the prognosis for pcs is generally considered positive, with total resolution of symptoms in many, but not all, cases. for 50% of people, post-concussion symptoms go away within a few days to several weeks after the original injury occurs. in others, symptoms may remain for three to six months, but evidence indicates that many cases are completely resolved within six months. the majority of symptoms are largely gone in about half of people with concussion one month after the injury, and about two thirds of people with minor head trauma are nearly symptom-free within three months. persistent, often severe headaches are the longest lingering symptom in most cases and are the most likely symptom to never fully resolve. it is frequently stated in the literature and considered to be common knowledge that 15–30% of people with pcs have not recovered by a year after the injury, but this estimate is imprecise because it is based on studies of people admitted to a hospital, the methodologies of which have been criticized. in approximately 15% of people, symptoms may persist for years or be permanent. if symptoms are not resolved by one year, they are likely to be permanent, though improvements may occur after even two or three years, or may suddenly occur after a long time without much improvement. older people and those who have previously had another head injury are likely to take longer to recover. the way in which children cope with the injury after it occurs may have more of an impact than factors that existed prior to the injury. children's mechanisms for dealing with their injuries may have an effect on the duration of symptoms, and parents who do not deal effectively with anxiety about children's post-injury functioning may be less able to help their children recover. if another blow to the head occurs after a concussion but before its symptoms have gone away, there is a slight risk of developing the serious second-impact syndrome (sis). in sis, the brain rapidly swells, greatly increasing intracranial pressure. people who have repeated mild head injuries over a prolonged period, such as boxers and gridiron football players, are at risk for chronic traumatic encephalopathy (or the related variant dementia pugilistica), a severe, chronic disorder involving a decline in mental and physical abilities. epidemiology it is not known exactly how common pcs is. estimates of the prevalence at three months post-injury are between 24 and 84%, a variation possibly caused by different populations or study methodologies. the estimated incidence of ppcs (persistent postconcussive syndrome) is around 10% of mtbi cases. since pcs by definition only exists in people who have had a head injury, demographics and risk factors are similar to those for head injury; for example, young adults are at higher risk than others for receiving head injury, and, consequently, of developing pcs. the existence of pcs in children is controversial. it is possible that children's brains have enough plasticity that they are not affected by long-term consequences of concussion (though such consequences are known to result from moderate and severe head trauma). on the other hand, children's brains may be more vulnerable to the injury, since they are still developing and have fewer skills that can compensate for deficits. clinical research has found higher rates of post-concussion symptoms in children with tbi than in those with injuries to other parts of the body, and that the symptoms are more common in anxious children. symptoms in children are similar to those in adults, but children exhibit fewer of them. evidence from clinical studies found that high school-aged athletes had slower recoveries from concussion as measured by neuropsychological tests than college-aged ones and adults. pcs is rare in young children. risk factors a wide range of factors have been identified as being predictive of pcs, including low socioeconomic status, previous mtbi, a serious associated injury, headaches, an ongoing court case, age and female sex. being older than 40 and being female have also been identified as being predictive of a diagnosis of pcs, and women tend to report more severe symptoms. in addition, the development of pcs can be predicted by having a history of alcohol use disorder, low cognitive abilities before the injury, a personality disorder, or a medical illness not related to the injury. pcs is also more prevalent in people with a history of psychiatric conditions such as clinical depression or anxiety before the injury. mild brain injury-related factors that increase the risk for persisting post-concussion symptoms include an injury associated with acute headache, dizziness, or nausea; an acute glasgow coma score of 13 or 14; and having another head injury before recovering from the first. the risk for developing pcs also appears to be increased in people who have traumatic memories of the injury or expect to be disabled by the injury. history the symptoms that occur after a concussion have been described in various reports and writings for hundreds of years. the idea that this set of symptoms forms a distinct entity began to attain greater recognition in the latter part of the 19th century. john erichsen, a surgeon from london, played an important role in developing the study of pcs. the controversy surrounding the cause of pcs began in 1866 when erichsen published a paper about persisting symptoms after sustaining mild head trauma. he suggested that the condition was due to "molecular disarrangement" to the spine. the condition was originally called "railroad spine" because most of the injuries studied had happened to railroad workers. while some of his contemporaries agreed that the syndrome had an organic basis, others attributed the symptoms to psychological factors or to outright feigning. in 1879, the idea that a physical problem was