Post-Concussion Syndrome: Evaluation & Treatment

Concussions represent one of the most common injuries in sports and recreation.¹ The number of reported concussions has increased in recent years, which is likely due to increased societal awareness and the risk of long-term sequelae.^2,3 According to the American Academy of Neurology, a concussion is a clinical syndrome caused by a biomechanically induced alteration of brain function.^4,5 A 2012 consensus statement reported that concussions related to sports “may be caused by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.”⁵

Given the pathophysiology of an acute concussion is similar to that of a mild traumatic brain injury (mTBI) secondary to blunt trauma and/or whiplash,⁶ the term mTBI is sometimes used interchangeably with concussion.⁷ While the symptoms of concussions vary, they often include headaches, dizziness, vertigo, fatigue, irritability, difficulty with concentration and memory, photophobia, phonophobia, neck pain, sleep impairment, and reduced tolerance to stress.^5,6,8–12  Most patients recover from a concussion within the first few weeks,^5,6,13 but symptoms often persist in 10-30% of cases,^5,7,9,14 a phenomenon more commonly referred to as post-concussion syndrome (PCS). ^9,11,15

The diagnosis of PCS is complicated,^16,17 as the mechanism of injury can often lead to bias.⁶ Moreover, there is significant overlap in symptoms related to concussion and whiplash-associated disorder (WAD).²⁰Concomitant injury to the cervical spine resembling whiplash has been shown to occur as a result of the acceleration–deceleration forces sustained in concussive trauma.²¹ Thus, while 80-90% of patients with PCS report headaches,^{5,9,10,22–24}  there may be a significant cervicogenic component.^25,26,27

Headaches can occur secondary to symptomatic zygapophyseal joints,³¹ intervertebral disc inflammation, and increased muscle tension.^32,33 Given the relationship between the upper cervical spine and proprioceptive afferents, injury or lesions to the periarticular tissues of the upper cervical spine may further propagate dizziness,^28,29 a symptom commonly reported in patients with PCS and WAD.^29,30 As such, physical therapists must review how to evaluate and diagnose patients with PCS so as to provide optimal treatment strategies. In addition to the cervical spine, emerging evidence suggests that vision, exertion, and vestibular function must be assessed in patients with PCS.^2,18,19

EXERTION & CARDIOVASCULAR INVOLVEMENT

A number of cardiovascular manifestations are associated with concussion and PCS.³⁴ Although not routinely performed and not typically required, exercise stress testing and tilt table testing have revealed abnormal cardiovascular function in patients with PCS, despite normal orthostatic vital signs.^7,35 In addition to evaluating exercise tolerance, a number of investigators have also recommended the use of graded aerobic treadmill testing as a way to differentiate physiological, cervicogenic, and vestibulo-ocular PCS.^18,36–41 A standardized aerobic treadmill test known as the Buffalo Concussion Test (a modified version of the Balke protocol) is often recommended.⁴² That is, individuals that report an early symptom-limiting threshold during treadmill testing may be diagnosed with physiological PCS. However, individuals who experience persistent concussion symptoms that are not exacerbated by treadmill testing typically fall into two categories, cervicogenic and vestibulo-oculomotor PCS, in which case further testing is required.^42,4336

CERVICOGENIC INVOLVEMENT

In a recent literature review and case series of 5 patients, Marshall et al makes a strong case for the involvement of the cervical spine in some individuals with PCS.⁴⁵ Most cervicogenic symptoms are attributed to an injury or impairment of the upper cervical spine (C1–C3).²⁹   Therefore, special tests that target the upper cervical region and provoke or reproduce symptoms of PCS strongly suggest a cervicogenic component.²⁵ For example, Escaloni et al²⁸ found that palpation and dry needling of the superficial muscles in the upper neck consistently provoked symptoms associated with cervicogenic dizziness. As such, physical examination of the cervical spine and motor control testing of the deep cervical flexors and extensors is recommended in patients with PCS.²⁵ While there is presently a lack of consensus on how to diagnose dizziness related to the cervical spine, a recent Delphi study surveyed healthcare professionals with experience treating concussions (i.e. physical therapists, neurologists, etc.) and recommended the cervical joint position error test, the cervical flexion-rotation test, the smooth pursuit neck torsion test, and the head-neck differentiation test.⁴⁴

VESTIBULAR/OCULOMOTOR INVOLVEMENT

Notably, patients with vestibular/oculomotor symptoms following concussion may experience a more prolonged recovery.²⁵ Testing for vestibulo-ocular PCS should include the Romberg test, Tandem gait test, Dix–Hallpike test, and vestibulo-ocular reflex (VOR) test.^46,47 Valid instruments that uniquely assess vestibular and/or ocular motor function such as the Balance Error Scoring System and the King-Devick Test exist,^48,49 however, these tests do not sufficiently evaluate the complexity and/or synergy of the vestibular and oculomotor systems.¹⁹ On the other hand, the Vestibular/Ocular-Motor Screening (VOMS) tool is a comprehensive assessment of the vestibular and oculomotor system.¹⁹ VOMS includes smooth pursuit, horizontal and vertical saccades, near point of convergence, horizontal and vertical vestibulo-ocular reflex, and visual motion sensitivity;³⁴ therefore, the VOMS may be useful for evaluating vestibulo-ocular PCS.⁴⁶ However, a formal evaluation by an optometrist experienced in assessing this patient population may also be appropriate.³⁴

TREATMENT of PCS

Graded activity, education, and multimodal treatment, consisting of manual therapy techniques and neuromotor, sensorimotor, and vestibular retraining is recommended for most patients with PCS.⁵⁰ However, the type (or types) of PCS that the patient is experiencing will ultimately inform the treatment. For physiologic PCS, current research recommends a brief period of rest and light asymptomatic aerobic activity (as early as 48 hours) followed by graded, subsymptomatic exercise.^38,39,51,

Regarding the treatment of cervicogenic and vestibulo-ocular PCS, manipulative therapy has been shown to improve joint position sense,^52,53 neck pain,^54,55 and cervicogenic headaches.⁵⁶ In fact, mechanical management of headaches is required so that patients can tolerate vestibular adaptation activities aimed at improving dizziness.^29,38,57,54 A recent systematic review⁵⁸ reported reasonable rationale and level-2 evidence for the use of manual therapy (i.e. upper cervical spinal manipulation/mobilization) in the treatment of cervicogenic dizziness. Notably, Escaloni et al²⁸ found dry needling to the suboccipital muscles may be beneficial in the management of cervicogenic dizziness. In addition, and provided they do not exacerbate symptoms, exercises that target the deep neck flexors along with gaze stability, neck proprioception, vestibulo-ocular, and general balance training are indicated for PCS.^29,50,59

CONCLUSION

Differentiating between physiologic, cervicogenic and vestibulo-ocular PCS is vital, as the management of each differs considerably. Based on the current evidence, and depending on the type of PCS, the following interventions may be useful in promoting efficient neurologic recovery and/or resolution of associated musculoskeletal impairments:  light asymptomatic aerobic activity (as early as 48 hours) followed by graded subsymptomatic exercise, upper cervical spinal manipulation/mobilization, dry needling to the suboccipital muscles, exercises that target the deep neck flexors along with gaze stability, neck proprioception, vestibulo-ocular and general balance training.

AUTHORS

S. Jake Thompson, PT, MPT, ATC, SCS, Cert. DN, Cert. SMT, Dip. Osteopractic
Instructor, University of North Dakota School of Medicine & Health Sciences
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Devils Lake, ND

Raymond Butts, PhD, DPT, MSc (NeuroSci), Dip. Osteopractic
Senior Instructor, American Academy of Manipulative Therapy
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Louisville, KY

James Dunning, PhD, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery, AL

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