Post-Concussion Syndrome: Evaluation & Treatment

Share:

Share on facebook
Share on twitter
Share on pinterest
Share on linkedin
Share on email
Share on print

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

REFERENCES

  1. Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. Cmaj. 2011;183(11):1249-1256. doi:10.1503/cmaj.101540
  2. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-1298. doi:10.1136/bjsports-2013-093267
  3. Coronado VG, Haileyesus T, Cheng TA, et al. Trends in sports-and recreation-related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30(3):185-197. doi:10.1097/HTR.0000000000000156
  4. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257. doi:10.1212/WNL.0b013e31828d57dd
  5. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus Statement on Concussion in Sport-The 4th International Conference on Concussion in Sport Held in Zurich, November 2012. PM R. 2013;5(4):255-279. doi:10.1016/j.pmrj.2013.02.012
  6. Laker SR. Sports-Related Concussion. Curr Pain Headache Rep. 2015;19(8):41. doi:10.1007/s11916-015-0510-3
  7. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847. doi:10.1136/bjsports-2017-097699
  8. Rivara FP, Graham R. Sports-Related Concussions in Youth. Vol 311.; 2014. doi:10.1001/jama.2013.282985
  9. Tapia RN, Eapen BC. Rehabilitation of Persistent Symptoms After Concussion. Phys Med Rehabil Clin N Am. 2017;28(2):287-299. doi:10.1016/j.pmr.2016.12.006
  10. Wasserman EB, Kerr ZY, Zuckerman SL, Covassin T. Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes from 2009-2010 to 2013-2014. Am J Sports Med. 2016;44(1):226-233. doi:10.1177/0363546515610537
  11. Broglio SP, Cantu RC, Gioia G a., et al. National athletic trainers’ association position statement: Management of sport concussion. J Athl Train. 2014;49(2):245-265. doi:10.4085/1062-6050-49.1.07
  12. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26. doi:10.1136/bjsports-2012-091941
  13. Castillo I, Wolf K, Rakowsky A. Concussions and Osteopathic Manipulative Treatment: An Adolescent Case Presentation. J Am Osteopath Assoc. 2016;116(3):178. doi:10.7556/jaoa.2016.034
  14. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptomsamong children with acute concussion in the ED. JAMA – J Am Med Assoc. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203
  15. Rutherford WH, Merrett JD, McDonald JR. Symptoms at one year following concussion from minor head injuries. Injury. 1979;10(3):225-230. doi:10.1016/0020-1383(79)90015-9
  16. Dean PJA, O’Neill D, Sterr A. Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj. 2012;26(1):14-26. doi:10.3109/02699052.2011.635354
  17. Meares S, Shores EA, Taylor AJ, et al. Mild traumatic brain injury does not predict acute postconcussion syndrome. J Neurol Neurosurg Psychiatry. 2008;25(4):454-465. doi:10.1136/jnnp.2007.126565
  18. Leddy JJ, Baker JG, Merchant A, et al. Brain or Strain? Symptoms Alone Do Not Distinguish Physiologic Concussion From Cervical/Vestibular Injury. Clin J Sport Med. 2015;25(3):237-242. doi:10.1097/JSM.0000000000000128
  19. Mucha A, Collins MW, Elbin RJ, et al. Brief VOMS assessment to eval concussions. Am J Sports Med. 2014;42(10):2479-2486. doi:10.1177/0363546514543775.A
  20. Leslie O, Craton N. Concussion: Purely a Brain Injury? Clin J Sport Med. 2013;23(5):331-332. doi:10.1097/JSM.0b013e318295bbb1
  21. Barth JT, Freeman JR, Broshek DK, Varney RN. Acceleration-Deceleration Sport-Related Concussion: The Gravity of It All. J Athl Train. 2001;36(3):253-256. http://www.journalofathletictraining.org.
  22. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. In: Journal of Neurologic Physical Therapy. Vol 34. ; 2010:87-93. doi:10.1097/NPT.0b013e3181dde568
  23. Duhaime A-C, Beckwith JG, Maerlender AC, et al. Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets. J Neurosurg. 2012;117(6):1092-1099. doi:10.3171/2012.8.jns112298
  24. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):2311-2318. doi:10.1177/0363546511410655
  25. Cheever K, Kawata K, Tierney R, Galgon A. Cervical injury assessments for concussion evaluation: A review. J Athl Train. 2016;51(12):1037-1044. doi:10.4085/1062-6050-51.12.15
  26. Benson BW, Meeuwisse WH, Rizos J, Kang J, Burke CJ. A prospective study of concussions among National Hockey League players during regular season games: The NHL-NHLPA Concussion Program. CMAJ. 2011;183(8):905-911. doi:10.1503/cmaj.092190
  27. Treleaven J, Jull G, Atkinson L. Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia. 1994;14(4):273-279. doi:10.1046/j.1468-2982.1994.1404273.x
  28. Escaloni J, Butts R, Dunning J. The use of dry needling as a diagnostic tool and clinical treatment for cervicogenic dizziness: a narrative review & case series. J Bodyw Mov Ther. 2018;22(4):947-955. doi:10.1016/j.jbmt.2018.02.015
  29. Kristjansson E, Treleaven J. Sensorimotor Function and Dizziness in Neck Pain: Implications for Assessment and Management. J Orthop Sport Phys Ther. 2009;39(5):364-377. doi:10.2519/jospt.2009.2834
  30. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003;35(1):36-43. http://www.ncbi.nlm.nih.gov/pubmed/12610847. Accessed July 10, 2019.
  31. Bogduk N. Headaches and the cervical spine. Cephalalgia. 1984;4(1):7-8. http://www.ncbi.nlm.nih.gov/pubmed/6713527.
  32. Brandt T, Huppert D. A new type of cervical vertigo: Head motion–induced spells in acute neck pain. Neurology. 2016;86(10):974-975. doi:10.1212/wnl.0000000000002451
  33. Peng B. Cervical Vertigo: Historical Reviews and Advances. World Neurosurg. 2018;109:347-350. doi:10.1016/j.wneu.2017.10.063
  34. Craton N, Ali H, Lenoski S. COACH CV: The seven clinical phenotypes of concussion. Brain Sci. 2017;7(9):1-7. doi:10.3390/brainsci7090119
  35. Heyer GL, Fischer A, Wilson J, et al. Orthostatic Intolerance and Autonomic Dysfunction in Youth With Persistent Postconcussion Symptoms. Clin J Sport Med. 2016;26(1):40-45. doi:10.1097/JSM.0000000000000183
  36. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation of Concussion and Post-concussion Syndrome. Sport Heal A Multidiscip Approach. 2012;4(2):147-154. doi:10.1177/1941738111433673
  37. Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370-376. doi:10.1249/JSR.0000000000000008
  38. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment. Brain Inj. 2015;29(2):238-248. doi:10.3109/02699052.2014.965207
  39. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Phys Med Rehabil Clin N Am. 2016;27(2):437-454. doi:10.1016/j.pmr.2015.12.003
  40. Leddy JJ, Baker JG, Kozlowski K, Bisson L, Willer B. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med. 2011;21(2):89-94. doi:10.1097/JSM.0b013e3181fdc721
  41. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi:10.1177/0333102417738202
  42. Ellis MJ, Leddy J, Willer B. Multi-disciplinary management of athletes with post-concussion syndrome: An evolving pathophysiological approach. Front Neurol. 2016;7(AUG):1-14. doi:10.3389/fneur.2016.00136
  43. Kozlowski KF, Graham J, Leddy JJ, Devinney-Boymel L, Willer BS. Exercise intolerance in individuals with postconcussion syndrome. J Athl Train. 2013;48(5):627-635. doi:10.4085/1062-6050-48.5.02
  44. Reneker JC, Clay Moughiman M, Cook CE. The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study. J Sci Med Sport. 2015;18(4):366-372. doi:10.1016/j.jsams.2014.05.002
  45. Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015;43(3):274-284. doi:10.1080/00913847.2015.1064301
  46. Anzalone AJ, Blueitt D, Case T, et al. A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated with Increased Recovery Time after Sports-Related Concussion in Youth and Adolescent Athletes. Am J Sports Med. 2017;45(2):474-479. doi:10.1177/0363546516668624
  47. Yorke AM, Smith L, Babcock M, Alsalaheen B. Validity and Reliability of the Vestibular/Ocular Motor Screening and Associations With Common Concussion Screening Tools. Sports Health. 2017;9(2):174-180. doi:10.1177/1941738116678411
  48. Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. 2001;11(3):182-189. doi:10.1097/00042752-200107000-00009
  49. King D, Brughelli M, Hume P, Gissane C. Concussions in amateur rugby union identified with the use of a rapid visual screening tool. J Neurol Sci. 2013;326(1-2):59-63. doi:10.1016/j.jns.2013.01.012
  50. Schneider KJ. Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice. J Orthop Sport Phys Ther. 2016;46(8):613-616. doi:10.2519/jospt.2016.0607
  51. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: A systematic review. Br J Sports Med. 2017;51(12):930-934. doi:10.1136/bjsports-2016-097475
  52. Gong W. Effects of cervical joint manipulation on joint position sense of normal adults. J Phys Ther Sci. 2013;25(6):721-723. doi:10.1589/jpts.25.721
  53. McNair PJ, Portero P, Chiquet C, Mawston G, Lavaste F. Acute neck pain: Cervical spine range of motion and position sense prior to and after joint mobilization. Man Ther. 2007;12(4):390-394. doi:10.1016/j.math.2006.08.002
  54. Gergen DM. Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report. J Chiropr Med. 2015;14(3):220-224. doi:10.1016/j.jcm.2015.08.006
  55. Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-1169. doi:10.3233/BMR-169615
  56. Dunning JR, Butts R, Mourad F, et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: A multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016;17(1):64. doi:10.1186/s12891-016-0912-3
  57. Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scand J Med Sci Sport. 2017;27(12):2009-2018. doi:10.1111/sms.12827
  58. Lystad RP, Bell G, Bonnevie-svendsen M, Carter C V. Manual therapy Cervicogenic dizziness. 2011:1-11.
  59. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and Emerging Rehabilitation for Concussion. Clin Sports Med. 2015;34(2):213-231. doi:10.1016/j.csm.2014.12.005

Rates:

• Initial evaluation & first treatment session: $95
• Follow-up treatment session: $60 to $85 (depending on the case complexity)

Payment:

Visa, Mastercard, American Express or Discover credit/debit cards are accepted for payment. FSA/HSA cards are also accepted.

Insurance is not accepted:

Montgomery Osteopractic does not accept insurance. As of January 1, 2020, Medicare and Blue Cross Blue Shield consider acupuncture, dry needling and spinal manipulation to be “non-covered” procedures.

At Montgomery Osteopractic, Dr. Dunning (not the insurance company or case manager) will determine the most appropriate treatment for your specific condition and symptoms. Furthermore, Dr. Dunning will have the option to administer procedures (such as acupuncture, dry needling or spinal manipulation) that Medicare, BCBS and other third-party payers deem as “non-covered”.

Montgomery Osteopractic has chosen to focus on what counts, the patient care itself.

Cancellation Policy:

In the event that you need to cancel a scheduled appointment, please do so at least 24 hours prior to your appointment time to avoid being charged a $25 missed appointment fee.