Concussion injuries are heterogenous, multi-faceted injuries, which have uniquely individual presentations (1). There is a broad consensus among experts that a one-size-fits-all approach to post-concussion management is ineffective (11). Concussion, also known as mild traumatic brain injury, is a common, sometimes debilitating condition that reflects impairment of brain function (4). A mild traumatic brain injury can be caused by a direct or indirect hit, or force to the head or body, which can induce a range of symptoms, that vary in duration, severity, and number between individuals (5).
It is estimated that upwards of 3.8 million concussions occur annually in the USA from sports participation or recreational activities (3).
10%-33% of patients may remain symptomatic for months to years after the initial injury(10).
After concussion, two of the most commonly reported symptoms are headache and dizziness, followed closely by nausea and neck pain. The majority of symptoms resolve in 7-10 days, but in approximately 30% of athletes they persist. Cervical spine trauma may cause prolonged postconcussion headaches. The upper cervical spine may cause cervicogenic headaches. Dizziness and balance dysfunction are also commonly reported symptoms following sport related concussion and may be due to dysfunction of the vestibular, proprioceptive or central systems (8).
The research suggests that the strongest evidence for treatment of Concussion (3,8) is as seen below. All of which are at the core of Portland Chiropractic Neurology's concussion rehablitation program.
- Cervical rehabilitation
- Vestibular Rehabilitation
- Low-intensity, controlled aerobic exercise when appropriately prescribed and monitored by a practitioner.
There is now compelling evidence that the physical and cognivitve rest period has been decreased to 24 to 48 hours immediately following a concussion. There are also detailed, stage-specific accomodations for RTS (return to school) adn RTA (return to activity) to ensure that children and youth can progress through recovery without giving up the acivities that they enjoy (6).
The research suggests that prescribed rest inhibits the beneficial effects of controlled aerobic exercise, including improved depression and anxiety, reduced persistent post-concussion symptoms, improved exercise tolerance, and enhanced brain function. Several reviews suggested that early initiation of exercise following a concussion was advantageous (3).
For some individuals, Post Concussion Syndrome, or PCS will occur and cause symptoms for months to years if not rehabilitated properly. Since Concussion is defined as a complex physiological process affecting the brain, induced by biomechancial forces (2), it is difficult to determine who will experience PCS. Although factors can help determine longevity, such as the presence of certain presenting symptoms. Postconcussion headache has been reported as a predictor of longer time loss (7)
Proper orientation in space requires accurate and consistent input from the proprioceptive, visual and vestibular systems. If one or more of these systems provide inaccurate information about spatial location, alteration in balance and dizziness may result due to mismatching of sensory information. Dysfunction of these systems may persist and may alter risk for future concussion (8).
In the case of persistent dizziness, neck pain and/or headaches with suspected cervical or vestibular causes, treatment of the affected systems may facilitate functional and symptomatic improvements and shorten recovery (9)
I have arranged the symptoms patients experience into two different formats, the six clinical phenotypes and secondly, straight-forward symptoms
Six clinical phenotypes of concucsion are described as (11)
- (1) Cognitive-Fatigue with symptoms of fatigue, decreased energy, non-specific headache, sleep disruption, or difficulty concentrating
- (2) Vestibular with symptoms of dizziness, fogginess, nausea, feeling of being detached, or overstimulation in complex environments
- (3) Oculomotor with symptoms of fatigue, distractability, difficulties with visually based classes, pressure behidn the eyes, or blurred or double vision
- (4) Anxiety/mood with symptoms of anxiety, hypervigilance, feeling of being overwhelmed, sadness, or hopelessness
- (5) Post-traumatic migraine, with symptoms of headache with a pulsating quality associated with nausea, photosensitivity, or phonosensitivity
- (6) Cervical with symptoms of headache, neck pain or numbness/tingling in the extremities
Symptoms may include one or more on this list (11)
- Fogginess (brain fog)
- Tiring more easily
- Cognitive fatigue
- Feeling depressed or tearful
- Feeling frustrated or impatient
- Easily angered
- Neck pain
- Ataxia (walking becomes more difficult and uncoordinated)
- Noise sensitivity
- Light sensitivity, easily upset by bright light
- Difficulty reading
- Visual changes
- Double vision (diplopia)
- Blurry vision near objects
- Pain behind the eyes
- Spatial disorientation
- Disconnected feeling
- Poor concentration, focus
- Forgetfullness (memory)
- Taking longer to think
- Autonomic dysregulation
- Sleep disruption
Who is susceptible:
- Whiplash during Motor Vehicle Accidents
- Injuries sustained during otherwise normal Activities of Daily Living
- Non penetrating or penetrating injury sustained to the head or body
Diagnostic Testing consists of a complete Functional Neurological and Chiropractic Neurological evaluation
- Clinical Neurological evaluation by the Doctor (Cranial Nerves, Cortical, Brainstem, Cerebellum, Vestibular, Reflexes, sensory, motor, gait, etc..)
- Videonystagmography (VNG) testing which will detect errors in specific parts of the brain and nervous system, utilizing specific eye movements that connect to specific areas of the brain that are affected after a concussion injury.
- Comprehensive Assessment of posturography systems (CAPS)- measures balance and coordination, detecting errors in vestibular and proprioceptive function while a patient performs activities on a force plate along multiple axis planes
- Autonomic/Tilt Table evaluation to evaluate for dysregulation witin the Autonomic Nervous System that is common after Concussion
- Musculoskeletal evaluation of Neck, Spine, Head, Jaw
- Occupational Therapy evaluation
- Determine whether you're a candidate for Hyperbaric Oxygen Therapy (HBOT)
- Gait evaluation
Treatments may include:
- Chiropractic adjustments to restore function of the proprioceptive system that shows very strong evidence through research to be highly involved with concussion.
- Cervicovestibular rehabilitation
- Physical Rehabilitation to restore strength and muscle symmetry as well as postural changes
- Muscle stimulation and cold laser therapy to reduce muscle tension, inflammation, asymmetry and promote healing
- Neurological rehabilitation (Neuroplasticity exercises) to reconnect and re-establish normal pathways of brain signaling that become disrupted due to axonal injury associated with mTBI (concussion)
- Non-invasive nerve stimulation
- Gait protocol
- Vestibular rehabilitation
- Low intensity aerobic exercise
- Proprioceptive neuromuscular facilitative stretching to retrain muscle groups and improve feedback to the brain
- mild Hyperbaric Oxygen Therapy (HBOT)
- Occupational Therapy
- Autonomic Rehabilitation
- Tilt Table Therapy
- Necessary Referral
Portland Chiropractic Neurology utilizes evidence based treatments in a multi-modal approach, patient centered model that allows individualized diagnosis and treatments by combining Neurology, Hyperbaric Oxygen Medicine (HBOT), Chiropractic, Physical Therapy and Occupational Therapy. It is recommended that evaluation occurs after concussive injuries by a trained professional, such as at PCN. Early intervention is encouraged, but not always necessary. As the leading Chiropractic Neurology office in Maine, the doctors at Portland Chiropractic Neurology (PCN) are highly trained in these areas and have a very successful track record for treatment of Post Concussion Syndrome. Dr. Aaron MacArthur is a Chiropractic Neurologist and has a fellowship in Brain Injury and Rehablitation as well as a fellowship in Vestibular Diagnosis and Rehabilitation. He teaches within the United States on various topics of concussion and migraine care. Dr. Haley Girard is also a Chiropractic Neurologist with extensive training in concussion.
(1) Dobney et al. (2019) Non-pharmacological rehabilitation interventions for concussion in children: a scoping review, Disability and Rehabilitation, 41:6, 727-739
(2) Aubrey M. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Br J Sports Med. 2002; 36:6-7
(3) Worts et al. (2019) A Physiologically Based Appraoch to Prescribing Exercise Following a Sport-Related Concussion. Sports Medicine (2019) 49:683-706
(4) DeMatteo C et al. Exertion testing in youth with mild traumatic brain injury/concussion. Med Sci Sports Exerc. 2015; 47:2283-2290
(5) Consensus statement on concussion in sport- the 5th International Conference on Concussion in Sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838-847
(6) DeMatteo et al. Concussion Management for Children Has Changed: New Pediatric Protcols Using the Latest Evidence. Clinical Pediatrics 2020, Vol 59 (1) 5-20
(7) Asplund CA, Mckeag DB, Olsen CH. Sport-related concussion: factors associated with prolonged return to play. Clinic J Sports Med 2004: 14:339-43.
(8) Scheider KJ, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports Med 2014; 48:1294-1298
(9) Schneider K, et al. Symptom and functional improvements following a course of vestiblar rehabilitation, manual therapy and spinal stabilization exercises in high performance athletes with complex concussions. Clin J Sort Med 2009: 19: 265-6
(10) Quatman-Yates, Catherine, et al. Physical Rehablitaiton Interventions for Post-mTBI Symptoms lasting Greather Than 2 Weeks: Systematic Review. Physical Therapy 2016. Volume 96 Number 11
(11) Maruta, Jun, Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire. frontiers in Neurology Dec 2018, Vol 9, Article 1034.