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Ross Hauser, MD

At our center, we generally see one group of patients with a diagnosis of post-concussion syndrome. It is the patient who has long-term, unexplained conditions and symptoms. While diagnosed with post-concussion syndrome, their problems have now turned into a persistent, chronic, non-responsive, and more permanent condition. From this sole group of patients, we can then describe the four main patient types. This is in no particular order.

The younger athlete with persistent post-concussion syndrome.

• The first group represents young school-age athletes who seek, along with their parents, answers that will help them do well in school again, maybe play their sport again, and/or, play at a lesser risk for future concussions. The concussion occurred a year, two years, or maybe three years ago and symptoms persist.

The whiplash accident injury people with persistent post-concussion syndrome

• The second group represents the people who were in some type of accident, and are trying to get themselves back to work on a full or even part-time basis. In this latter group are older patients, their symptoms have been going on for years. They have reached that point in their “recovery” that their neurologist says there’s nothing that can be done for them because MRI, CAT Scan, and EEG say nothing is wrong with them.

The “I have had many concussions” people

• The second group represents people who are feeling the effects that multiple concussions have brought them. These are the people who have a greater likelihood of problems considered neurologic mysteries.

No one knows what is wrong with me people.

These people’s stories are told below. These are from emails we received, they have been edited for clarity.

Chronic Fatigue and POTS

• I have a diagnosis of Myalgic encephalomyelitis / chronic fatigue syndrome, Fibromyalgia, Postural Orthostatic Tachycardia Syndrome (POTS) all stemming from a concussion a few years back. I believe I have cervical instability, but I cannot get any doctor to order imaging, testing, or any attempt at any kind of treatment. It may be that their doctors think it is all in their heads. I discuss this below.

Persistent Postural Perceptual Dizziness, Meniere’s Disease, migraine

• I’ve been diagnosed with Persistent Postural Perceptual Dizziness, Meniere’s Disease, and migraine. I have had multiple concussions and cervical and lumbar herniations. A problem with my gait was noted four years ago, and now I have a wide gait, am extremely dizzy, nauseous, etc. Recently advised by an otolaryngologist I have square-wave jerk nystagmus (rapid back-and-forth eye movement when fixed on a stationary object). My former neurologist advised me I have Meniere’s and balance problems due to a stroke I never had. My question would the eye jerking and cervical instability and herniations be related? The answer is yes, I cover this below and at length in my article: Nystagmus – Oscillopsia caused by cervical spine instability and neck pain.

Diagnosed with multiple sclerosis, I don’t have multiple sclerosis, I am being treated for multiple sclerosis.

• I have tinnitus, ear fullness, ears not draining and feels like fluid buildup in the ear on the left side. Vertigo, balance, coordination, disoriented vision. Also temperature sensitivity, light sensitivity, brain fog, mood swings, eye twitching, sinus, and digestive problems. Diagnosed with multiple sclerosis when the symptoms started by MRI, and they say I had optic neuritis. I explained to them I was struck by a door on my left side and the symptoms didn’t start until after that incident. All the symptoms are primarily on my left side. I was diagnosed with a cerebral concussion and prescribed inflammations medications but that was it. Once I had the multiple sclerosis diagnosis they basically contributed all my symptoms to that diagnosis. We frequently see patients with an MS diagnosis who do not have MS. I discuss this in my article Cervical Spine Instability and Potential Effects on Brain Physiology.

Is Post-Concussion Syndrome a diagnosis label that is too broad and too general to help patients?

In the above stories we see symptoms, we see diagnosis and we see sometimes confusion as to what is the cause of the patient’s problems.

A June 2022 study led by St George’s University of London and published in the medical journal Brain (1) notes that the use of the term post-concussion syndrome remains widespread and this may be causing patients to not be treated correctly. These researchers suggest that this term is poorly used because it undermines the complexity of the patient’s problems and “its use acts to close off diagnostic and treatment pathways. In addition, misinformation or lack of understanding about the nature of the condition can lead to unrealistic expectations, frustration with the medical process, and symptom amplification.” Here in this paper the authors give an example: “rather than attributing dizziness following a head injury to ‘PCS’, without this diagnostic label further assessment for the cause of the dizziness would be required. This would allow, for example, the identification of potentially treatable causes such as benign paroxysmal positional vertigo. It would also improve the initial education process for patients, with early education recognized to reduce persistent symptoms following Mild Traumatic Brain Injury (mTBI).”

The reasoning behind better classifications for patients so that their doctors can understand their symptoms better is seen in the story given to us by someone looking for answers.

 I had a Motocross accident where I fell from my bike and impacted the ground head-first. I was wearing full protective gear and really took the impact hard however I was not seen emergently that day because I did not have much of any serious pain and only had a bad headache and felt like maybe I had a little concussion. The days following my accident I actually was quite okay just a little dazed and moderately sore feeling. It wasn’t until a week later when I actually got back on my bike and started racing again that I started to come down with horrible symptoms, this started the beginning of a diagnostic nightmare that brought me to tens and tens of doctors and more tests than I care to admit. I also tried every holistic and unusual treatment modality there is to try to relieve my symptoms.

My main issues initially were the sensation of my head falling off and a lot of odd numbness and lack of sensation throughout my body, and pretty severe heart palpitations in the form of Premature ventricular contractions and also heart racing. A lot of doctors speculated I was dealing with post-concussion syndrome.  

Currently, I am still dealing with very high-pitched tinnitus, the sensation of my head not being connected right with my neck especially when I look left right, and up and down. I get these momentarily stunned sensations when I move certain ways that almost feel like I’m going to fall over but I never do. I have a constant fullness in both my ears and my ears pop when I swallow. The odd thing is I do not have much of any pain in my neck… My head and neck appear slightly tilted to the right visually and this I believe has caused issues around my upper back that have gotten progressively worse, as now for the past year when I take a deep breath my whole upper back around the spine cracks and pops, my shoulders have also begun to feel loose and clunk and pop. 

Is it a brain injury that caused all this? This person found help at other clinics with neck stabilization treatments. Their doctors provided injection treatments to address structural problems in the cervical spine that were not being explored by the tens and tens of doctors that they had seen prior. This story, the research above, gives us a clear indication that post-concussion syndrome can be a very complex, multi-symptom, non-treatment responding problem. For some, the answers to the relief of symptoms may be found in the cervical spine. These treatments are discussed later in this article. 

Post-Concussion Syndrome- Symptoms from the Neck, NOT the Brain

Discussion points we will be covering in this article:

This is a review outline of the topics we will be covering in this article.

Part 1: Understanding Post-Concussive Syndrome:

• Sometimes it only takes one bad bang to the back of the head. Sometimes it takes many impacts to develop many and mysterious symptoms.
• “Unexpected neurological and other somatic symptoms after concussion should not be dismissed as an exaggeration.”
• The medical history and journey a patient suffering from post-concussion syndrome may take.
• My brain scan shows nothing: Do I have a neurologic mystery? Mild traumatic brain injury and whiplash-associated disorder post-collision symptoms.
  • My neurologist says there’s nothing that can be done. MRI, CAT Scan, and EEG say nothing is wrong with me.
• Should a patient suffering from an apparent post-concussion syndrome ask the doctors first, how many symptoms do I need to be diagnosed, in your opinion?
• Controversy: Do I have Post-concussion syndrome? Or do I NOT have Post-concussion syndrome?
  • Can you go to one doctor and be told you have Post-concussion syndrome and go to another one and be told you don’t have Post-concussion syndrome?
  • Overlap Between Whiplash Dysfunction and Post-Concussive Syndrome
  • Overlap Between  COVID-19 syndrome and post-concussion syndrome in patients suffering from both.
  • Anxiety caused by these mixed messages of confusing diagnosis can lead to an exacerbation of post-concussion syndrome in the patient.
  • Anxiety, specifically separation anxiety impacts patients.

Part 2: Post-Concussion Syndrome in the younger athlete

• For the newest or more recent concussion event, many people recommended 4 – 6 weeks total rest no activity period suggestion does provide the healing time necessary for symptoms to clear.
• “A greater percentage of athletes in the concussion group was not participating at their perceived pre-injury level of sport competition one-year.”
• 163 individuals were seen and treated at a concussion clinic until cleared for sports activity. Confusion involving vestibular impairments can lead to prolonged or delayed recovery.

Part 3: Vestibular impairments

• The vestibular system is complicated and includes cognitive disorders including amygdalar, prefrontal connectivity, and cingulate connectivity.

Part 4: Cervical instability, the missing diagnosis of post-concussion syndrome

• Persistent post-concussion symptoms – it may not be all in your head, it may be all in your neck.
  • “These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mild traumatic brain injury.”
• Neck treatment can play a valuable role in people’s recovery from post-concussion syndrome that extends beyond local effects on the neck.
• The need for a comprehensive neck assessment should be considered in post-mild traumatic brain injury.
• Cervical afferent dysfunction: A distortion of time and space in post-concussion syndrome patients – it starts with the ligaments.
• Altered cervical joint position.
  • Altered cervical joint position – cervical neck ligament damage.
  • Altered cervical joint position – cervical neck ligament damage – How we explain treatment to the Neck for post-concussion syndrome.
• Orthostatic intolerance in younger concussion athletes is different than in general orthostatic intolerance patients.
• When I turn my head my symptoms get worse – when I get an MRI no one asks me to turn my head.
  • Turning their head to one side or another will make the patient dizzy or blur their vision or cause ringing in the ears or make them pass out.
• Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and arterial compression.
• Understanding blood flow to the brain in patients.
• Post-Concussion Syndrome, Intracranial Hypotension and cerebrospinal fluid (CSF) leak
• Post-Concussion and carotid artery compression.
• Kinking or compression of the carotid sheath at the craniocervical junction.
• Treatment of interest: Prolotherapy for cervical ligament damage and cervical neck instability may help post-concussion syndrome.

Part 1: Understanding Post-Concussive Syndrome:

Sometimes it only takes one bad bang to the back of the head. Sometimes it takes many impacts to develop many and mysterious symptoms.

Many people contact us with a story about hitting the back of their heads. Some tell us about walking into things backward or mostly from standing up and not realizing something was right behind them. Many times the person didn’t even think anything of it. A few days later they had a panic or anxiety attack. Many of these people never knew what a panic or anxiety attack was having never suffered from one before. They describe the panic attack as building from a weird or indescribable type of sensation from the back of the skull. I cover this further in my article: Emotional stress: Anxiety, Depression and Panic Attacks: A neurologic and psychiatric like condition caused by cervical spine instability. They also develop visual hallucinations that last for a brief moment. This includes a quick burst of light or seeing an object that is not there.  Then they develop long-lasting hearing loss.

Another story:

We will hear the story of a person who has a cerebrospinal fluid (CSF) leak. This is causing them positional or orthostatic headaches. Despite various treatments to address the cerebrospinal fluid (CSF) leak and a seemingly successful patch of the fluid leak, that person describes the chronic and worsening symptoms of tinnitus, neck pain, light and vision sensitivities, tachycardia, and digestive disorders amongst the many problems. Please see my article: Spontaneous intracranial hypotension for more information on understanding cerebrospinal fluid leak and the similar common conditions it shares with post-concussion syndrome.

Everyone tells me I am okay. I am not okay

A person will describe a story that goes like this: I have post-concussion syndrome. I was in an accident a few years back and diagnosed with a concussion. I had all the tests, CAT Scan, MRI, X-Ray, and Electroencephalography (EEG). My doctors told me I was cleared. Nothing is wrong with me. While the doctors cleared me, I was still having symptoms. Chronic headaches, blurred vision, difficulty reading because of sight challenges and memory retention, memory loss, concentration problem, head pressure, and light sensitivity make computer work difficult. I continue to go from doctor to doctor.

My doctors think it is all psychological now, that I have Post-traumatic stress disorder

A person will describe a journey of years from the time of their injury to trying to get back to where they once were. They will tell us, like those above that they have had a barrage of tests that show nothing, yet they have symptoms. Doctors have told them they have PTSD from the injury and that nothing is wrong with them. But many of these people report “noisy” cracking, popping sounds in their necks. They recognize a physical manifestation of their neck pain.

Post-Concussion Syndrome and hypermobile Ehlers-Danlos syndrome

A person will contact us with their history of treatment for hypermobile Ehlers-Danlos Syndrome (hEDS). They will then tell us about an accident and a concussion. Treatment of Ehlers-Danlos Syndrome-related craniocervical instability is challenging enough. Not having an initial, accurate diagnosis can make it more challenging. A lack of a diagnosis can send patients on a many-year journey searching for help that they cannot get because they and their doctors are chasing the wrong problem.

When people contact us they tell us about their symptoms, especially those which are new-onset after the accident. They will also tell us about what was going on in their spine prior to the concussion incident. A complete loss of cervical lordosis, kyphosis lumbar and thoracic spine, scoliosis, and significant pelvic tilt and rotation.

We have a more extensive discussion on this problem in our article Ehlers-Danlos Syndrome, Atlanto-axial instability, and Craniocervical Instability.

The image below is a general description of events and symptoms surrounding traumatic brain injury. A concussion is a traumatic brain injury that affects your brain function.

Injury can occur as:

• Direct impact brain injury
• Acceleration-deceleration brain injury and
• Blast impact brain injury concussion

Symptoms include headache or feeling of pressure in the head; temporary loss of consciousness; confusion or feeling as if in a fog; amnesia surrounding the traumatic event; dizziness or seeing stars; ringing in the ears; nausea; vomiting; slurred speech; delayed response to questions; appearing dazed fatigue.

“Unexpected neurological and other somatic symptoms after concussion should not be dismissed as an exaggeration”.

A December 2021 study in the Journal of Psychosomatic Research (2) looked at people reporting unexpected symptoms after a concussion. In some of these people, the researchers noted it may reflect a Functional Neurological Disorder (balance, functional motor skills, seizures, vision problems, etc.), Somatic Symptom Disorder (problems of excessive unexplainable pain or loss of function), or exaggeration (feigning or faking). In this study, the researchers aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for Functional Neurological Disorder / Somatic Symptom Disorder, exaggeration, or both.

How was the study done?

• Seventy-seven adults with persistent symptoms following concussion rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing Functional Neurological Disorder and/or Somatic Symptom Disorder (e.g., fear-avoidance behavior).

Results:

• Fear-avoidance behavior was most strongly related to unexpected neurological symptoms
• Current anxiety scores were most strongly related to unexpected somatic symptoms.

Conclusion: Unexpected neurological and other somatic symptoms after concussion should not be dismissed as an exaggeration. Psychological factors thought to perpetuate Functional Neurological Disorder and Somatic Symptom Disorder (e.g., fear-avoidance behavior) may contribute to unexpected symptoms following concussion.

The medical history and journey a patient suffering from post-concussion syndrome may take.

Above I described a few stories and situations. We see many patients with difficult post-concussion challenges. When they were initially diagnosed with a concussion they were likely given a guarded but more optimistic outlook of what they could expect from their treatment.

The travels a patient suffering from post-concussion syndrome may take.

A June 2018 paper published in The Journal of the American Academy of Orthopaedic Surgeons (3) basically describes the travels a patient suffering from post-concussion syndrome may take. I present this here to give you a different perspective. Here the focus is on the athlete where the post-concussion syndrome is not resolving.

• In many patients, typical symptoms of concussion are usually self-limited and resolve within 2 to 3 weeks.
• Initial treatment consists of a reduction in cognitive activity and physical rest.
• A stepwise return-to-play protocol, taking into consideration state laws, with a gradual increase in activity until the athlete is able to perform the full activity without symptoms should be followed.
• Neuropsychologic testing (brain function) may be used as a tool in management.
• For prolonged concussions, physical rehabilitation or medications for headaches, mood, or sleep disturbance may be required.

Is this 2018 research current? A December 2021 paper included the above study in their list of the Top-100 Most-Cited Sports-Related Concussion Articles. The 100 articles that researchers use to support their own work and research. In this paper published in the journal Arthroscopy, sports medicine, and rehabilitation (4) the number one article is the Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 (5) which outlines diagnosis, assessment, and treatments on concussion in sports. Eleven years later, doctors reference the 2012 paper. The research then is current.

My brain scan shows nothing: Do I have a neurologic mystery? Mild traumatic brain injury and whiplash-associated disorder post-collision symptoms.

In our practice, we see many people with a long list of symptoms that are described throughout this article. In many cases, it is initially thought that neurologic conditions mean mild traumatic brain injury as a result of the concussion. When there are neurologic-like conditions, it is clear that something is going on in the brain. But is it the concussion itself that caused injury to the brain or is it a continued injury because of cervical spine instability? Both? This is one of the challenges of diagnosis and treatment of persistent post-concussion syndrome.

Overlapping symptoms point to cervical spine instability in many people. We are going to focus on the neck to show that neck injury may be A or THE main component of persistent post-concussion syndrome. 

Symptoms common to Altlantoaxial instability (Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). Whiplash-associated disorder, post-concussion disorder, cervicocranial syndrome, vertebrobasilar insufficiency.

• Headaches
• Dizziness / Vertigo
• Insomnia
• Tinnitus / Ringing in the ears
• Anxiety
• Light-headedness

Symptoms of Mild traumatic brain injury 

Here are symptoms of Mild traumatic brain injury common to those of cervical spine instability or whiplash injury to the neck.

• Headaches
• Dizziness/Vertigo
• Insomnia
• Tinnitus/Ringing in the ears
• Anxiety

Post-Concussion Syndrome will also share these symptoms with some of the diagnoses above:

• Fatigue
• Irritability
• Tinnitus
• Nausea/Vomiting
• Visual disturbances
• Cognitive impairment
• Memory Problems
• Crepitation (noisy, cracking neck).
• Balance difficulties
• Migraines

What we see is that it may be difficult for doctors to discover the source of the patient’s symptoms. Is it a whiplash neck injury, or is it a traumatic brain injury? Cognitive problems are not the dividing line.

Typically when a patient exhibits cognitive dysfunction, memory problems, mood problems, emotional swings, and depression, it can be thought that this is evidence of brain injury. In fact, it can be. But it can also be evidence that the problem is not in the brain but in the neck as these neurologic-like symptoms are also common in neck injury.

The table below is a visual that demonstrates the text information above.

My neurologist says there’s nothing that can be done. MRI, CAT Scan, and EEG say nothing is wrong with me.

There are many things that can cause Post-Concussion Syndrome. There are many treatments that can help Post-Concussion Syndrome. But what if you continue to have symptoms, nothing is helping, you have had a barrage of tests and your neurologist then walks into the exam room and says: “Your MRI, CAT Scan, and EEG say nothing is wrong with you. I can’t help you beyond antidepressants or anti-anxiety medications.” Now what?

If you are reading this article it is very likely that you have done a lot of research. You may have found your way through articles that discuss “hidden,” or “controversial,” causes this has led you to try different types of remedies.

• For some, experimentation with nutritional supplements may begin. Some people report great benefits with B complex and vitamin B12 supplementation. Others add high doses of Vitamin C, E, and D3 along with Omega 3. There are numerous studies supporting and non-supporting the use of nutritional supplementation.
• For some, fatigue will send them to an endocrinologist for thyroid and hormone testing with the hope that supplementing levels of testosterone and other hormones will improve their condition.
• For some, various manipulation techniques will be tried.

Should a patient suffering from an apparent post-concussion syndrome ask the doctors first, how many symptoms do I need to be diagnosed, in your opinion?

Canadian and Australian university researchers combined in recent 2017 research published in the British Journal of Sports Medicine (6) that indirectly support the findings above. In this study, confusion over what are ‘persistent symptoms’ of sports-related concussions are discussed.

” ‘Persistent symptoms’ following sports-related concussion can be defined as the clinical recovery that falls outside expected time frames (for example more than 10-14 days in adults and more than 4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies.”

In other words, it is usually not ONE thing that is causing persistent symptoms but a constellation or many problems that are the symptoms of post-concussion or the result of compounding problems of existing symptoms. In other words, a doctor needs to thoroughly investigate the problem of post-concussion.

Controversy: Do I have Post-concussion syndrome? Or do I NOT have Post-concussion syndrome?

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Can you go to one doctor and be told you have Post-concussion syndrome and go to another one and be told you don’t have Post-concussion syndrome?

Can you go to one doctor and be told you have Post-concussion syndrome and go to another one and be told you don’t have Post-concussion syndrome? The answer is yes. One doctor may be using one set of criteria to diagnose post-concussion syndrome and another doctor may be using another set of criteria to diagnose post-concussion syndrome.

This article is filled with possible symptoms because criteria and diagnosis are matched to symptoms. Above we showed that mild traumatic brain injury and whiplash-related disorders can share post-concussion syndrome symptoms but can be considered separated non-related entities, or as demonstrated below, they can be considered related, concurrent entities.

There is research that can be somewhat alarming to patients and their families where post-concussion syndrome is present. Published in the medical journal Brain Injury – doctors of the American College of Sports Medicine (ACSM) say a standard definition of Post-Concussion Syndrome (PCS) does not exist. (7)

• Symptoms vary from patient to patient but can include
  • headaches,
  • chronic neck pain,
  • difficulty with concentration,
  • sleep disturbance,
  • irritability,
  • slower reaction times,
  • memory deficits,
  • sensitivity to noise,
  • problems with judgment,
  • dizziness,
  • vertigo,
  • blurred vision,
  • anxiety and depression.

  These symptoms can range in severity from being slightly annoying to becoming an overwhelming disability.

When the doctors in the study asked what would be the minimum number of symptoms required to diagnose PCS, responses varied:

• one symptom (55.9%),
• two symptoms (17.6%),
• three symptoms (14.6%)
• and four or more symptoms (3.2%).

When asked how long these symptoms should persist before a diagnosis of Post Concussion Syndrome is made, the doctors of the studies responded:

• Less than 2 weeks (26.6%),
• 2 weeks to 1 month (20.4%),
• 1-3 months (33%) and
• More than 3 months (11.1%).

Physicians who see more than 10% of concussion patients in their practice, as well as physicians whose concussion population consists of more than 50% pediatric patients, were more likely to require more than 1 month of symptoms.

So, presenting to one doctor with one symptom would get a diagnosis of post-concussion syndrome while going to a second doctor for a second opinion who believes that there are three symptoms needed will not.

Overlap Between Whiplash Dysfunction and Post-Concussive Syndrome

It is also important to note the overlap between whiplash dysfunction and post-concussive syndrome. The whiplash-associated disorder symptoms including headache, tinnitus, neck pain, memory and concentration disturbances, muscle tension, sleep disturbances, and dizziness, muscle tension, and tinnitus are also seen with post-concussion syndrome. Both disorders have the same mechanism of acceleration-deceleration transferred to the cervical spine and/or brain and are indistinguishable based solely on symptoms. It is likely that during just about every whiplash injury, there is some mild brain trauma and vice versa. Because of its large mobility, it is the upper cervical spine that is injured when a person suffers a concussion. When there is a blow to the head, it is transferred to the top vertebrae, at which time there is a rotation force as the body tries to absorb the force. In the following order, the C1-C2, C2-C3, C0-C1, and C3-C4 facet joints (capsular ligament injuries) are the most often described in association with cervical symptoms following minor traumatic brain injury.

Let’s look at a March 2021 study in the medical journal Injury (8). The challenges of diagnosis are explained:

“Although post-motor vehicle collision pain and symptoms are largely convergent among those with mild traumatic brain injury and whiplash-associated disorder, and patients oftentimes report initial neck and head complaints, the clinical picture of mild traumatic brain injury and whiplash-associated disorder has been primarily studied as separate conditions which may result in an incomplete clinical picture.”

“It seems that while mechanisms of the neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.”

Overlap Between  COVID-19 syndrome and post-concussion syndrome in patients suffering from both.

In a February 2023 paper, doctors at the University of Houston and Baylor College of Medicine write in the journal Neurologic clinics (9) about a new complication of diagnosis. Post Covid-19 Syndrome. “Diagnosis and treatment of post-concussional syndrome (PCS) is challenging because symptoms are vague, difficult to confirm, and attributable to other conditions. There are no uniformly accepted diagnostic PCS criteria. Clinical care largely focuses on symptom reduction and management. Moreover, the coronavirus disease 2019 (COVID-19) pandemic has increased the challenge because post-acute COVID-19 syndrome symptoms overlap with PCS.”

Anxiety caused by these mixed messages of confusing diagnosis can lead to an exacerbation of post-concussion syndrome in the patient

In the journal Brain Injury, (10)  August 2019, Nigel King of the Oxford Institute of Clinical Psychology Training, University of Oxford wrote this concerning the confusion of understanding post-concussion syndrome in patients:

“The last 20 years have seen the emergence of a sub-category of the mild traumatic brain injury literature termed ‘sport-related concussion’. Some important differences now exist between this sub-category and the wider findings in the field and these could be detrimental to patients with persisting post-concussion symptoms (PCS). Sport-related studies often emphasize the cerebral risks associated with concussive injuries whilst the broader literature typically focuses on the relatively benign organic implications and the role of psychological factors in persisting symptoms. Clinically, anxiety caused by these mixed messages could lead to an exacerbation of post-concussion syndrome.“

What makes this 2019 research so impactful is that the same researcher, Nigel King, wrote in the October 2003 edition of The British Journal of Psychiatry (11) an article titled: “Post-concussion syndrome: clarity amid the controversy?” In established research, doctors have long questioned the traditional diagnostic tools for determining post-concussion syndrome. In 2006 in research in BMC Neurology, (12) doctors noted that: “One well-accepted hypothesis claims that chronic PCS has a neural origin, and is related to neurobehavioral deficits. But the evidence is not conclusive.”

Anxiety, specifically separation anxiety impacts patients

A November 2022 paper in The Journal of neuropsychiatry and clinical neurosciences (13) found “higher attachment anxiety was associated with greater persistent symptom severity, greater depression and anxiety symptoms, and worse quality of life. . . Attachment anxiety, the fear that a significant other will not be available in stressful circumstances, maybe a particularly important social factor associated with health among adults with persistent symptoms after Mild Traumatic Brain Injury (Postconcussion Syndrome).

A February 2023 paper in the American journal of physical medicine and rehabilitation (14) found a strong connection between anxiety and catastrophizing at initial neuropsychological evaluation in a post-concussion sample.

A December 2022 paper in the JAMA network open (15) found significant connections between PPCS and depressive symptoms . . . the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported.

Part 2: Post-Concussion Syndrome in the younger athlete

I am 16 years old and recently diagnosed with gastroparesis and other digestive symptoms. I have lost over thirty pounds and have constant vomiting and other symptoms of dysautonomia. I fell in my head whilst on a trampoline and also had a concussion in which I fell playing sport and landed on the back of my skull. I have headaches and neck discomfort frequently.

This section will deal briefly with research as to why younger athletes have not only a difficult time returning to sports, but why they also have a difficult time returning to a normal life routine.

For the newest or more recent concussion event, many people recommended 4 – 6 weeks total rest no activity period suggestion does provide the healing time necessary for symptoms to clear.

For the newest or more recent concussion event, many people recommended the 4 – 6 weeks total rest no activity period suggestion does provide the healing time necessary for symptoms to clear and the person to regain a sense of “being normal.” For others, the reintroduction of sports or work activity at the end of the 4-6 week rest period may reboot the symptoms. These new symptoms may also clear after a short period of time. These are not the people who are coming to our office. We see the people who this has not helped.

The people we see with post-concussion syndrome that come into our clinics begin their stories with the event. . . , “I was concussed during a game . . ; “I was skiing and crashed. . . “; “I was in a serious car accident . . . “; “I think I have had more than a few concussions, I am really not sure.” They describe their past or the current severity of symptoms and recommendations for this injury as:

• I get these annoying headaches, they are not intense headaches, but mostly annoying. I have had them for years.
• I don’t have energy some days, I feel deep and lingering fatigue. The more I push myself, the more tired I get. I am trying to keep my physical activity up but I have to watch my walking. Running is impossible because of the impact.
• Some days I am very nauseous, other days I actually vomit. I have dizziness some days.
• I have been told to do absolutely nothing.

“A greater percentage of athletes in the concussion group was not participating at their perceived pre-injury level of sport competition one-year.”

In January 2021 paper published in the  Journal of Science and Medicine in Sport (16) tried to provide estimates of the times taken to receive clearance to return to sporting activity and to return to the pre-injury level of sport competition following a sport-related concussion, and to estimate the proportion of athletes who were participating at their pre-injury level of sport competition six months and one-year following sport-related concussion.

These are the learning points of this research:

• Study participants: Amateur, adult athletes (16-38 years old) diagnosed with sport-related concussion.
• Participants were assessed at:
  • within one week, upon medical clearance to return to sporting activity,
  • two weeks following the return to sporting activity,
  • six months following a sport-related concussion
  • and 12 months following a sport-related concussion.
• Participants were asked during each study assessment whether they were:
  • participating in any sport,
  • in a different sport than before their sport-related concussion,
  • in the same sport but at a lower level of competition than before their sport-related concussion,
  • or in the same sport at the same level of competition as before their sport-related concussion.
• Fifty concussed participants and 50 non-injured, control participants completed the study.

Results:

• The average time taken to receive clearance to return to sporting activity was 13 days
• The average time taken to get to the pre-injury level of sport competition following a sport-related concussion were 31 days

One year following sport-related concussion:

• 52% of participants reported that they were no longer participating in the same sport and at the same level of competition as they were before their sport-related concussion.
• Factors that explain the lower proportion of amateur athletes participating at their pre-injury level of sport competition one year after a sport-related concussion are likely multifaceted and should be considered in future investigations.

163 individuals were seen and treated at a concussion clinic until cleared for sports activity. Confusion involving vestibular impairments can lead to prolonged or delayed recovery.

A May 2020 study in the Archives of Physiotherapy from Duke University (17) offered a list of risk factors for prolonged or delayed recovery. Here is what they wrote:

“Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery in individuals with concussion diagnoses. A secondary aim explored the influence of early examination on individual prognosis.”

• In this study, 163 individuals were seen and treated at a concussion clinic until cleared for sports activity.
• Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at the initial evaluation.
• Delayed recovery was calculated by taking the average time to clearance for activity.

Cognitive impairments, visual exam findings, and vestibular exam

Results:

• 80 of 163 individuals were considered delayed in their clearance to activity.
• Cognitive impairments, visual exam findings, and vestibular exam findings all increased the odds of delayed recovery. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examine after injury was a mediator for delayed recovery.

Conclusions: The clinical examination provides value in identifying individuals who are likely to exhibit delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a delayed recovery to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.

Part 3: What are vestibular impairments?

Here is an example story however of someone who had many concussions:

Twenty years of concussions

The main problems I am having are Vestibular VOR dysfunction which is causing spontaneous vertigo, dizziness, loss of balance, oscillopsia (shaky vision),  neck pain at the base of the skull, tachycardia, tinnitus, headaches, and migraines. I have had many concussions over the last twenty years. 

A few years ago I started having migraines which began with blurry vision in both eyes followed by aura then dull pain at the back of my skull. (See our article Occipital neuralgia and suboccipital headache).

I was on a lot of medications that I did not want to be on. So I tried lifestyle modification changes, mainly dietary changes, vitamins, meditation, and stress reduction techniques. I also started chiropractic adjustments. My chiropractor specialized in upper cervical problems. He identified that my C1 had rotated and moved far out of place. After a few adjustments, my migraines were gone but the other issues did not resolve.

I was seeing a neurologist who, after hearing this story sent me to an orthopedic surgeon. The orthopedist did an MRI, said I don’t need surgery, and sent me back to my neurologist. My neurologist, who had come to a dead-end with me now sent me to a neuro-ophthalmologist who is not interested in my so-called neck instability issues and focused solely on my vision dysfunction. Unfortunately looking only at my eyes, he cannot find any cause. My neuro-ophthalmologist thinks it may be Multiple Sclerosis but a brain MRI  has ruled that out.

Above is a sample story of a person who contacted us when the number of their conditions and symptoms have become so overwhelming that post-concussion syndrome became one of many problems. Unfortunately, this is not a unique situation or the most complicated situation we have seen.

We are going to move away from this research for some brief understanding notes and then we will return:

• The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment).
  • It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism.
    • As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.

What are we seeing in this image?

The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.

Vestibular impairments can be:

• Vestibular migraine and spontaneous vertigo
• Chronic Post-Traumatic Instability of the Cervical Spine: Persistent neck pain that develops into problems with hearing, vision, swallowing, dizziness, and chronic headache
• Oscillopsia vision disorders
• Blurred or Double Vision Problems

The vestibular system is complicated and includes cognitive disorders including amygdalar, prefrontal connectivity, and cingulate connectivity.

In December 2021, researchers writing in the journal Human Brain Mapping (17) sought to expand the understanding of what is happening in the brain of post-concussion syndrome patients in specific regard to the vestibular system.

Convergent clinical and neuroimaging evidence suggests that higher vestibular function is compromised by a distributed network including visuospatial (in simplest terms depth-perception and space between objects), cognitive-affective, proprioceptive (sense of space), and integrative brain regions (simply the processing of information to help you identify your place in space) as may disturb this network, resulting in deficits across a variety of functional domains

Clinical vestibular syndromes: These are identified as: (18)

• Benign paroxysmal positional vertigo,
• Menière’s disease,
• acute unilateral vestibulopathy/vestibular neuritis,
• bilateral vestibulopathy,
• vestibular paroxysmia, and the third mobile window syndrome (Superior canal dehiscence being one – an anatomical structure defect).

In this study in the journal Human brain mapping, the researchers examined structural and functional neuroimaging to characterize this extended network in healthy control participants and patients with post-concussive vestibular dysfunction (PCVD).  . . PCVD participants exhibited diminished integration and centrality among vestibular and affective nodes and increased centrality of visual, supplementary motor, and frontal and cingulate eye field nodes. Clinical outcomes, derived from dynamic posturography, were associated with approximately 62% of all connections but best predicted by cognitive disorders including amygdalar (the area of fear and apprehensive), prefrontal connectivity (the ability to process information including predicting what will happen, and the consequence of what will happen. For example, if you take a step you predict that you are moving closer to that which you are walking towards,) and cingulate connectivity (the control of emotions). . . These findings indicate that cognitive, affective, and proprioceptive substrates contribute to vestibular processing and performance and highlight the need to consider these domains during clinical diagnosis and treatment planning.

Part 4: Cervical instability, the missing diagnosis of post-concussion syndrome

In this section, we will begin our discussion of cervical instability, the missing diagnosis for patients who do not see a resolution of their symptoms. Let’s point out that we are talking about people who received a blow to the neck and/or head and may or may not have lost consciousness who are not getting 100% relief of symptoms such as headache, neck pain, and dizziness, but everything appears everything is normal (or just about normal) upon neurological examination. The main point of this discussion is that the reason the symptoms are not resolving as time goes on is that the person with PCS is being treated for a brain injury when in reality the true diagnosis (for many) causing the symptoms is missing: cervical ligament injury causing cervical instability. The cervical injury often involves the upper cervical segments and occurs because the head trauma induced a forced rotational force at the atlantoaxial articulation (C1-C2), which is loose to begin with. Upper cervical instability can be a good and realistic explanation for PCS symptoms.

As with any approach to a chronically painful condition, the first step in treating post-concussion syndrome is to identify the cause, taking into account the structures that may have been injured as a result of the jarring motion of the head. After the neurologic examination, the cervical spine should be carefully assessed for tenderness, spasms, and range of motion. Precipitation of headaches, dizziness, or vertigo should direct therapy to address a cervical injury.

Persistent post-concussion symptoms – it may not be all in your head, it may be all in your neck.

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“These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mild traumatic brain injury.”

In September 2019, the Archives of Physical Medicine and Rehabilitation (19) researchers at the Medical College of Wisconsin Department of Neurosurgery examined the frequency of neck pain in mild traumatic brain injury/concussion patients. The purpose? How many of these patients will develop primary neck pain?

• 95 patients came into the emergency room with mild traumatic brain injury – suspected concussion
• These patients were asked within three days, then at 8 days, then at 15 days, and then at 45 days post-injury how their neck pain was.
  • At three days 68.4% reported neck pain
  • At eight days 50.6% reported neck pain
  • At 15 days 49% reported neck pain
  • At 45 days 41.9% reported neck pain.
• These patients were then asked was the neck pain equal to or greater than any other symptom.
  • At three days 35.8% reported neck pain was equal to other symptoms, 17.9% said it was the worse symptom.
  • At eight days 34.9% reported neck pain was equal to other symptoms, 14.5% said it was the worse symptom.
  • At 15 days 37% reported neck pain was equal to other symptoms, 14.8% said it was the worse symptom.
  • At 15 days 39.2% reported neck pain was equal to other symptoms, 10.8% said it was the worse symptom.

The researchers concluded: These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mild traumatic brain injury.

At our center, we see many patients with the many symptoms of post-concussion syndrome that we discussed above. In some patients, we explain that while they have a general diagnosis of post-concussion syndrome, their problem may lie in the domain of damaged, weakened cervical neck ligaments. For some patients, this makes a lot of sense. For others, this is a “curious,” theory that they do want to explore further as they have not been provided relief from traditional treatment. We have published research and gathered research that helps show that cervical neck instability can be the missing diagnosis of post-concussion syndrome.

In our 2014 research led by Danielle R. Steilen-Matias, MMS, PA-C, and published in The Open Orthopaedics Journal (20) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine, this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. Vertebrobasilar insufficiency describes a narrowing of the arteries that is usually treated with blood thinners and cholesterol medication. In this context, vertebrobasilar insufficiency is describing a situation where hypermobility of the neck vertebrae is causing a “squeezing,” of the arteries by pinching movement. This could lead to dropping attacks, fainting spells, and blackouts.

In Ross Hauser’s, MD open letter of August 2017, Could Neck Injury Be the Culprit in Post-Concussion Symptoms and the Development of Chronic Traumatic Encephalopathy? Dr. Hauser wrote: “Understanding cervical instability as a possible cause of Chronic Traumatic Encephalopathy is understanding the difference between cellular damage in the brain caused by repeated blows to the head and cellular damage caused by cervical instability pinching and compromising oxygen flow and interrupting message signaling between the brain and the body.”

In the research below we present arguments and evidence that understanding damage caused by cervical instability pinching and compromising oxygen flow and interrupting message signaling between the brain and the body, may be the missing diagnosis in many post-concussion syndrome patients.

• Symptoms of headaches:
  • In our article: Cervicogenic headaches – Migraines, tension headaches, and cervical neck instability, we demonstrate research and clinical observation that people suffering from these headaches have a high incidence of neck pain and neck instability.
  • In our article Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments we also demonstrate research and clinical observation that people suffering from these headaches have a high incidence of neck pain and neck instability.
• Difficulty with ringing in the ears, postural sway, head tremors
  • In our article Treatment of Whiplash associated disorders, we demonstrate that problems that can be related to post-concussion syndrome Swaying, posture control, balance, jaw pain TMD, head tremors, and ringing in the ears (tinnitus) are problems of cervical neck instability.
• Symptoms of  dizziness and vertigo:
  • In our article Can neck problems cause vertigo? Cervical Vertigo and Cervicogenic Dizziness we discuss:
    • The diagnosis and treatment of cervical vertigo and chronic dizziness are associated with neck movement.
    • We present research on when neck pain causes dizziness and possible conservative treatment options.
    • We will also include research and evaluation on regenerative medicine injections including Prolotherapy.
• Symptoms of  blurred vision:
  • In our article: Chronic Neck Pain and Blurred Double Vision Problems – Is the answer in the neck ligaments? we discuss seeing patients following an acute head or neck trauma, such as concussion, whiplash, and sports injury who suffer from these various problems including double vision and other vision problems. In these patients, we see cervical vertebrae that are hypermobile and are moving in and out of their natural position because of weakened, damaged cervical neck ligaments.

Neck treatment can play a valuable role in people’s recovery from post-concussion syndrome that extends beyond local effects on the neck.

A paper from the School of Physiotherapy, Division of Health Sciences, University of Otago in New Zealand was published in November 2021 in The Journal of Manual & Manipulative Therapy. (21) The question the study authors were seeking to answer was: “Can the neck contribute to persistent symptoms post-concussion?” What the authors did to answer this question was to assess individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment as part of multidisciplinary concussion care. The authors then noted that a secondary objective they wanted to help answer was how participants described the outcomes of neck treatment.

To do this they followed 11 patients long-term (12 months). They had the patients at the initial start of the study, at the completion of their neck manipulation treatments, and at six and 6, and 12 months assess their neck disability, dizziness, headache, and neck pain. Ten of the 11 participants reported neck treatment as a beneficial part of their care and described the effects on the neck, multiple symptoms, and their overall recovery. However, seven participants experienced recurrent headaches, neck pain, or dizziness at their 6- or 12-month follow-up. Conclusion: “Long-term follow-up of individuals receiving neck treatment shows improvement across a range of patient-reported outcomes, yet highlights frequent recurrence of symptoms. Neck treatment can play a valuable role in people’s recovery that extends beyond local effects on the neck.”

So what do we make of this? Most patients that we have seen have a sense they have neck instability because they have done chiropractic manipulation with some success, it is just that the adjustments don’t hold.  Manipulation corrects the initial misalignment, thereby helping the vertebral segments to more evenly distribute the forces, thus eliminating pain but without addressing the cervical ligaments, the treatments will not hold.

The need for a comprehensive neck assessment should be considered in post-mild traumatic brain injury

A concussion is considered a mild traumatic brain injury (mTBI) and is defined as any transient neurologic dysfunction resulting from a biomechanical force, usually a sudden or forceful blow to the head which may or may not cause a loss of consciousness. Traumatic brain injury (TBI) or concussion induces a barrage of ionic, metabolic, and physiological events and manifests in a composite of symptoms affecting a patient’s physical, cognitive, and emotional states, and his or her sleep cycle, any of which can be fleeting or long-term in duration.

A November 2021 study published in the journal Musculoskeletal science & practice (22) starts off by stating “Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report being recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mild traumatic brain injury.” What this study then wanted to assess was to determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls.”

Methods: Participants aged 18-60 years consisted of 39 people who were healthy controls, and 72 individuals, 4 weeks to 6 months post mild traumatic brain injury of which 35 considered themselves asymptomatic, and 37 symptomatic. Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test, and balance.

Results: Individuals in the mild traumatic brain injury displaying symptoms group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance, and movement accuracy as well as increased postural sway, and a higher percentage had positive cervical joint dysfunction. The mild traumatic brain injury group who considered themselves recovered and asymptomatic demonstrated significantly lower rotation range, and flexor endurance, and a higher percentage had positive cervical joint dysfunction compared to HCs.

Conclusion: “Individuals reporting symptoms post mild traumatic brain injury demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.”

At this point let’s jump to a connection between some of the common symptoms of post-concussion syndrome and “neurologic mysteries.” The relevance and importance of understanding the role of the cervical ligaments in post-concussion syndrome symptom relief will become apparent.

Cervical afferent dysfunction: A distortion of time and space in post-concussion syndrome patients – it starts with the ligaments.

In some patients with post-concussion syndrome, they report symptoms of “out of body,” or a sensation of “exaggerated movement,” like they are moving at a high rate of speed. Things around them have become “accelerated.”

Cervical afferent dysfunction in simple terms means something is not working correctly within the nerves of the neck. This dysfunction can be caused by a traumatic injury to the neck such as in sports or whiplash.

In her study in the Journal of Orthopaedic & Sports Physical Therapy, (23) Dr. Julia Treleaven of the University of Queensland wrote:

• There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms.
• However, there are other possible causes for these symptoms beyond cervical afferent dysfunction
• Understanding the nature of these symptoms and differential diagnosis of their potential origin is important for rehabilitation.
• In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits.

Altered cervical joint position

Let’s look at the altered cervical joint position

• The cervical joint position error test is a test that measures cervicocephalic proprioception and neck reposition sense. In simplest terms, tests to measure if the neck is in the correct position and if it is not, what type of problems it causes by restricting blood vessels and nerve networks.
• Cervicocephalic syndrome, symptoms caused by cervical joint position error results in pain and restriction of motion of the upper cervical spine which may result in the many symptoms attributed to post-concussion listed above.

Altered cervical joint position – cervical neck ligament damage

Let’s now explore cervical joint position errors. A recent piece in the medical journal Child’s Nervous System – Official Journal of the International Society for Pediatric Neurosurgery, (24) from Vanderbilt University School of Medicine researchers can make for a fascinating revelation and a great understanding of how to treat the post-concussion syndrome persistent symptoms. Notice that in this study discussed below, the obvious treatment recommendation, in our opinion, is not mentioned but certainly alluded to… that is the treatment of the cervical neck ligaments for cervical stability and alleviation of symptoms.

The goal of the Vanderbilt study was to assess the usefulness and cost-effectiveness of neurologic imaging two or more weeks post-injury in youth athletes with post-concussion syndrome (PCS).

Here are the numbers:

Of 52 patients with PCS, 23 of 52 (44 %) had neuroimaging at least 2 weeks after the initial injury, for a total of 32 diagnostic studies.

• 1 of 19 MRIs (5.3 %), 1 of 8 CT Scans (13 %), and 0 of 5 x-rays (0 %) yielded significant positive findings, none of which altered clinical management.
• Chronic phase neuroimaging estimated costs from these 52 pediatric patients totaled $129,025. We estimate the cost to identify a single positive finding was $21,000 for head CT and $104,500 for brain MRI.
• Read the conclusion
  “brain imaging in the chronic phase (defined as more than 2 weeks after concussion) was pursued in almost half the study sample, had:

• low diagnostic yield,
• and had poor cost-effectiveness.
• Based on these results, outpatient management of pediatric patients with long-term post-concussive symptoms should rarely include repeat neuroimaging beyond the acute phase.

So what should be said here? The problems of long-term PCS should not be confined or even be supported by brain imaging because images will not help and may hinder the treatment of PCS symptoms.

In other words – you need to look somewhere else to help these people. That place is the cervical neck ligaments as symptoms of PCS, including headaches, dizziness, or vertigo can be caused by a cervical injury. In such cases, recovery from PCS can be addressed and resolved with Prolotherapy.

Altered cervical joint position – cervical neck ligament damage – How we explain treatment to the Neck for post-concussion syndrome

Many people we see have a demonstrated ligament problem. The problem is that the ligament problem offer gets lost in a sea of neurological problems. People will contact us saying that they have an MRI and the MRI clearly demonstrates that their alar ligament is damaged. That they, the person, not their doctors suspect, from their own research, that the alar ligament is a problem because their post-concussion syndrome has worsened and that they have taken to wearing neck collars to minimize pain, discomfort, and headaches.

As discussed in the video below by Ross Hauser, MD., we explain to patients that a concussion can be caused by many things including blunt force trauma to the head. When the head receives that blunt trauma impact, the force of that blow radiates like an aftershock into the neck area and causing injury and disruption. The area where most of this aftershock occurs is in the C1 – C2 vertebrae and at the Atlas, the small boney platform that the head sits on. It is not the vertebrae themselves that are impacted, but the strong bands, the cervical ligaments that hold the vertebrae in place that are also impacted and damaged.

We have seen when the cervical joint capsule (capsular) ligaments are damaged, the patient has many of the symptoms, already outlined in this article, which is typically applied to a diagnosis of post-concussion syndrome.

It can be difficult for people to believe that their problems, including memory problems, are coming from neck instability, dizziness, or ringing in the ears. These are symptoms commonly and well known to be those of getting “your bell rung,” in football, soccer, or any contact sport or falling off a bike, or skis, or being in an accident.

Orthostatic intolerance in younger concussion athletes is different than in general orthostatic intolerance patients.

In this next section, we will discuss the body and head positions as a cause of worsening or sudden onset of symptoms

My high school-age daughter was recently discovered to have had multiple concussions in the last two years. She has headaches, neck pain, TMJ pain, memory problems, and difficulty in school. When she gets up, many times she has to get right back down again and lay down to relieve her symptoms.

A July 2021 study in the journal The Physician and Sports Medicine (25) discusses the problem of understanding symptoms and outcomes in patients with orthostatic intolerance following pediatric concussion. Orthostatic intolerance is the development or worsening of many of the above-described symptoms when the person stands upright which are, many times, quickly relieved when reclining.

To help doctors understand orthostatic intolerance the doctors of this study “set out to describe concussion-related orthostatic intolerance in adolescence, with particular emphasis on time to recovery and differences from non-concussion-related orthostatic intolerance  (including male vs. female prevalence).”

They did this by retrospective chart reviews of patients with post-concussion and symptoms of orthostatic intolerance. The patients’ gender, sports history, previous concussions, time since injury, and recovery time were analyzed and compared between males and females as well as against general orthostatic intolerance statistics.

• Thirty-nine pediatric patients, representing 8.7% of all new patients referred to a specialized concussion clinic over a 13-month interval, were included in the chart review.
• The average age of onset was 15 years old, 18 patients (46%) were males.
• The average times from evaluation to symptom resolution were 120 days.
• Of 18 patients who completed head-up tilt table testing, 17 (94%) had an orthostatic tachycardic response (more than a 40 bpm heart rate increment).

These observations helped the researchers suggest that post-concussive orthostatic intolerance differs from other orthostatic intolerance etiologies, lacking a strong female predominance (a typically post-concussion syndrome in adolescents is seen more in the girls) and exhibiting a shorter time course to recovery compared to other etiologies of orthostatic intolerance (but longer recovery time compared to concussion patients in general).

Here is the conclusion: “Clinical orthostatic vital signs may not be sensitive for diagnosing orthostatic intolerance in athletes, likely due to the higher vagal tone and more efficient skeletal muscle pump.”

So what does this mean?

• The guidelines for recognizing orthostatic intolerance as a problem in post-concussion athletes cannot be used to accurately assess the adolescent athlete with suspected orthostatic intolerance. This makes treatment understanding more complex. The doctor has to thoroughly invest the symptoms that the patient is displaying.

Vagal tone. What does this mean?

• The younger athlete has a better course of recovery from post-concussion syndrome due to higher vagal tone and a more efficient skeletal muscle pump.

Many people reading this article will have a great understanding of the role of the vagus nerve and its function. The vagus nerves work optimally when their signals, messages, and relayed brain instructions flow through the body unimpeded.

The most important nerve in the body is the vagus nerve and we have two of them – one on each side of the neck. The health of the body is determined by the ability of these two vagus nerves to accurately, quickly, and effectively assess everything going on from moment to moment. The vagus nerves assess everything we eat, say, hear, think, and do and help the body make the proper adjustments for vigorous optimal health. With healthy vagus nerves, the overall nervous system is stronger, faster, calmer, and better equipped to handle stress. Strong vagus nerves are correlated with energy, mental alertness, intelligence, and vibrant functioning of the human body. Poor vagus functioning, called vagopathy or vagal tone, precedes illness and chronic condition It also perpetuates illness and makes recovery from diseases difficult. Low vagus nerve function has four main manifestations in the human body that increase the risk for almost all human diseases: chronic inflammation, elevated oxidative stress, sympathetic dominance, and coagulopathy. For more information on the Vagus nerve please see our article: Testing the vagus nerve.

What we suggest here is that if the athlete has better recovery time and better response to recovery in situations of orthostatic intolerance because of a stronger vagal tone, should we not look for vagus nerve dysfunction in athletes who are not responding well?

When I turn my head my symptoms get worse – when I get an MRI no one asks me to turn my head

The title of a December 2020 paper, “Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers” published in the journal Brain Sciences (26) explored the idea that a novel test to determine if someone is suffering from post-concussion syndrome, is to have the patient turn their head to one side and then the next. Let’s get to the research and then the explanation of what this would mean to someone suffering from these symptoms:

“Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB).”

Some of you reading this article may be familiar with Computerized Dynamic Posturography testing. The idea is that there are three systems in our bodies that help maintain proper balance. They are:

• Vestibular (inner ear system),
• Somatosensory (simply how your feet sense a change in the surface that you are standing or walking on and how the feet transmits messages back to the brain)
• Vision

As comprehensive as this sounds, there is a problem with this system. According to these researchers, that problem is: ” . . . tests relying largely on eyes-open and eyes-closed standing positions with the head in a neutral position, associated with the probability of missing postural instabilities associated with head positions of the neutral plane.”

In other words, testing when someone is standing even on the ground may miss problems associated with someone walking on an uneven surface. Uneven surfaces would also impact the position of the head with the rest of the body.

Let’s hear more from the researchers: “Postural stability scores are compromised with changes in head positions after a concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores. . . ”

In other words, when the patients turn their heads, they have less stability.

Here is the summary conclusion of this research:

“Balance loss or compromise may be caused by neurological disorders that increase the time delay in the neuromuscular system. (The study authors) have demonstrated that the position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores . . . Sport-related concussion is associated with inconsistency in clinical assessment integrity, largely focusing on the function of neurocognition, symptom scores, and postural stability.  . . Concussion represents a functional rather than a structural injury that results in shear stress to the brain and neck. The standardized (test) head-neutral postural examinations are not adequate to identify individuals that have suffered a concussion. However, this study has identified significant differences in the postural stability scores with head turns in post-concussion syndrome subjects that differentiate them from normal healthy controls.”

The suggestion was then made that head turns be included in post-concussion patient analysis.

Turning their head to one side or another will make the patient dizzy or blur their vision or cause ringing in the ears or make them pass out

Many patients we see with post-concussion syndrome, whiplash, and cervical spine instability, will often tell us that their symptoms are worse when they turn their head from side to side. What can cause this? In some instances, it can be some type of brain injury that is causing a blockage to the brain. But what about MRIs and Scans that don’t show anything out of the norm?

Most patients know the exact head position that gives them the symptoms of dizziness, “lack of oxygen to the brain,” and related problems. I can tell you that head position is almost always when they are standing or sitting upright, not when they are lying down or standing upright with a stiff postural position. Their head does not move.

For this and other reasons, we offer to test with Transcranial Doppler & Extracranial Doppler Ultrasound. For the full article on this testing please visit our page: Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center.

Here is a summary of that article and how this type of testing can show disruptions in blood flow to the brain and may help explain to patients why they feel that they are “not getting enough oxygen.”

• Transcranial doppler (TCD) can track real-time, moment-to-moment changes in blood flow to the brain. This allows for an assessment of blood flow changes to the brain and their impact on patient symptoms when the patient moves their head and creates changes in neck positioning. This includes monitoring the blood flow even while the patient walks into the office.

Understanding that blood flow may only be suppressed in certain positions of the neck

• If the blood flow is intermittently compromised, such as only when the neck is in certain positions, it will be difficult to catch and diagnose. To assess proper blood flow to the body’s most important nerves and nervous tissue (the brain), especially with head and neck motions, we perform transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound examinations.
• It is through dynamic transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound analysis that this decrease in blood supply can be documented with its root cause being compression of the arteries as they run through the cervical spine.

Digital motion X-Ray C1 – C2

• Digital Motion X-ray can show instability at the C1-C2 Facet Joints
• The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine which may lead to an understanding of why the patient is not responding to conventional treatments for post-concussion syndrome.

You can also visit this page on our site for more information on Digital Motion X-rays (DMX)

Treatment of interest: Prolotherapy for cervical ligaments damage and cervical neck instability may help post-concussion syndrome

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and non-effective conservative care treatments.

The above research shows us where medicine is in regard to difficult-to-treat patients with persistent chronic whiplash disorder. In our opinion, prolonged symptoms of concussion or whiplash – and difficulties with concentration and memory or other neurologic-type issues are usually not problems solely correlated with the cervical discs damaged in whiplash concussion but a problem of damage to the cervical ligaments.

When ligaments are subjected to quick forces, as occurs in whiplash concussion traumas, it does not take much to tear or overstretch them. All whiplash traumas have the potential to significantly injure cervical ligaments and cause neck instability.

The treatment of cervical spine instability at the Hauser Neck Center – Research on cervical instability and Prolotherapy

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Our research documents our experience with our patients.

In 2015, our research team at Caring Medical published findings in the European Journal of Preventive Medicine (29) investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots. Irritation of nerve roots causes many of the symptoms and challenges our patients face.

Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

• Ninety-five percent of patients reported that Prolotherapy met their expectations in regard to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
• Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
• Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicate the safety and viability of Prolotherapy for cervical spine instability.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (30) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

This is what we wrote in this paper: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems is not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs (such as excessive sweating or inability to sweat and temperature dysregulation or other skin sensations mentioned in this article) or symptoms.”

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of many of the symptoms we mentioned above.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

The diagnosis of post-concussion syndrome is often made after suffering a head injury where the patient loses consciousness and develops a myriad of symptoms a year after the injury. These symptoms include headache, neck pain, dizziness, fatigue, irritability, nausea, anxiety, and memory problems. Many of these symptoms overlap with those of atlanto-axial instability, cervicocranial syndrome, and whiplash-associated disorder. This is not just a coincidence. Typical causes of concussion include blows to the head or falls. If you fall and hit your head on the ground, it is easy to understand that the fall would put a large force on the skull. In addition to that, however, that same force can also be transmitted to the ligaments of the upper cervical spine. A blow to the head or a fall could also cause a hyperextension-hyperflexion type movement of the neck, insinuating that those who suffer concussions also suffer a concurrent whiplash injury. For that reason, patients who suffer from one or multiple concussion(s) can easily develop upper cervical instability and associated symptoms. Further explanation could be that post-concussion syndrome, which was once thought to be due to residual brain trauma, could be the result of upper cervical instability that develops during the injury. Symptoms of post-concussion syndrome occur long after imaging of the brain appears normal, suggesting that there is another cause for the headaches, dizziness, etc. that develop weeks after the fall/injury. It is likely that this other cause is ligament laxity in the upper cervical spine. Treatments to restore cervical spine instability can help this condition.

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References:

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This article was updated on March 2, 2023

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