Post-concussion syndrome

Post-concussion syndrome

Ross Hauser, MD

In this article, Ross Hauser, MD., discusses Prolotherapy injection treatments to the neck to help patients suffering from post concussion syndrome.

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.

  • Before continuing on with this article, do you have a question about Post-concussion syndrome? Ask us Send us an email.
  • 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 judgement,
    • 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%). 1

So presenting to one doctor 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.

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 new research appearing in the British Journal of Sports Medicine that indirectly support the findings above. In this study, confusion over what are ‘Persistent symptoms’ of sports related concussion are discussed.

‘Persistent symptoms’ following sports related concussion can be defined as clinical recovery that falls outside expected time frames ( for example more that 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.”10

In other words, it is usually not ONE thing that is causing the 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.

Cervical afferent dysfunction and post-concussion syndrome

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, 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. 11

Let’s look at altered cervical joint position

  • Cervical joint position error test is a test that measures for 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 in 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.

Treatment of the cervical neck ligaments for cervical stability and alleviation of symptoms

However, a recent piece in the medical journal Child’s nervous system, official journal of the International Society for Pediatric Neurosurgery, 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 we will discuss below, the obvious treatment recommendation, in my opinion, is not mentioned but certainly alluded to – that is treatment of the cervical neck ligaments for cervical stability and alleviation of symptoms.

In established research, doctors have long questioned the traditional diagnostic tools of determining post-concussion syndrome. In research in The British Journal of Psychiatry, and BMC Neurology, doctors noted that approximately 90% of concussions are transient, with symptoms resolving within 10-14 days. However, a minority of patients remain symptomatic several months post-injury and that the treatment of these patients can be challenging.2,3

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.4

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 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 cervical injury. In such cases, recovery from PCS can be addressed and resolved with Prolotherapy see below.

Cluster Post-concussion syndrome symptoms

Concussion Symptoms

When the brain is subjected to a violent force, it can bleed, swell and, occasionally, shut down. In addition, PCS can manifest itself as chronic pain in the form of headaches and neck pain, following a concussion or MTBI Mild Traumatic Brain Injury.

 

Post-Concussion Syndrome Treatments

After an MRI to rule out the existence of a hematoma, doctors usually try a number of different approaches to deal with the headache and pain. “The primary forms of PCS treatment have traditionally included rest, education, neurocognitive rehabilitation, and antidepressants, with little evidence of success.”5,6

Pain control may also be approached using nerve blocks or transcutaneous electrical nerve stimulation (TENS), which involves the electrical stimulation of muscle groups. These modalities might provide temporary relief, but they only modify symptoms and usually do not address the root cause of chronic pain and symptoms associated with post-concussion syndrome.

Cervical instability conditions symptoms overlap

Treatment to the Neck

Treatment approaches depend on the clinician’s ability to differentiate among the various conditions associated with PCS. 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.

It’s quite possible that the cause of post concussion syndrome may be due to injured neck ligaments. “After the neurologic examination, the cervical spine should be carefully assessed for tenderness, spasm, and range of motion. Precipitation of headaches, dizziness, or vertigo should direct therapy to address a cervical injury.”6

If cervical injury is diagnosed, treatment would involve correcting the alignment of the vertebrae in the neck posteriorly, so they no longer pinch the sympathetic nerves. This can be accomplished with Prolotherapy treatments. In our own research from Caring Medical lead by Danielle Steilen, cites that treating the capsular ligaments of the neck which are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain – we can stabilize the neck and symptoms not only of neck pain, but of post concussion syndrome as well.

When the capsular ligaments are injured, they become elongated and exhibit laxity (weakness), which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), 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.

In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic pain.

In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.  We contend that prolotherapy offers a potentially curative treatment option for chronic pain related to capsular ligament laxity and underlying cervical instability.

The areas to be treated with Prolotherapy are determined by palpatory examination. Using this method we find that the accuracy in diagnosing the actual pain-producing area is excellent. Once identified these tender areas are treated with Prolotherapy injections.


References:
1. Rose SC, Fischer AN, Heyer GL. How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj. 2015 Apr 14:1-6. [Pubmed]
2. King NS. Post-concussion syndrome: clarity amid the controversy?The British Journal of Psychiatry. 2003; 183: 276-278. [Citation]
3. Sterr A, Herron KA, Hayward C, Montaldi D. Are mild head injuries as mild as we think? Neurobehavioral concomitants of chronic post-concussion syndrome. BMC Neurology. 2006; 6:7.  doi:10.1186/1471-2377-6-7 [BMC Neurology]
4. Morgan CD, Zuckerman SL, King LE, Beaird SE, Sills AK, Solomon GS. Post-concussion syndrome (PCS) in a youth population: defining the diagnostic value and cost-utility of brain imaging. Childs Nerv Syst. 2015 Dec;31(12):2305-9. doi: 10.1007/s00381-015-2916-y. Epub 2015 Sep 29.
5. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation of Concussion and Post-concussion Syndrome. Sports Health. 2012; 4(2): 147–154. doi:  10.1177/1941738111433673 [Pubmed]
6. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome. Clin J Sport Med.  2010; 20: 21–27.
9. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. doi: 10.2174/1874325001408010326. eCollection 2014. [Pubmed]
10. Makdissi M, Schneider KJ, Feddermann-Demont N, Guskiewicz KM, Hinds S, Leddy JJ, McCrea M, Turner M, Johnston KM. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med. 2017 May 8. pii: bjsports-2016-097470. [Pubmed] [Google Scholar]
11. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-25. [Pubmed] [Google Scholar]

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