Caring Medical - Where the world comes for ProlotherapyDo I have Post-concussion syndrome? Or do I NOT have Post-concussion syndrome?

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida

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

In our clinics we mostly see two types of patients suffering from post-concussion syndrome. The first group who are young school age athletes who need, along with their parents, to get some answers that will help them maybe play again, play at lesser risk for future concussions, or at least do well at school again. We also see people, either very active lifestyle people or people who were in some type of accident, who are trying to get themselves back to work on a full or even part-time bases. In this later group of older patients, their symptoms may be going on for years. The 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 says nothing is wrong with them. This is how these people have wound up in our office.

Of course the common denominators to these two types of patients is that they have had at least one concussion. Some of these people it will later be revealed have had a series of concussions, recent concussions or old concussions. They have lingering effects of that concussion or concussions, and they are having a difficult time finding their way back to “normal.” At the end of this article we will present the argument and evidence for various treatments including those we employ at our clinics that we have found successful in many patients.

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

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

A June 2018 paper published in The Journal of the American Academy of Orthopaedic Surgeons (1) basically describes the travels a patient suffering from post-concussion syndrome may take.

  • 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 full activity without symptoms should be followed.
  • Neuropsychologic testing (brain function) may be used as a tool in management.
  • For prolonged concussion, physical rehabilitation or medications for headaches, mood, or sleep disturbance may be required.

For the newest or more recent concussion event, the many people recommended to the 4 – 6 week 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 current severity of symptoms and recommendations to this injury as:

  • I get these annoying headings, they are not intense headaches, mostly annoying. I have had them for years.
  • I don’t have energy some days, I feel a 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.

My neurologist says there’s nothing that can be done. MRI, CAT Scan, and EEG says 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 says 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 researching. You may have found your way through articles that discuss “hidden,” or “controversial,” causes this has lead to you to try different types of remedies.

  • For some, experimentation with nutritional supplements may begin. Some people report great benefit with B complex and  vitamin B12 supplementation. Others add hi doses of Vitamin C, E, and D3 along with Omega 3. There are numerous studies supporting and non-supportive of 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.

At this point of our article we will examine the controversies in published research and hopefully provide some information that may help you find your own path of treatment.

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?

The answer is yes. One doctor may be using one set of criteria to diagnosis post-concussion syndrome and another doctor may be using another set of criteria to diagnosis 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.(2)

  • 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%).

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% concussion patients in their practise, 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 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 recent 2017 research published in the British Journal of Sports Medicine (3) 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.”

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.

In the journal Brain Injury, (4)  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 has 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 PCS.”

What makes this 2019 research so impactful is that the same researcher, Nigel King, wrote in the October 2003 edition of the The British Journal of Psychiatry (5) an article entitled: “Post-concussion syndrome: clarity amid the controversy?” In established research, doctors have long questioned the traditional diagnostic tools of determining post-concussion syndrome. In 2006 in research in BMC Neurology, (6) 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.”

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


Frequency of primary neck pain in mild traumatic brain injury/concussion patients.


Cervical afferent dysfunction and post-concussion syndrome

In a September 2019 in the Archives of physical medicine and rehabilitation (7) 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 our 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.

In our clinics 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 some patients 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 lead by Danielle R. Steilen-Matias, MMS, PA-C and published in The Open Orthopaedics Journal (7) 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 drop 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’s cause 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:
  • 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, 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 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.

Cervical afferent dysfunction: A distortion of time and space in post-concussion syndrome patients

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, (8) 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 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.

Altered cervical joint position – cervical neck ligament damage

Let’s now explore cervical joint position error. A recent piece in the medical journal Child’s nervous system, official journal of the International Society for Pediatric Neurosurgery, (9) 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 our opinion, is not mentioned but certainly alluded to – that is 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 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.

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

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 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, that are typically applied to a diagnosis of  post-concussion syndrome.

It can be difficult for people to believe that their memory problems are coming from neck instability, or their dizziness or their 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, skis, or being in an accident.

Prolotherapy treatments

Introduction: Prolotherapy is the injection of (in most cases) of a simple dextrose solution. The goal of the treatment is to naturally tighten and strengthen weak tendons, ligaments or joint capsules. In this case the cervical neck region. Prolotherapy works by stimulating the body to accelerate the inflammatory healing response. It is within this inflammatory stage of healing that collagen is made that provides the building blocks to repair ligaments and tendons repair.

Digital motion x-ray
In this video, Ross Hauser, MD is performing Prolotherapy under DMX guidance to the upper cervical region.

Treating cervical ligaments – published research from Caring Medical

Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, We also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae. Treating and stabilizing the cervical ligaments can alleviate the problems of cervical neck instability attributed to post-concussion syndrome.

An introduction to the treatment is best observed in the video below. A patients with cervical neck instability is treated with Prolotherapy using a Digital Motion X-ray machine.

Caring Cervical Realignment Therapy (CCRT) was developed by Ross Hauser, M.D. after decades of treating patients with neck disorders, including cervical instability and degenerative disc disease

Caring Cervical Realignment Therapy combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connect vertebrae, and re-establish normal biomechanics and encourage the restoration of lordosis. This is our treatment method of moving towards putting a patient’s cervical spine back into place.

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

spine curves

 

A February 2017 study in the European journal of physical and rehabilitation medicine (10) investigated the immediate and long-term effects of a 1-year multimodal (multi-treatment) program, with the addition of cervical lordosis restoration and anterior head translation (Forward Head Posture) correction, on the severity of dizziness, disability, cervicocephalic kinesthetic sensibility (proper head orientation), and cervical pain in patients with cervicogenic dizziness.

Patients were divided into two groups, both groups received therapy and exercise programs, one group received a cervical neck traction device.  At 10 weeks, the between group analysis showed equal improvements in dizziness outcome measures, pain intensity, and head repositioning accuracy, severity of dizziness , dizziness frequency and neck pain.

At 1-year follow-up, the between-group analysis identified statistically significant differences for all of the measured variables including anterior head translation, cervical lordosis, severity of dizziness, dizziness frequency, and neck pain, indicating greater improvements in the traction group. The results lead the researchers to conclude that “appropriate physical therapy rehabilitation for cervicogenic dizziness should include structural rehabilitation (traction) of the cervical spine (lordosis and head posture correction), as it might to lead greater and longer lasting improved function.

Caring Cervical Realignment Therapy (CCRT) weight protocol

If this article has helped you understand the problems of cervical vertigo and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

References:

1 Shirley E, Hudspeth LJ, Maynard JR. Managing sports-related concussions from time of injury through return to play. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2018 Jul 1;26(13):e279-86. [Google Scholar]
2 Rose SC, Fischer AN, Heyer GL. How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain injury. 2015 Jul 3;29(7-8):798-803. [Google Scholar]
3. 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.  [Google Scholar]
4 King NS. ‘Mild Traumatic Brain Injury’and ‘Sport-related Concussion’: Different languages and mixed messages?. Brain injury. 2019 Aug 18:1-8. [Google Scholar]
5 King NS. Post-concussion syndrome: clarity amid the controversy?The British Journal of Psychiatry. 2003; 183: 276-278. [Google Scholar]
6 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  [Google Scholar]
7 King JA, McCrea MA, Nelson LD. Frequency of primary neck pain in mild traumatic brain injury/concussion patients. Archives of Physical Medicine and Rehabilitation. 2019 Sep 4. [Google Scholar]
8 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
9. 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. [Google Scholar]
10 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. [Google Scholar]
11 Moustafa IM, Diab AA, Harrison DE. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. European journal of physical and rehabilitation medicine. 2017 Feb;53(1):57-71.


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