Conditions
Persistent Post-Concussion Symptoms
Persistent post-concussion symptoms or PPCS describes the symptoms that can linger beyond the expected recovery time for a concussion. Unfortunately, for the significant minority that suffer persistent symptoms, long-held assumptions about what may be causing the symptoms often leads to inappropriate or absent care, when in many cases, significant improvement can be achieved in relatively short time-frames.
Specifically, the upper cervical spine is only considered a target for treatment of headache or dizziness when neck pain and/or restriction of movement is also reported. This leads to treatments designed to improve range of motion and stretch/strengthen muscles.
Clinical evidence collected in this clinic indicates that there is often a significant dysfunction affecting the small sub-occipital muscles. This dysfunction is not pain inducing but does impact the sensory feedback these muscles send, otherwise known as proprioception – the sense of where the head is relative to the neck that can occur independent of, and even without neck pain or limitation of movement.
While this may not seem like a significant issue compared to pain, the ‘head-position’ sense that these muscles generate helps to inform critical reflexes that regulate blood pressure in response to posture change, help the eyes to coordinate when the head is moving, help the inner ear (vestibular organ) differentiate between head movements (looking down) versus whole body movements (falling forwards), and form a critical link between the head and the body to allow smooth movement and coordination of balance. Errors in these systems can predictably lead to difficulty regulating heart rate and blood pressure, visual disturbances, vertigo (spinning/falling sensations), and imbalance.
This is exactly what we see in clinic, that beyond the traditional symptoms of neck pain, headache and dizziness, commonly plays a major role in symptoms including:
- Vertigo
- Balance problems
- Nausea/vomiting
- Impaired memory
- Photophobia
- Phonophobia
and accompanied by difficulty concentrating, insomnia, irritability, pressure in head, fatigue, blurred vision, feeling slowed down, brain fog, confusion, drowsiness, sadness and nervous or anxiousness.
This is not to say that ALL of these symptoms are solely coming from the neck, but that in different cases we have seen any of these symptoms resolve wth neck treatment (including mood and anxiety based symptoms!).
Not only can this proprioceptive dysfunction be measured, but also corrected within a few weeks. We are not waiting months for changes to occur.
PPCS must be viewed as a combination of traumatic brain injury and whiplash or neck injury for the following reasons:
- The minimum force required for a concussion has been recorded as 60 G in American football players. Neck tissues can be damaged with as little as 4 G. If there is even a mild concussion it is likely the neck has experienced significant forces, and may have sustained trauma.
- The more severe the head injury, the less common headache is. If the TBI was responsible for the headache, wouldn’t a more severe TBI cause a more severe headache? Could something else like the neck be causing the symptoms?
- Symptoms associated with cervicogenic headache and whiplash can be identical to persistent PCS. i.e. neck problems can cause the same symptoms without a TBI.
- Neck pain, dizziness and headache have been implicated as risk factors for sustaining a concussion.
- A history of migraine is a significant risk factor for developing persistent symptoms post concussion.
This makes a strong case for having an examination of the neck in people with persistent post-concussion symptoms using techniques designed to treat brain sensitivity. At present sufferers are left to wait for symptoms to recover relying on medication to manage symptoms, meanwhile giving up careers, social life and daily activities.
Diagnosis & Symptoms
There are major issues with the validity with diagnosis of concussion, and what then constitutes persistent symptoms.
In short, concussion is diagnosed based on the signs and symptoms presenting after an impulsive force is transmitted to the brain.
The key issue is that these impulsive forces almost always have to pass through the upper part of the neck, and the signs + symptoms associated with neck injuries can be identical to concussion.
Once neck pain associated with headache and/or dizziness has gone (or if it was never present) the neck is generally excluded as part of the
After 6 consensus statements spanning 2 decades of compiled research the peak body for concussion internationally (Concussion In Sport Group or CISG) are still yet to reach agreement on a definition of concussion.
They have agreed that concussion occurs when an impulsive force is transmitted to the brain and does not need to involve direct contact with the head.
Instead they defer to the American Congress of Rehabilitation Medicine’s (ACRM) diagnostic criteria. NB: the term concussion and mild traumatic brain injury (mTBI) are considered interchangeable terms under this classification (this in itself is a major problem – more on that in a moment);
Mild TBI is diagnosed when, following a biomechanically plausible mechanism of injury one or more of the criteria (i-iii) listed below are met:
i. One or more clinical signs attributable to brain injury (loss of consciousness, altered mental status, amnesia for events immediately before the injury, other acute neurological signs – incoordination, seizure, tonic posturing)
ii. At least 2 acute symptoms and at least one clinical or laboratory finding (feeling confused, disoriented, dazed; feeling slowed down cognitively, difficulty concentrating and or memory problems; uncharacteristic emotional lability (crying) or irritability) (Lab findings; cognitive impairment, balance impairment, oculomotor impairment, elevated blood biomarkers indicative of of intracranial injury)
iii. Neuroimaging evidence of TBI
It is interesting to note that the Sport concussion assessment tool (SCAT) lists 22 symptoms, including headache, pressure in the head, neck pain, dizziness, blurred vision, balance problems, sensitivity to light, sensitivity to noise, feeling slowed down, feeling like ‘in a fog’, “Don’t feel right”, fatigue or low energy, drowsiness nervous or anxious, trouble falling asleep, which are in addition to those listed under the ACRM guidelines.
The problem is that all of these can occur independently of concussion, and none of them indicate with certainty that a brain injury has occurred.
Concussion occurs when an impulsive force is transmitted to the brain and does not need to involve direct contact with the head.
The first assumption is , and are assumed to be associated with a mild traumatic brain injury (mTBI). There are a number of terms that are often used interchangeably such as ‘head injury’, ‘traumatic brain injury’ and ‘concussion’.
According to studies conducted with Professional American Football players the
The typical causes of these types of symptoms are after having a concussive event many of which occur at home, at work or after a motor vehicle accident – only 20% relate to sports injury.
Persistent symptoms following whiplash are similar but covered under Whiplash Associated Disorder (WAD).
Post-concussion syndrome is defined by the International Classification of Diseases as the persistence of 3 or more symptoms for 4 weeks following minor head injury. The diagnostic and statistical manual of mental disorders definition required symptoms to be persistent for 3 months.
The overlap with migraine, persistent whiplash and cervicogenic disorders is obvious with
Post concussion syndrome is defined under the World Health Organisation’s (WHO) International Classification of Diseases and Related Health Problems (10th edition), with the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) actually removing it from their latest edition (5th edition), due to the lack of clarity around the criteria and numbers of misdiagnosis resulting.
The ICD-10 diagnostic criteria describe:
Postconcussional syndrome occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes symptoms such as:
- Headache
- Dizziness
- Fatigue
- Irritability
- Difficulty in concentrating and performing mental tasks
- Impairment of memory
- Insomnia
- Reduced tolerance to stress, emotional excitement, or alcohol
May be accompanied by feelings of depression or anxiety resulting from some loss of self-esteem and fear of permanent brain injury.
Note: We find the presumption here by the American Psychiatric association of why people might be experiencing feelings of depression and anxiety to be overly presumptuous. While these could be the reason, there are a host of other possibilities, the most direct of which is via an irritation of the ‘stress response’ (reticular activating) system – this can lead to symptoms of anxiety and depression as a result of the physiological stress of the TBI, rather than an emotional and behavioural response to the TBI.
Persistent post concussion symptoms:
Influenced by factors other than head injury status, suggesting these symptoms may not be related directly to the TBI.
The International Classification of Headache Disorders (ICHD-3) only describes the ‘headache’ aspect, which is interesting, and probably due to the fact that the presentation of PCS often looks like migraine. It is defined as Post-traumatic headache which is a secondary headache. That means a headache that is directly caused by another disorder:
Headache attributed to trauma or injury to the head and/or neck.
Under this section are six sub-types:
- Acute headache attributed to traumatic injury to the head (concussion)
- Persistent headache attributed to traumatic injury to the head (concussion)
- Acute headache attributed to whiplash
- Persistent headache attributed to whiplash
- Acute headache attributed to craniotomy (surgical hole drilled in the head)
- Persistent headache attributed to craniotomy (surgical hole drilled in the head)
The delineation of acute versus persistent is symptoms is whether symptoms last beyond three months.
This relates to ‘new headache’ occurring for the first time in close temporal relationship to trauma or injury to the head.
A. Any headache fulfilling criteria C and D
B. Traumatic injury to the head has occurred; (i.e. structural or functional injury resulting from the action of external forces to the head)
C. Headache is reported to have developed within 7 days or after one of the following:
- The injury to the head
- Regaining of consciousness following the injury to the head
- Discontinuation of medication(s) impairing ability to sense or report headache following the injury to the head
D. Either of the following for ‘acute’:
- Headache has resolved within 3 months after its onset
- Headache has not yet resolved but 3 months have not yet passed since its onset.
For Persistent D. reads: Headache persists for > 3 months after its onset
E. Not better accounted for by another ICHD-3 diagnosis.
As you will see below, the requirement for headache to develop within 7 days is problematic.
Epidemiology
0%
report neck symptoms0%
have 3+ symptoms0%
have dizziness & imbalance90-95% of TBI considered to be mild (< 30 min LOC), disorientation < 24 hours.
Over the first 12 months after concussion injury 71% can expect to suffer headache at some point in time.
- 54% occur within the first week
- 62% with headache at 3 months
- 69% with headache at 6 months
- 58% still suffering headache at 12 months post concussion
- 41% suffer symptoms through all 12 months
- 41% headaches are intermittent
OR 59% of headaches are continuous!!
9% of children suffer
Common Treatments
What happens after concussion?
Rest. Gradual return to activity (walking etc) without making symptoms worse.
Historically, very little else has been done with this group, as over 90% are able to return to symptoms free activity within 30 days. The problem is their brain function isn’t back to baseline. Ground breaking research has demonstrated that while people can pass neuropsychological tests and be symptom free, that they are ‘working harder’ for the same result.
What about the small group who do not recover within 30 days? Often they get passed around from general practitioner, to Ear/Nose/Throat specialist to Neurologist chasing diagnosis that try to fit each symptom – vestibular neuronitis, BPPV,
Without structural damage visible on scans, they are often medicated depending on their predominant symptoms. If symptoms persist – more rest, more medication, maybe do vestibular rehabilitation for dizziness.
Headache medications will be provided based on whether their symptoms look more like a migraine, or more like a tension-type headache.
Beyond this it is , which often fails, and psychology (for persistent anxiety and/or depression symptoms), with some symptomatic management of balance, sleep and gut issues. many also have mild cognitive impairments with memory loss, inability to concentrate and mood disturbance/irritability.
Very little attention is given to the neck post concussion. This is astounding given that:
- The force required to damage tissues in the neck is 4-5kg
- The force to produce a concussion to 10 to 20 times higher at 60-160kg (average 96kg)
This is why when you see an athlete with concussion the first thing they do is to put a hard collar on the neck. However once major structural damage is ruled out (no broken bones or torn ligaments) then neck is all but forgotten about.
This is a mistake, and one that can be rectified, however the method is critical. The symptoms of persistent post concussion syndrome mimic migraine and thats due to the sensitisation of the brainstem that occurs. Treating the neck as a sensitive structure that can decrease this central ‘noise’ in the brainstem, rather than a ‘stiff piece of meat’ to be pummelled into oblivion is a much better option.
Deep tissue work and stretching are thus often provocative. Finding a clinician highly skilled in an approach designed specifically to use the neck to decrease sensitivity in the brain is what is required.
This is exactly what the Watson Headache ® Approach offers, and aside from Dean Watson, there are no more highly skilled practitioners in the country than here at the Melbourne Headache Centre.
Causes
The symptoms of concussion have historically been attributed to a diffuse axonal injury in the brain. In the absence of a focal injury observable on brain imaging, the interpretations are based on animal models of physiological change
stead of a frank brain
Research demonstrates that in people suffering vertigo and eye movement disorders after whiplash have no signs of vestibular dysfunction or injury to the central nervous system. The authors attribute the dysfuncction to the neck injury.
Differential Diagnosis
TBD
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