Concussion is one of the most common traumatic brain injuries, with approximately 288,000 concussion related hospitalizations in the United States per year (Centre for Disease Control and Prevention, 2019). Approximately 30% of those diagnosed with a concussion, report persistent post-concussion symptoms (PCS) 4 weeks post injury (Zemek et al., 2016). It is estimated that the number of concussions will continue to rise due to an aging population and increased risk of falls (Papa et al., 2012). However, despite this increased rate of occurrence, only 15% of Canadians can correctly identify the best ways to manage concussion (Public Health Agency of Canada, 2018).  Individuals who are slow to recover are at risk for secondary problems, such as physical deconditioning and mental health issues (Leddy et al., 2012). Concussion injuries cause an excess in care of $110 million for Ontario, due to poor diagnosis, and lack of early coordination of follow-up care (Hunt et al., 2016). Additionally, $2.4 million was spent on hospitalizations alone for concussion treatment in British Columbia in 2010 (Rajabal et al., 2016). Similar data is not yet available in Ontario. Current concussion management programs for this population are inconsistent and lack supporting evidence in regard to their efficacy (Leddy et al., 2012; Gagnon et al., 2009).

No evidence guidelines exist for treatment and rehabilitation services for individuals with PCS (Macpherson et al., 2014). Research is emerging in the development of pediatric concussion protocols, but there is no evidence based guidelines for youth and adults, despite research concluding the need for further studies in this area (DeMatteo et al., 2019; Alsalaheen et al., 2019; Leddy et al., 2016; Schneider et al., 2014). Interventions to date have focused on the use of low intensity exercise to address PCS but have overlooked the potential role of other physiological mechanisms that may be contributing to persisting symptoms after concussion (Leddy et al., 2015; McCroy, 2009). The acute symptoms of concussion are considered to be the result of functional neuronal disturbance and an altered cerebral environment (Marshall, 2012). However, the etiology of chronic post-concussion symptoms remains unclear (Marshall et al., 2015). A concussion can result from a direct or indirect blow to the head or body, and the force of this blow has the potential for secondary injuries by harming other physical structures, such as the cervical spine (McCrory et al., 2010). Concurrent injury to the cervical spine with a concussion injury, is also likely to cause concurrent injury to the joints and soft tissues of the cervical spine. Literature has concluded that cervical spine dysfunction can result in numerous signs and symptoms synonymous with concussion, including headache, dizziness, as well as cognitive and visual dysfunction (Schneider et al., 2014). Due to the emerging connection between the cervical spine and PCS (Marshall et al., 2015), it is imperative that outcome measures, clinical studies, and protocols designed for assessing the cervical spine in individuals post-concussion are established (Leddy et al., 2015; Marshall, 2012).

As discussed, injuries to the cervical spine, particularly the upper segments, can mimic the symptoms of concussion (Leddy et al., 2012). Neck pain (cervical spine) can radiate to the head, which can contribute to cervicogenic headaches (Leddy et al., 2012;  Haldeman & Dagenais, 2001). Cervicogenic headaches are well-documented in the literature, and although difficult to diagnose, can cause local neck pain as well as pain referral to the head (Page, 2011). Neck pain referring to the head can originate from a number of anatomical structures including the occipital nerve, soft tissues, or facet joints (Leddy et al., 2012). Cervical spine injuries (often referred to as whiplash in the literature) have been reported to cause headaches (Sizer, 2002; Vincent, 2011), dizziness, and neck pain (Alsalaheen et al., 2010) which are also the most frequently reported symptoms in individuals with persistent post concussion symptoms are headaches, dizziness and pain in the back of the head (Gagnon et al., 2009). Thus, it stands to reason that the evaluation of cervical spine contribution to symptoms post-concussion should be a routine component of standard practices in the care of those who have sustained a concussion.

For this reason, assessment of cervical spine dysfunction should be considered in the management of individuals with concussion and related persistent symptoms. In fact, Ellis et al. (2018) suggested that comprehensive evaluation of patients with head trauma should always include careful medical assessment for concurrent cervical spine injuries and that these findings have an important impact on patient management and return to function. Streifer et al. (2019) acknowledged that specific recommendations for cervical spine assessment post-concussion are limited, but suggested including measures into clinical practice and future research. Furthermore, Hynes and Dickey (2006) examined junior A hockey players immediately following injuries that appeared as whiplash mechanisms or ones that appeared as concussion mechanisms. They concluded that 100% of the injured athletes had signs and symptoms of both whiplash-associated disorder and concussion, which suggests that these injuries are happening concurrently. A year long prospective study by Krogh and Kasch (2018) concluded that cervical muscular function is impaired for at least one year after a whiplash injury.

Dr. Charlotte Anderson posits that if the cervical spine is properly assessed, and the identified cervical spine dysfunction is properly treated, symptoms of PCS may be remedied, and individuals may return to their normal activities sooner than if this piece is overlooked. To date, there is no validated clinical outcome measure to determine cervical spine dysfunction in PCS, suggesting a clinical need for such a measure to accurately diagnose and manage this population. Furthermore, understanding how rehabilitative professionals working with individuals with a concussion manage the assessment and treatment of these patients will aid in future work developing, implementing and facilitating the correct screening tools, rehabilitation services, curriculum content in Canadian University programs and care pathways for those with PCS. The proposed studies will address the knowledge gap in clinical rehabilitation for individuals with concussion and/ or neck pain and have the potential to continue to serve clinical practice and influence protocols and treatment approaches in concussion management. With proper screening for those with a suspected concussion that includes the cervical spine, we will be lessening the burden on our health care system, triaging appropriately, utilizing appropriate resources, and contributing to the rehabilitation of this population.

Dr. Charlotte Anderson, physiotherapist at ALPHA Health Services, is completing research studies that will contribute towards the development of a clinical outcome measure to diagnose cervical spine dysfunction in individuals with concussion/PCS, as well as explore current concussion rehabilitation in Canada to better understand the clinical landscape for this population in order to implement knowledge translation strategies which will benefit patients and the health care system.  The overall goal of her proposed research is to improve the access and management of rehabilitation services for people with concussion and/or PCS in Canada. The results of these studies have the potential for direct and immediate impact in clinical rehabilitation, and to catalyze change in concussion clinical practice. Stay tuned for more information as the results become available.

Charlotte Anderson

Physiotherapist Charlotte Anderson