No evidence-based guidelines exist for treatment and rehabilitation services for children and adolescents who are slow to recover following a mild traumatic brain injury (or concussion). While the child is acutely injured, we believe that it is prudent to provide children and their families with early education and reassurance as well as strongly encourage (a) rest; (b) taking time off from sports (including noncontact activities like physical education class in school and extracurricular music or dance), and (c) avoiding vigorous play. Children might also benefit from greatly reducing mental activity and stimulation, such as attending school, writing exams, or playing video games, during this time period. Mental and physical rest following injury has been strongly encouraged in the area of sport-related concussion in agreement and consensus statements [1, 2]. From a practical perspective, enforcement of complete rest, especially for active children and adolescents involved in many sports, is very difficult, and determinations of how much school is reasonable to miss are not easy. Basically, parents are expected to monitor injured children’s symptoms and work with a physician and other health care professionals with expertise in concussion management (if available) on a plan for returning to school, extracurricular activities, and sports. As we wait for further scientific evidence to accumulate regarding the best strategies for managing the acute recovery period and for returning to activities, common sense and clinical judgment prevail.
Fortunately, most children who sustain mild TBIs (mTBIs) appear to recover, functionally, within the first few weeks post injury. Some children, however, report persisting symptoms. A recently published prospective epidemiologic study from Alberta again confirmed the recovery patterns in children by illustrating that 14% of children were symptomatic at 3 months post injury and 2.3% were still symptomatic at 1 year. For children with persisting symptoms, four options are currently available for ongoing management: (a) encourage continued rest and avoid vigorous activity, (b) allow the child to engage in limited activities under parental supervision, (c) provide symptomatic treatment (e.g., analgesics and anti-migraine medications for headaches, or psychological intervention for behavioral issues), or (d) implement active rehabilitation. The first two options rely on “watchful waiting.” Children who are slow to recover are at risk for secondary problems and consequences if their normal activities are curtailed for extended periods of time – while they wait for complete resolution of symptoms. These problems include, but are not limited to, physical deconditioning, anxiety and stress, mild depression, irritability, and acting out behavior at home and at school. Moreover, as time passes, the strength of the association between the neurobiology of the original injury and the ongoing symptoms likely diminishes, while the importance of pre-existing factors (e.g., mental health problems, ADHD, familial stressors, anxiety, social-emotional adjustment issues) and current non-injury factors (e.g., dispositional, mental health, situational, and environmental issues) increases. Eventually, for most cases, determining what is causing, maintaining, or exacerbating symptoms becomes nearly impossible. Thus, prolonged activity restrictions and rest might actually be iatrogenic in some cases.
For children suffering prolonged symptoms, recent studies have started to hypothesize the role of other physiological mechanisms contributing to post concussion symptoms (PCS) symptoms. The cervical spine and its involvement in head injury and its anatomical connection to the head is a logical and likely area for referral of symptoms. If the cervical spine can be assessed, and any child presenting with cervical spine dysfunction receives treatment, PCS symptoms may be remedied, and the child may return to their normal activities sooner. Not only will addressing the cervical spine have the potential to rehabilitate the child, but it will decrease the prevalence of mental health issues, decreased quality of life, and stress on the patient and their family, if it is found to be the source of symptoms.
The role of the cervical spine has not been thoroughly investigated in youth suffering from post concussion symptoms. In any concussion injury, whether the youth receives a direct blow to the head or a contrecoup injury, the cervical spine will be vulnerable to a whiplash like injury. Whiplash is a neck injury due to forceful, rapid back-and-forth movement of the neck. Whiplash can cause neck pain and stiffness. The upper cervical spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system that has connections to the vestibular and visual systems. Injuries to the upper cervical spine can mimic the symptoms of concussion and post concussion syndrome. Neck pain (cervical spine) can radiate to the head, which can lead to cervicogenic headaches. Neck pain can originate from a number of anatomical sites including occipital nerve compression, soft tissue injury, or facet joint dysfunction. Whiplash injuries have been reported to cause cervical vertigo, dizziness, or pain in the neck. The most frequently reported symptoms in youth with PCS is headaches, dizziness and pain in the back of the head. It seems logical to investigate the relationship between cervical spine symptoms and true concussion symptoms.
Headaches arising from the cervical spine are specific in nature. Patients with cervicogenic headaches report the following: unilateral head or face pain, pain localized to the occipital, frontal, temporal or orbital regions, intermittent or constant pain, head pain triggered by neck movement or sustained postures, restricted active and passive neck range of motion, associated signs and symptoms such as nausea, dizziness or neck pain. Many of these reported symptoms relating to a headache are subjectively found in children suffering PCS.
Youth who do not recover in seven to ten days post injury may have a different mechanism contributing to their symptoms, such as a neck physiological issue. Their symptoms may be arising from cervical spine dysfunction, and thus treatment for such a physiological issue may be warranted. Physical examination can help determine whether the PCS symptoms may be a result of cervical spine injury. An assessment including the following will help determine if there is cervical spine dysfunction: trigger point in the jaw or posterior cervical or shoulder girdle muscles, decreased cervical spine range of motion, pain with movement, forward head posture, static head tilt positions, strength and endurance loss of cervical and scapular muscles groups. Furthermore, completion of the Neck Disability Index has been validated as a reliable tool to diagnose cervical spine pain and disability in a clinical setting.
There has been a demonstrated need for further research in the area of cervical spine management, as a clinical treatment and a possible contributor to PCS. To date, no study has isolated cervical spine assessment and treatment in youth as a possible management strategy for children with PCS. Until now, physiotherapists at ALPHA Health Services have started this research, and the answers are coming!
By Charlotte Anderson