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.
So… isn’t it time to start developing protocols to assess the cervical spine in those with PCS? Stay tuned… I am on it!
Written by Charlotte Anderson, MSc. PT, PhD