Updated June 27 2021
In part one, it was established that both concussion and whiplash/neck injuries happen because of acceleration and/or deceleration. It was also established that concussion injury requires between 70-120 G’s of acceleration (G= Force of Gravity, 9.8m/s2), whereas neck injuries only require 4.5G’s. Since the head and neck cannot move or accelerate independently of one another, it is highly likely that with every concussion injury there may also be an underlying neck injury, which may or may not present with neck pain. Part one of this post also demonstrated scientific evidence that symptom presentation in both whiplash and concussion injuries are the exact same.
If these injuries are happening together, with the same mechanism of injury, and the symptoms are the same, how can we tell these two injuries apart from one another? What would happen if we included treatment of the neck in both acute and chronic concussion patients?
In the acute stages, it is next to impossible to distinguish concussion injury from neck injury. In these cases, it is always safer to err on the side that it is a concussion until proven otherwise! If there is a mechanism of injury (fall, hit to the head, or forceful whiplash-type injury) and the individual experiences any concussion-like symptoms, a concussion diagnosis should be made.
Removal from high-risk sports for a period of time and gradual reintegration back into cognitive and physical activity is recommended (as per the most recent international concussion guidelines). As you will see, it is also prudent to include early examination and treatment of other areas, such as the neck, which could be contributing to the symptomatology.
Investigating the evidence to support manual therapy of the neck in concussion management
Treatment of the cervical spine is one of the top evidence-based treatments for concussion symptoms. One of the best studies to highlight the effectiveness of including early intervention involving the cervical spine (neck) was Schneider et al., in 2014.1 In this randomized clinical trial, the authors included subjects who were slow to recover (beyond 10 days post-injury) and randomized them to two groups. Both groups received weekly sessions with a physiotherapist for 8 weeks including postural education, cervical spine range of motion exercises and cognitive and physical rest until asymptomatic followed by a protocol of graded exertion (RTP). The treatment for the intervention group also included cervical spine manual therapy (soft tissue and mobilizations), and cervical spine and vestibular rehabilitation. At the end of the 8 weeks, individuals in the treatment group were almost four times more likely to have completely recovered and cleared to return to play!
Considering these results, we must ask: in those that are slow to recover, is the concussion injury still present? Or are the symptoms due to underlying, and possibly treatable, neck dysfunction?
If we examine the timeline for concussion recovery, it is estimated that only 10-15% of patients will experience symptoms beyond a 10-day period.2 The timeline for whiplash recovery is actually much longer; with as much as 50% of patients having symptoms at 1 year (Carroll:2009gv).
As concussion tends to be a short-duration injury and whiplash a longer one, the question now becomes: how many chronic “concussion” patients are simply suffering the ongoing effects of a neck injury (or neck dysfunction) that has never been addressed?
In 1990, Jensen and colleagues explored this theory using a randomized controlled trial. Subjects with ongoing Post-“Concussion” Syndrome and experiencing daily headaches for an average of 359 days post-injury were either randomized to receive manual therapy to their cervical spine or an intervention control (having an ice pack applied to their neck).
After two treatment sessions, each 1 week apart, the manual therapy group had a 60% reduction in their headache pain scores, whereas the ice-pack group remained unchanged.3 Similarly, a case series published in 2015 demonstrated 4 out of 5 patients had a complete, or near-complete recovery after 6-8 sessions (1x/week) of manual therapy and rehabilitation directed at their cervical spine.4
Several other studies have demonstrated positive treatment effects when including manual therapy and rehabilitation of the cervical spine in the treatment plans of patients with post-concussion syndrome. This can be confusing for both patients and healthcare providers as patients who respond to this treatment often don’t report any neck pain.
In part one, we established that concussions and cervical spine injuries are happening together, have the same symptom presentation and are very difficult to distinguish from one another. In this post, we learned that including treatment of the cervical spine in both acute and chronic concussion patients has shown to speed recovery and improve outcomes in patients who are still symptomatic beyond a 10-day period.
Appropriate concussion management should therefore involve manual therapists with extensive training and expertise in the full spectrum of concussion management and rehabilitation, including specific expertise in cervical spine function.
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A recent paper by Cheever et al., published in the Journal of Athletic Training5 explains how cervical spine dysfunction may be the cause of dizziness, headaches, postural stability, and oculomotor function (Warning that this is a little heavy for non-medical professionals):
“Afferents from the upper cervical spine provide somatosensory information for head and neck position, and multilevel integration of cervical somatosensory information occurs in the central nervous system. Cervical afferents have a complex neurophysiologic interaction with the sensory and motor nuclei of the brainstem. In addition, cervical somatosensory information is integrated with visual and vestibular information in the cerebellum for adaptive postural and oculomotor regulation. Cervical afferents also project through the dorsal column/medial lemniscus to the thalamus and the primary somatosensory cortex for perception of head and body position and contribute to anticipatory ocular and postural adjustments during voluntary functional movements. Direct interactions of cervical afferents with the vestibular nuclei, superior colliculi, and central cervical nuclei help coordinate important reflexes required for gaze stabilization and postural stability.” (5)
“Most cervicogenic symptoms have been attributed to injury or impairment of the upper cervical spine (C1–C3). Researchers have suggested that abnormal somatosensory afferents arising from the muscle spindles, joint and pain receptors, or nerve roots of the cervical spine contribute to cervicogenic headache and vertigo or dizziness. Convergence of the C1–C3 cervical afferents with the trigeminal sensory afferents of the head and face in the trigeminal nuclei leads to referred hemicranial pain associated with cervicogenic headache.”5
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- Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, Barlow K, Boyd L, Kang J, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal of Sports Medicine. 2014;48(17):1294–8.
- McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvořák J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine. 2013;47(5):250–8.
- Jensen OK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache. Cephalalgia. 1990;10(5):241–50.
- Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015;43(3):274–84.
- Cheever K, Kawata K, Tierney R, Galgon A. Cervical Injury Assessments for Concussion Evaluation: A Review. Journal of Athletic Training. 2016:1062–6050