When assessing a patient with a suspected concussion (mTBI), there’s a relatively simple outline: 

  1. Did this patient experience a relevant mechanism of injury? 
  2. Do they have significant symptoms (e.g., PCSS) that are not explained by other conditions or medication/drug side effects?
  3. Is the neurological exam clean? Is imaging (e.g., CT) clean?
  4. Do they have relevant concussion-specific exam findings (e.g., symptom provocation on the VOMS or during a BCTT, etc..)?

Assuming the patient meets all four criteria, we are confident that we’re looking at a concussion. But, up to this point, everything is quite grayscale. To add some color and detail to the diagnosis, patient education, and eventual rehab, we can begin to recognize that patients suffering from concussion/PCS will typically fall into “subtypes” or “clinical profiles” of symptoms (1-6). (I like to call them “flavors.”)

Recognizing these symptom clusters in your patients will help you let them know that they are seen; their invisible injury is, in fact, visible to you. With careful attention to your history and physical exam, these clinical profiles can be clues into the symptom generators we can leverage as targets for rehabilitation. 

So, What “Flavor” Concussion Does Your Patient Have?

Depending on the study, you’ll see different numbers of profiles emerge, but overall, we appear to be settling on five main subtypes/clinical profiles:

  1. Cognitive/Fatigue
  2. Anxiety/Mood
  3. Ocular
  4. Vestibular
  5. Migraine

Additionally, the research mentions “modifiers,” which typically include “sleep” and “neck” symptoms. 

 

Context and Cautionary Notes.

Context: We will dive more deeply into four major profiles over the next few weeks. For example, what makes a vestibular (vestibulo-ocular) profile different from a cervicogenic (vestibulo-spinal; “neck”) modifier? And, I want to acknowledge here that you probably also think, “Wait… my patients experience all those symptoms.” Yes, they do. It is more common than not that your patient will fit multiple profiles vs. just one. When using the flavor analogy, I tell my patients to imagine a young kid (in the ’90s) putting all the different flavors in their cup at a soda fountain. 

Cautionary note: In preparation for these future blogs, please keep a critical clinical eye and distinguish between clinician and technician when using these profiles. What do I mean? You cannot simply “plug and play” symptoms into a CP Screen and determine that the “clinical profile” indicates a “symptom generator.” 

For example, we know from the literature (6) that adolescent girls will endorse higher total symptom scores and severity than boys, particularly in cognitive/fatigue and anxiety/mood profiles. However, we also know from the literature (4) that visual/vestibular dysfunction, sleep-wake problems, the nocebo effect of diagnosis, and pain from the injury can all exacerbate anxiety/mood symptoms. 

  • So, the takeaway is not that “My young female patient scores highly in the anxiety/mood profile. Thus, she needs CBT.” 
  • The takeaway is, “Wow, my young female patient scores highly in the anxiety/mood profile; I may have to adapt my communication and patient education style while uncovering potential exacerbating factors that are contributing to her mental/emotional experience.” 

Bringing it all Together.

Once you’ve made the diagnosis, identifying your patient’s clinical profiles/subtypes can add an extra level of care that truly sets you apart as a “specialist.” However, remember not to confuse a predictable symptom pattern (“clinical profile”) with an explanatory cause (“symptom-generator”). Over the next few weeks, we’ll attempt to give you a tangible understanding of the leading clinical profiles, how to assess, and what to consider for rehab. 

References:
  1. Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S., Kane, S. F., … & Roberts, W. O. (2019). American Medical Society for Sports Medicine position statement on concussion in sport. British journal of sports medicine, 53(4), 213-225.
  2. Kontos, A. P., Sufrinko, A., Sandel, N., Emami, K., & Collins, M. W. (2019). Sport-related concussion clinical profiles: clinical characteristics, targeted treatments, and preliminary evidence. Current sports medicine reports, 18(3), 82-92.
  3. Kontos, A. P., Elbin, R. J., Trbovich, A., Womble, M., Said, A., Sumrok, V. F., … & Collins, M. (2020). Concussion Clinical Profiles Screening (CP Screen) tool: preliminary evidence to inform a multidisciplinary approach. Neurosurgery, 87(2), 348-356.
  4. Leddy, J. J., Haider, M. N., Noble, J. M., Rieger, B., Flanagan, S., McPherson, J. I., … & Willer, B. (2021). Clinical assessment of concussion and persistent post-concussive symptoms for neurologists. Current neurology and neuroscience reports, 21, 1-14.
  5. Leddy, J. J., Haider, M. N., Noble, J. M., Rieger, B., Flanagan, S., McPherson, J. I., … & Willer, B. (2021). Management of concussion and persistent post-concussive symptoms for neurologists. Current neurology and neuroscience reports, 21, 1-7.
  6. Stephenson, K., Womble, M. N., Frascoia, C., Eagle, S. R., Covassin, T., Kontos, A. P., … & Elbin, R. J. (2023). Sex differences on the concussion clinical profiles screening in adolescents with sport-related concussion. Journal of athletic training, 58(1), 65-70.