Case Study: Concussion

Patient: 15 year-old girl

Chief complaint: Constant headache, neck pain and dizziness after a concussion 2+ months ago

Back Story: The high school athlete sustained a concussion in Feb during a soccer game. At the ER, she was diagnosed concussion and was prescribed Ibuprofen. Her mom was proactive, and quickly got her involved in several rehab programs and therapies. By the time she saw me, she had gone through about 10 weeks of physical therapy, vestibular training, vision therapy, massage and chiropractic care. At that time, her neurocognitive testing (ImPACT test) had improved, but she continued to have constant headache on the top of her head, average 2-4/10 pain, and 6/10 at its worst. She also continued to have dizziness and neck pain.

Results

After 2 visits, her headache was gone for the first time in 11 weeks, and because of that, her emotional irritability also improved.

During the first month of specific Neuro-Structural Chiropractic Care, she was also undergoing speed and agility training prescribed by her MD a couple times a week. The problem was the jolting movements in this training always left her dizzy for quite some time after.

After we tweaked her vestibular exercises and gave her only a couple very specific eye exercises to do at home, she had no dizziness for the first time in weeks, and continued to be headache-free.

After 1.5 months of treatment (12 visits), she had no headache, dizziness or neck pain, and was cleared by her MD to return to play.

Discussion

1. Realistic expectation of recovery timeline

This is somewhat counterintuitive, but research has shown that young athletes recover from concussion more slowly than older athletes. ⁽¹⁾ If your child sustains a concussion, this is what you can expect. It is unlikely for the child to return to play within a couple days (2.5% probability). Most adolescent athletes make their way back to the sports within about a week (71.3% chance). ⁽²⁾ However, if your child is not able to return to play within 10 days, there is a good chance that he/she will have a prolonged recovery, which is the case for the girl in our case study. In this case, seek professional help as soon as possible.

2. Not all vestibular rehabs are the same.

Many of my post-concussive patients are slightly apprehensive when they hear vestibular rehab, because in their experience, the exercises often make them dizzy and they feel awful afterwards. But then they thought to themselves, I have to feel worse before I feel better, right? WRONG. When your rehab makes you feel worse afterward, this is a good indicator that the intensity and/or duration of the exercises are too much for your brain to handle. Less is more. Again. Less. Is. More.

Conclusion

1. If your child had a concussion, and was cleared by his/her physician to go home. Rest him/her for the first week. If he/she is not able to return to play after the first 7-9 days, seek professional help.

2. Although research suggests that the chance of return to play beyond 21 days post concussion does not increase, we beg the differ by what we see clinically. With the right therapies, the child can still make a relatively smooth recovery.

References:

1. Nesmith JD. Sports concussion in the child and adolescent athlete. J Ark Med Soc. 2010 Nov;107(6):111-4. [PubMed]
2. McKeon JMM, et al. Trends in concussion return-to-play timelines amon ghighscholl athletes from 2007 through 2009. J Athl train. 2013 Nov-Dec;48(6):836-843. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

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The post Case Study: Post-Concussion Headache, Neck Pain And Dizziness – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

First Things First, To Rest Or Not To Rest?

For those who don’t get better in 7-10 days, the universal recommendation used to be “continue to rest in a dark room”, and I still hear this from time to time.

Unlike the acute care immediately after concussion, as of 2016, there is still no consensus for treating chronic post-concussive symptoms. ⁽³⁾ Although conventionally, doctors tend to tell their patients to rest as long as symptoms still exist, new research suggests that it’s not a good idea to simply rest beyond the first few days after concussion. ⁽⁴⁾

This makes a lot of sense from a neurological perspective. Our brain is an ever-changing organ that constantly remodels itself based on the stimulations it receives from the environment. Deprivation of sensory stimulation, albeit temporarily necessary, hinders rather than aid recovery in the long run.

While uncontrolled activity will most likely exacerbate the symptoms ⁽⁴⁾, emerging evidence suggests that controlled physical and cognitive exercises can aid recovery ⁽⁵⁾.

Is Post-Concussive Headaches Driving You Crazy?

As I mentioned before, headache is the most commonly reported symptom after concussion. Ironically, there is a serious lack of research and very little evidence supporting any particular treatment for post-traumatic headache. ⁽⁶⁾

So meanwhile, the researchers basically say until we know more about it, forget about the label “post-traumatic headache” for a second, simply categorize these headaches, just like we do other headaches, and treat accordingly. ⁽⁷⁾ And that’s what we do in our practice, and we find success with many cases.

Most of the headaches from concussion are migraine or tension type, but they can also be related to peripheral nerves (occipital neuralgia), to the neck (cervicogenic headache), and to medication overuse. ⁽⁸⁾ Whether you are seeking medical treatment or conservative care, there is really not one treatment that would be effective for all post-concussive headaches. If you are not getting better with treatment, maybe, just maybe, the treatment you are receiving is not specific enough. The key to an effective treatment plan is rigorous evaluation and diagnosis ⁽⁸⁾, and taking a comprehensive approach to address all possible causes of headache ⁽⁹⁾.

In my experience, headaches related to peripheral nerve irritation resolve the fastest. Sometimes, within a few visits. Tension headache and headaches coming from the neck are also fairly simple to treat. If your headaches have migrainous features, it will take a bit longer to stabilize.

Is Your Post Concussion Dizziness Lingering As Well?

If you have a concussion and immediately experience dizziness at the time of your injury, then chances are you will have a prolonged recovery (>21 days). ⁽¹⁰⁾ And chances are strict rest is not going to fix your problem. This type of concussion requires targeted therapies. ⁽⁵⁾

Without going into too much detail, the therapies are basically designed to reintegrate three of your systems that are responsible for balance—vision, muscles, and vestibular system. Therapies typically involve a lot of eye exercises, head eye coordination exercises, visual stimulations, and balance training.

Why Aren’t The Vestibular Rehab And Vision Therapy Working?

It used to be that patients had never even heard of these therapies. Now, most of the patients who came to me had already gone through a course of vestibular and vision therapy, but the relief was limited.

These therapies are a must when rehabbing post-concussive patients, but somehow they don’t always work. After talking to my patients and having all of them show me the exercises they were given, it becomes apparent why these therapies had failed them, and we are able to make changes accordingly.

1. Neglecting the neurological hierarchy. One thing I’ve learned very quickly when I started practicing is that less is more. There is a hierarchy within the nervous system. Often, one primitive function serves as the building block of a more sophisticated function. So, when it comes to rehab, you do one thing at a time, and build from the bottom up. Personally, I do not progress my patients to a more sophisticated exercise if they fail to perform the basic exercise. Too many exercises all at once are often unnecessary and counterproductive.
2. Neglecting the fatigability of the brain. Concussive brains are fragile. They get tired faster, like a muscle that hasn’t been used in a while. If you train too hard, your brain pukes out, and you continue to train, it is like lifting over and over again with bad form that makes your trainer pull his hair out. It facilitates bad patterns=bad pathways in your brain, and, again, it is counterproductive. When my patient tells me that he/she gets super dizzy for 30 minutes after his/her previous rehab, then there is something wrong. Knowing when to stop is half the battle.
3. Neglecting the imbalance between the systems. Anyone who has seen a vestibular test report knows that there can be imbalance between the right and the left vestibular system. These imbalances often become more profound in those who had sustained a concussion. So why is it that in therapy the right and the left are almost always stimulated equally? It doesn’t make sense, and we need to be more specific instead of giving every patient generalized stimulations to both sides and all directions.

If your vestibular and visual therapies don’t seem to be working for you, don’t give up. You are on the right track. You may just need to find someone who can be more specific and fine-tune your exercises for you.

Don’t Forget About Your Neck

Concussion is an acceleration/deceleration injury, ⁽¹¹⁾ so as whiplash. Concussion doesn’t really happen unless the impact generates a minimal acceleration of 70-75g. ⁽¹¹⁾ On the other hand, it only takes as little as 4.5g to cause a whiplash. ⁽¹²⁾

In other words, the impact that causes a concussion is certainly enough to cause a whiplash. If you have a concussion, get your neck checked as well.

References:

1. DePalma RG. Combat TBI: history, epidemiology, and injury modes. In: Kobeissy FH, editor. Brain Neurotrauma: Molecular, Neurophysiological, and Rehabilitation Aspects. Boca Raton (FL):CRC Perss/Taylor & Francis;2015. Chapter2. Frontiers in Neuroengineering. [PubMed]
2. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for sports medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. [BMJ]
3. Hadanny A, Efrati S. Treatment of persistent port-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother. 2016 Jul 4:1-13. [PubMed]
4. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. PM R. 2016 Mar;8(3 Suppl):S91-S100. [PubMed] http://www.ncbi.nlm.nih.gov/pubmed/26972272
5. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sport Med. 2015 Apr;34(2):213-31. [PubMed]
6. Kjeldgaard D, Forchhammer HB, Teasdale TW, Jensen RH. Cognitive behavioral treatment for the chronic post-traumatic headache patient: a randomized controlled trial. J Headache Pain. 2014 Dec 2;15:81. [PubMed]
7. Theeler B, Lucas S, Riechers RG 2^nd, Ruff RL. Post-traumatic headaches in civilians and military personnel: a comparative, clinical review. Headache. 2013 Jun;53(6):881-900. [PubMed]
8. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):263-9. [PubMed]
9. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):270-80. [PubMed]
10. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011 Nov;39(11);2311-8. [PubMed]
11. Broglio SP, et al. The biomechanical properties of concussions in high school football. Med Sci Sports Exerc. 2010 Nov;42(11):2064-2071. [PubMed]
12. Panjabi MM, Nibu K, Cholewicki J. Whiplash injuries and the potential for mechanical instability. Eur Spine J. 1998;7(6):484-92. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Post-Concussion Syndrome: When Symptoms Persist – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.