What is post-concussion syndrome?

Concussions are Serious 

In the 80s, when I was a kid, you would get a ding to the head and the gym teacher would let you sit out for the rest of the class. Things are a bit different now. My son had an actual concussion protocol come home with him from elementary school. I was happy and impressed.

In sports, especially professional sports now, concussions are taken seriously (though I would say, not seriously enough!) and athletes are treated for their concussions. While the concussion treatments athletes receive might be improved, it’s way more than most people get. Many laypeople don’t even realize they have had a concussion. They are unable to recognize the symptoms or they think that loss of consciousness is a requirement for a head injury to be considered a concussion. 

Signs and Symptoms of Concussion

The signs and symptoms of a concussion may be physical, cognitive (confusion, slurred speech, amnesia), emotional (anxiety, depression, personality changes), or related to sleep (increased or decreased sleep). The most common symptom of a concussion is a headache. Here’s a list of the most common physical symptoms.

• Blurred vision

• Dizziness

• Fatigue

• Headache

• Ear ringing

• Nausea

• Vomiting

• Loss of consciousness

Sometimes the onset of symptoms is delayed for days. 

What causes concussion symptoms?

I’m not going to get deep into it, but it is important to understand that immediately after a concussion or traumatic brain injury, there is huge energy demand in the brain. In an article by Giza and Hovda in 2014 this energy demand in the days and weeks after a concussion is related to the symptoms listed above. It’s a “period of metabolic crisis for the injured brain. These physiological perturbations can now be linked to clinical characteristics of concussion, including migrainous symptoms, vulnerability to repeat injury, and cognitive impairment.”1 

Post Concussion Syndrome

But sometimes the headaches, dizziness, mental fog, and other symptoms persist long past the three or four weeks it takes the brain to heal.  When they do, it’s called Post Concussion Syndrome (PCS). If the brain is no longer in a metabolic crisis, then why do the symptoms persist? 

One of the leading theories for the persistence of symptoms is a lack of sensory integration. This lack of sensory integration is also something that migraine-sufferers have in common with those with PCS, and a possible reason that concussion symptoms tend to be worse in those with a history of Migraine, ADHD, and other sensory processing disorders.  There is also evidence suggesting military personnel and athletes are at higher risk of migraine after head injuries.  Furthermore,  there are many articles showing how there is an increase in ADHD and mental health disorders for children and youth post-concussion. But, scientific research into the relationship between these other disorders and concussion is still limited.

Many times, post-concussion, I have found that even those who feel asymptomatic, have sensory or motor imbalances. They have found ways to compensate for these that let them be functional in the world. However, they are not optimal. Studies have shown that athletes are more likely to tear their ACL or have lower body injuries post-concussion. Why? The persistence of sensory processing deficits and motor dysfunction. 

Stability testing is functional assessment

Motor output – the ability to move –  is based on the ability to take in sensory information and effectively process it.  Integrative Movement Therapy uses stability testing as a way of cross-checking that Post Concussion Syndrome exercises and Post Concussion Syndrome treatments that we have given to clients are effective. Balance improves when the treatment is helpful. 

Treatment for Post Concussion Syndrome may include manual techniques for treatment of:

• Cranial and facial scarring

• Malpositioned cranial bones

• Cervical compression/decompression

• Ligament hyper-sensitivity

• Eye muscle hypertonicity

Treatment for Post Concussion Syndrome also includes

• Vestibular ocular reflex exercises

and

• Visual exercises, which are both performed in specific developmental positions, according to the client’s ability to tolerate those positions and the kinetic deficiencies they are dealing with

• Balance and coordination exercises

Vestibular system and balance

After a concussion, it is common for the output signals from the vestibular system to the brain to become disrupted. The constant re-calculating that happens while navigatinig movement in the world is confusing.

Concussion patients with an underlying vestibular component will downregulate the information from the vestibular system. But the brain still needs information to navigate the world. Vision gets upregulated to compensate. This can make environments that are complex to navigate and have a lot of stimuli (think crowded mall) completely unmanageable for a post-concussion patient. If the person is unaware of their status as post-concussive, this discomfort might be labeled as social anxiety or agoraphobia.

Anxiety and Concussion

Anxiety is one of the symptoms of PCS for a reason. In all of my Initial Assessments I look for signs of PCS, even in those that haven’t listed concussion on their history. Childhood concussions can lead people to believe that they are “just clumsy” or “accident prone”. Those who have a diagnosis of ADHD or symptoms that simulate those of ADHD might be suffering from post concussion syndrome also, and find these symptoms partially releived with theraputic interventions. My initial assessment intake form includes a variety of questions about the autonomic nervous system and mental health for these reasons among others.

Sometimes the big picture can really illuminate the small details.   

SOURCES:

1 Giza, Christopher C, and David A Hovda. “The new neurometabolic cascade of concussion.” Neurosurgery vol. 75 Suppl 4,0 4 (2014): S24-33. doi:10.1227/NEU.0000000000000505

Brooks MA, Peterson K, Biese K, Sanfilippo J, Heiderscheit BC, Bell DR. Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes. Am J Sports Med. 2016 Mar;44(3):742-7. doi: 10.1177/0363546515622387. Epub 2016 Jan 19. PMID: 26786903.

Lynall RC, Mauntel TC, Padua DA, Mihalik JP. Acute Lower Extremity Injury Rates Increase after Concussion in College Athletes. Med Sci Sports Exerc. 2015 Dec;47(12):2487-92. doi: 10.1249/MSS.0000000000000716. PMID: 26057941.