What percentage of patients post-mTBI have neck pain and dizziness?

mtbi.jpg

It is well known now that majority of individuals resolve following a mTBI (mild Traumatic Brain Injury), collectively can be a concussion and/or whiplash, within 10-14 days.  However, a certain percentage of patients still have symptoms post-mTBI, better known as post-concussive syndrome (or post-concussive symptoms).  In post-concussion, nearly half of patients report significant persistent symptoms at one-year post-injury.

There are multiple systems involved with mTBI and post-mTBI symptoms can involve visual, sensorimotor, peripheral, central and cervical origin.  These impairments vary between individuals but several common symptoms seen in a physical therapist's office are headaches, dizziness and neck pain, as well as fatigue and other cognitive deficits.

refer.png

The latter two are what we address under the umbrella term of Cervicogenic Dizziness, especially if the neck pain is causing, or part of (such as double entity) of the dizziness symptoms.  The cause and treatment of headaches can be multimodal and not a major part of our discussion within this expertise or within our courses.

Cervicogenic Dizziness, Cervical Vertigo, Concussion, Whiplash, mTBI

What percentage of patients post-mTBI have still have neck pain and dizziness?

Recently, Galea and colleagues in 2019 examined several validated impairment specific self-report clinical tools (referred to as impairment specific tools) in symptomatic mTBI, asymptomatic mTBI, and healthy controls.  For regards to this post, these self-reported clinical tools are the Neck Disability Index and Dizziness Handicap Inventory, for neck pain/disability & dizziness respectively.

A substantial proportion of individuals (79% overall) in the mTBI group reported clinically relevant scores on one or more of the impairment specific tools compared to healthy controls (12.5% overall).

In relevance to Cervicogenic Dizziness:

Fifty percent of individuals post mTBI (76% symptomatic and 21% asymptomatic) reported clinically relevant levels of neck pain and disability, and 45% (70% symptomatic and 17% asymptomatic) reported clinically relevant levels of dizziness associated handicap.

Red box: Neck Disability Index & Dizziness Handicap Inventory for HC (Healthy Control), Asymptomatic mTBI & Symptomatic mTBI Blue: Number of patients within those groups who meet significant cut-off score for being relevant

Red box: Neck Disability Index & Dizziness Handicap Inventory for HC (Healthy Control), Asymptomatic mTBI & Symptomatic mTBI Blue: Number of patients within those groups who meet significant cut-off score for being relevant

Here is an interesting quote from the article,

Overall higher levels of neck disability and hyperarousal were observed in the asymptomatic mTBI group compared to the healthy control group (p < 0.05). These results indicate that individuals may not recognise the persistence of symptoms post- mTBI.

The bolded statement is very interesting to me.  This says clinically that if a therapist just asks a patient if she/he has neck pain or dizziness, without objectively assessing it (via self-report measure or more simply through a manual assessment), then you may get a false negative!  

Symptoms may also be present in individuals who overall consider themselves symptom-free. The false negative leads to no treatment, or minimal treatment, for the neck pain and/or dizziness and therefore lead to further impairment as not addressed by the specialist!

Quote from the author's in conclusion:

Potentially generic self-reported symptom scales may not detect symptoms in these apparently asymptomatic individuals, questioning their appropriateness in determining recovery and ability to return to activity post-mTBI.

I wonder, in addition to self-report measures, if you assess the cervical spine in an asymptomatic, or symptomatic patient to determine if ability to return to activity and/or discharge from clinical care for:

  1. Pain pressure threshold to palpation over C0-3

  2. Pain pressure threshold to palpation over suboccipital musculature

  3. Two-point discrimination to the upper cervical spine

This is not just us talking, but this EXACTLY what Jennifer Reneker and colleagues did with patients suffering from dizziness after sports-related concussion in 2018. They found that 82.9% of patients had examination findings consistent with cervical dysfunction and actually diagnosed 26.8% of patients with actual cervicogenic dizziness.

Either you perform it with a specific self-report measure or with manual examination skills...but please do one of the other and not just "ask" if having neck pain or dizziness with this population as you will potentially miss very important and very treatable remaining symptoms.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts