review article cervical spine involvement in mild traumatic brain...

Review ArticleCervical Spine Involvement in Mild Traumatic Brain Injury:A Review

Michael Morin,1,2 Pierre Langevin,3,4 and Philippe Fait1,2,3,5

1Department of Human Kinetics, Universite du Quebec a Trois-Rivieres (UQTR), Trois-Rivieres, QC, Canada G9A 5H72Research Group on Neuromusculoskeletal Dysfunctions (GRAN), UQTR, Trois-Rivieres, QC, Canada G9A 5H73Cortex Medecine et Readaptation Concussion Clinic, Quebec City, QC, Canada G1W 0C54Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC, Canada G1V 0A65Research Center in Neuropsychology and Cognition (CERNEC), Montreal, QC, Canada H3C 3J7

Correspondence should be addressed to Philippe Fait; [email protected]

Received 1 March 2016; Revised 30 May 2016; Accepted 19 June 2016

Academic Editor: S. John Sullivan

Copyright © 2016 Michael Morin et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however,its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBIsymptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods.A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articlespublished since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinicalguidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Thosearticles were used to describe different subjects such as mTBI’s signs and symptoms, mechanisms of injury, and treatments of thecervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussionsyndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs,few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises asefficient tools for health care practitioners.

1. Introduction

Mild traumatic brain injury (mTBI) is commonly known asconcussion [1]. In a recent study, Statistics Canada estimatedmTBI annual incidence to be 600 per 100,000 people [1].The pediatric TBI population is the patients’ subgroup whoconsulted the most often in the emergency room [1]. Anestimated 1.6 to 3.8 million sport and recreation-related braininjuries occur in the United States annually, and up to 75% ofthem are classified as mild [2]. About 70 to 90 percent of allTBI cases are thought to be of mild severity, and the relatedsymptoms usually resolve within 7 to 10 days [3, 4]. However,as many as 50% of concussions may go unreported [5]. Inan epidemiologic study, Tator et al. (2007) reported that thehighest incidence for TBI is in the age group under 18 years,with almost 45%. Additionally, approximately one-quarter ofall patients with TBI are aged between 19 and 29 years [1].

The Centers for Disease Control and Prevention (CDC)describes mTBI as a silent epidemic [2].

Concussion in sports was defined in 2012 at the interna-tional consensus on concussion in sport held in Zurich as

a brain injury and is defined as a complex patho-physiological process affecting the brain, inducedby biomechanical forces. Several common featuresthat incorporate clinical, pathologic and biome-chanical injury constructs may be utilized indefining the nature of a concussive head injury.This is caused by a direct blow to the head, face,neck or elsewhere on the body with an “impulsive”force transmitted to the head. [4]

The number of reported concussions has increased inrecent years for multiple reasons. Recent studies identified anincreased awareness of the potential complications following

Hindawi Publishing CorporationJournal of Sports MedicineVolume 2016, Article ID 1590161, 20 pageshttp://dx.doi.org/10.1155/2016/1590161

2 Journal of Sports Medicine

concussion and repeated head trauma in the population [6]and higher involvement of health professionals in sports andin concussions recognition and follow-up [7]. Even though itis believed that most concussions usually resolve in between7 and 10 days [3, 4], the symptoms may persist longer forup to 33 percent of cases [8]. Symptoms persisting for a fewweeks to more than six months are defined in the literature aspostconcussion syndrome (PCS) [8].

PCS is a complex medical subject that few articles andstudies in the scientific literature explore concretely [4]. Con-sidering that mTBI is a multifaceted injury, many signs andsymptoms complicate its diagnosis [3]. Multiple impairmentslinked to this condition such as cognitive, vestibular, cervical,physical, and psychological dysfunctions [3, 4]. Therefore,with amultitude of clinical theories in the literature, it is diffi-cult to determine clinical guidelines for PCS [3]. Current con-sensus identifies that amultidisciplinary approach is essentialto the progress of the patient suffering from PCS [4].

One of the major challenges in the medical managementof concussion is that there is no “gold standard” for assessingand diagnosing the injury [9]. It has been shown by Schneideret al. (2014) that a combination of cervical and vestibularphysiotherapy decreased time to medical clearance for thereturn to sport in a cohort of 31 patients (12–30 years old) withpersistent symptoms of dizziness, neck pain, and/or head-aches following a sport-related concussion [10]. However,little research has been published on this very specific topic.

2. Problem

The problem targeted by this review of literature is the lackof data regarding the association between mTBI and cer-vicogenic impairment.Themajority of scientific publicationsfocus on diagnosing mTBI, and there is little evidence on thepossible involvement of the cervical region [4]. Cervical spineexamination after a cranial trauma is essential, but the asso-ciation between symptoms and mTBIs is poorly described inthe literature. A literature review will improve the medicalknowledge of all medical professionals and help the diagnosisand treatment of mTBI.

3. Goals

The aim of this review was to target scientific articles describ-ing mTBI and those involving cervicogenic headache (CGH)cases in order to look at the connections and similaritiesbetween these two types of injuries. The specific goals of thispaper are (1) to determine the common signs and symptomsof mTBI (including PCS) and cervical dysfunctions, (2) todescribe the mechanism of cranial trauma injury and linkit with the impact on the cervical spine, and (3) to give anupdate on the various types of effective treatments for theseconditions.

4. Methods

The following electronic resources were searched from Jan-uary 1, 1990, to May 19, 2015: PubMed, Index to Chiro-practic Literature (ICL), SportDiscus, Physiotherapy Evidence

Database (PEDro), Cumulative Index to Nursing and AlliedHealth Literature (CINAHL), andCochrane Library databases.The following keywords were used in different combinations:concussion, neck, TBI, mTBI, cervical, physiotherapy, physicaltherapy, athletic training, treatment, chiropractic, manipula-tion, manual therapy, and guideline. For the complete listof combinations, see Table 1. Three data collections werecarried out at different dates: February 16, 2014, May 15,2014, and May 19, 2015. Reference lists of articles meeting theselection criteria were also collected. All abstracts in Englishand French dealing with concussion involving the neck wereselected for a full reading of the article. A total of 4,854abstractswere foundon search engines. Following this search,the articles were selected according to three main streams:

(1) mTBI’s and PCS symptoms related to the cervicalspine.

(2) Mechanism of injury.(3) Therapies of the cervical spine with symptoms related

to mTBI.Inclusion criteria, based on the precited keywords, were

original data articles, literature reviews, and clinical recom-mendations, available in English and/or French, based on theobjectives of this research. Exclusion criteria were foreignlanguage papers other than English or French, case studies,magazine articles, and expert and editorial comments. Theselection of articles is shown in Figure 1, and combinations areexplained in Table 1.

5. Results

After a careful screening of 4,854 data entries, 82 abstractsmet the inclusion criteria of our research and were reviewed.All these articles were read and analyzed.Thirty-eight articleswere excluded because themain topic did notmatch the threetopics of this study (𝑛 = 34) or were case studies (𝑛 = 2),magazine articles (𝑛 = 2), and expert commentary (𝑛 = 1).Finally, 43 papers were included in this literature review. Eachselected article is described in Table 2 (see Appendix). Thesearticles were analyzed and assigned to the different categoriesof topics discussed: (1) the association between cervical spinesprain and mTBI signs and symptoms, (2) mechanism ofinjury, and (3) treatments. Results are represented in Figure 1and Table 1.

6. Discussion

6.1. The Association between Cervical Spine Sprain and mTBISigns and Symptoms. The 2012 Zurich consensus on concus-sion in sports led by McCrory et al. (2013) defined a list of 22common symptoms of mTBI divided into 4 main categories,as described in Table 3 [4, 6, 11–13]. The majority of mTBIs(80–90%) are resolved in 7 to 10 days [4, 14, 15]. However, inthe remaining 10 to 20%, symptomsmay persist formore than10–14 days, and even for several months after trauma [4, 16].This clinical picture is diagnosed as PCS and the etiology forPCS is not well defined in the literature [11, 14, 17].

As mentioned previously, the most common symptom insubjects after mTBI is posttraumatic headache (PTH) [18, 19].

Journal of Sports Medicine 3

Table 1: Preliminary search of literature (total results/abstracts (Abs) selection/articles (Art) for review).

Date January 1, 1990, to February16, 2014

February 16, 2014, to May15, 2014

May 15, 2014, to May 19,2015

Resources Keywords Total Abs Art Total Abs Art Total Abs ArtPubMed Concussion, Neck 180 12 8 10 0 0 21 5 1PubMed TBI, Neck, Treatment 56 0 0 0 0 0 7 2 1PubMed TBI, Cervical 83 0 0 33 0 0 17 0 0PubMed Concussion, Chiropractic 12 4 1 2 0 0 2 0 0PubMed Concussion, Physiotherapy 53 3 2 3 0 0 12 2 1

PubMed Concussion, PhysicalTherapy — — — 138 4 1 38 6 1

PubMed Concussion, AthleticTraining, Cervical 30 2 2 0 0 0 6 1 0

ICL Concussion 32 2 2 0 0 0 4 1 1SportDiscus Concussion, Neck 144 0 0 7 0 0 10 4 1SportDiscus TBI, Neck, Treatment 5 0 0 0 0 0 0 0 0

SportDiscus Concussion, Neck,Treatment 15 1 1 4 1 0 3 1 1

SportDiscus Concussion, Cervical 65 1 1 3 0 0 3 2 1SportDiscus Concussion, Chiropractic 9 2 0 0 0 0 2 0 0SportDiscus Concussion, Physiotherapy 34 2 2 0 0 0 7 2 1

SportDiscus Concussion, AthleticTraining, Cervical 13 1 1 0 0 0 1 1 1

CINAHL Concussion, Manipulation 3 3 2 0 0 0 2 1 1CINAHL Concussion, Guideline 19 0 0 1 0 0 7 0 0Cochrane Concussion 4 1 1 0 0 0 1 1 0

PEDro Concussion, PhysicalTherapy 2285 11 5 0 0 0 0 0 0

PEDro mTBI, Physical Therapy 215 1 1 0 0 0 0 0 0PEDro mTBI, Manual Therapy 99 0 0 0 0 0 0 0 0

PEDro Concussion, ManualTherapy 1132 2 2 0 0 0 0 0 0

PEDro Concussion, Chiropractic 22 0 0 0 0 0 0 0 0Total 4510 48 31 201 5 1 143 29 11

The incidence of PTH varies between 5 and 90% [16, 20].Their prevalence in children with mTBI is from 73 to 93%[19]. The diagnosis of PTH can be difficult to address insubjects with a history of preexisting headaches. However,PTH syndrome diagnosis is considered when the intensity orfrequency of headaches increases after trauma [19]. PTH isdefined as a headache that occurs within 1 week after regain-ing consciousness or within 1 week following head trauma[17].Themajority of PTH resolvewithin 6 to 12months, and itis caused by cervical muscle tension and posture impairment[17]. Because headache is one of themajor causes ofmorbidityin mTBI subjects, health care professionals should managethis symptom with a high level of priority [17].

Biologically, concussions usually resolve 7 to 10 days aftertrauma in adults [4, 21]. PCS related symptoms are nonspe-cific. Professionals must consider other pathologies as alter-native explanations to persistent symptoms [4, 17]. Mean-while, a recent study suggests that even at 1 month or moreafter concussion, the cerebral blood flow is decreased in 36%

of 11- to 15-year-old subjects who suffered mTBI comparedto a nonconcussed control group [22]. Further studies areneeded to clarify this phenomenon.

Rather than a structural problem, PCS would be relatedto a brain dysfunction problem [15]. This would explain thenegative results onmost of themedical imaging prescribed inemergencies [15]. In addition, a prospective Norwegian studyof 348 participants identified through a questionnaire thatheadaches persisting for more than 3 months after traumaand diagnosed as PCS are often related to a musculoskeletalpathology. In other words, the head or brain injury does notcause the persistent symptoms [23]. These results show theimportance of potential cervical impairment in patients withmTBI [4, 14, 16, 17].

6.2. Mechanism of Injury. Recent studies correlated mTBIwith whiplash occurrence [12, 16, 24, 25]. Furthermore,Schneider et al. (2013) demonstrated in a prospective studywith 3,832 male ice hockey players (11–14 years old) that


Original research

4,854 results (keywords)

82 abstracts selected and read

43 articles (inclusion criteria)

14 articles“the association

between cervical spine sprain and mTBI signs

and symptoms”

26 articles“mechanism of injury”

26 articles“treatments”Exclusion criteria

39 articles

34 articles did not match the three

objectives of this study

(i) 2 case studies(ii) 2 magazine articles

(iii) 1 expert comment

Figure 1: Research method for this review.

the presence of headache and neck pain in a preseasonevaluation increases the risk of concussions during the season[26]. Consequently, a neck examination should be part ofthe postconcussion follow-up in addition to the neurologicalscreening examination [6].

Whiplash is defined as a mechanism of acceleration-deceleration transferred to the cervical spine [6, 20, 27, 28](see Table 4). With its large range of motion, the uppercervical spine is the most mobile part of the spine. During awhiplash, cervical structures are stressed at their end rangesof motion which can lead to neck injuries [29]. The impactgenerates stresses and injuries in the bones and soft tissuesof the cervical spine, causing clinical manifestations [24].Among those, whiplash symptoms include neck pain, cer-vicogenic headaches, chest pain, memory and concentrationdisturbances, muscle tension, sleep disturbances, dizziness,fatigue, cervical range of motion restrictions, irritability,tinnitus, and visual disturbances [12, 17, 20, 24, 25]. Apreliminary study has demonstrated that low velocity impactsbetween 4 and 12 km/h can provoke neck and head injuriescausing dysfunctions and pain [12].These symptoms are oftensimilar to those listed for mTBI, which leads to confusion forthe medical community [12, 14, 16, 25].

The pathophysiology related to the patient’s symptomsoriginates from one or several structures of the cervical spine.

After a trauma involving the cervical region, the involvementof muscles, ligaments, arteries, nerves, the esophagus, thetemporomandibular joint, intervertebral discs, zygapophysialjoints, vertebrae, and the atlantooccipital joint creates acomplex challenge for clinicians [16, 17, 20].

One of the hypotheses raised in the literature for theorigin of neck pain is the involvement of the cervical zyga-pophysial joints [30]. Zygapophysial joints have been shownto be the source of neck pain, headaches, visual distur-bances, tinnitus, and dizziness in patients who have sustainedwhiplash [14, 24, 25]. In this following order, the C1-C2, C2-C3, C0-C1, and C3-C4 levels are the most often described inassociation with cervical symptoms following mTBI [16, 24,26, 31]. More specifically, cervical zygapophysial joint pain isexpressed by a hypersensitivity and hyperexcitability of thespinal cord reflexes, causing an increase of nociceptive pro-cesses in the central nervous system [32]. The cross-sectionalstudy of Smith et al. (2013) recruited 58 adults (18–52 yearsold)with chronicwhiplash disorder and provided a facet jointblock to all participants [32]. They analyzed characteristicsof responders and nonresponders to facet joint block andconcluded that patients with chronic Whiplash-AssociatedDisorder (WAD) show similar sensory disturbances, motordysfunction, and psychological distress [32]. Another studypublished by Treleaven et al. (1994) supports the implication


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ings

Harmon

etal.[5]

Toprovidea

nevidence-based,

bestpractices

summaryto

assist

physicians

with

thee

valuation

andmanagem

ento

fspo

rts

concussio

n

Adult

Child

ren

Statem

ento

fthe

American

Medical

SocietyforS

port

MedicineR

eview

(i)How

ever,asm

anyas

50%of

thec

oncussions

may

goun

repo

rted

(ii)H

eadacheisthe

mostcom

mon

lyrepo

rted

symptom

with

dizzinessthe

second

mostcom

mon

Headache

Classifi

catio

nCom

mittee

ofthe

International

HeadacheS

ociety

(IHS)

[33]

TheInternatio

nalC

lassificatio

nof

HeadacheD

isorder

may

bereprod

uced

freely

forscientifi

c,educational,or

clinicalu

sesb

yinstitu

tions,

societies,or

individu

als

Adult

Child

ren

Review

guideline

(i)Cervicogenic

headache

from

(1)m

igrainea

nd(2)tensio

n-type

headache

inclu

desside-locked

pain,provocatio

nof

typical

headache

bydigitalpressureo

nneck

muscle

sand

byhead

movem

ent,andpo

sterio

r-to-anteriorradiatio

nof

pain

(ii)D

iagn

ostic

criteria

Hecht

[16]

Thisarticlereview

sthe

literature

onmanagem

ento

fposttraumatic

headaches,presentsan

approach

tothea

ssessm

entand

treatment

ofindividu

alsw

ithheadaches

follo

wingTB

Ithatapp

eartobe

cervicogenic,focuses

specifically

onidentifying

occipital

neuralgia,anddiscussesthe

techniqu

eofo

ccipita

lnerve

blocks

7males

(18–

42yo)

3females

(22–64

yo)

Retro

spectiv

ereview

& Repo

rtof

tenpatie

nts

(i)Whiletherea

reav

arietyof

different

posttraum

atic

headaches,cliniciansm

ustb

eawareo

fallpo

tential

presentatio

nsinclu

ding

thosee

manatingfro

mthe

cervicalspinea

ndits

affiliatedstructures

(e.g.,

cervicogenic)

(ii)Injuryto

theses

tructures(innervated

byafferent

fibreso

fthe

3sup.cervicalroots)

(iii)Th

eseinclude

butare

notlim

itedto

muscle

s,ligam

ents,

vessels,somaticandsympatheticnerves,

esop

hagus,tempo

romandibu

larjoint,disc

s,zygapo

physealjoints,cervicalvertebrae,andthe

atlantoaxialcomplex

(iv)W

hiplashsynd

romem

aybe

thep

rimaryfactor

inmanypo

stcon

cussiveh

eadaches

Hyn

esandDickey

[12]

Toexam

inethe

relationship

betweentheo

ccurrenceo

fWhiplash-As

sociated

Diso

rders

andconcussio

nsymptom

sin

hockey

players

Highscho

ol,

college/university,

Ontario

Hockey

League,and

men’s

recreatio

nalteams

(15–35

yo)

20team

s

Prospectives

tudy

(i)183playersw

erer

egistered

forthisstudy

;13received

either

amechanicalw

hiplashinjury

orac

oncussion

injury

(ii)Th

ereisa

stron

gassociationbetween

whiplash-indu

cedneck

injurie

sand

thes

ymptom

sof

concussio

nin

hockey

injurie

s(iii)Ac

celeratio

nanddeceleratio

nof

theh

eadandneck

complex

occursin

sportsandcanpo

tentially

create

injurie

ssim

ilartothoseincurredin

lowvelocitymotor

vehicle

accidents,as

stated

inar

ecentliterature

review

focusedon

Whiplash-AssociatedDiso

rders


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

King

etal.[35]

Theo

bjectiv

ewas

todeterm

ine

thes

ensitivity,specificity,and

likeliho

odratio

ofmanual

exam

inationforthe

diagno

sisof

cervicalzygapo

physealjoint

pain

173patie

ntsw

ithneck

pain

inwho

mcervical

zygapo

physealjoint

pain

was

suspected

Retro

spectiv

estudy

(i)Manualexaminationhadah

ighsensitivityfor

cervicalzygapo

physealjoint

pain,atthe

segm

ental

levelscommon

lysymptom

atic,but

itsspecificitywas

poor

(ii)Th

epresent

study

foun

dmanualexaminationof

the

cervicalspinetolack

valid

ityforthe

diagno

sisof

cervicalzygapo

physealjoint

pain

Kozlo

wskietal.[3]

Toassessexercise

intolerancein

malea

ndfemalep

atientsw

ithPC

S

34patie

nts(PC

S)17

males,

17females

Age

=25.9±10.9

22un

injured

individu

als

Cross-sectionalstudy

(i)Symptom

sfrom

concussio

ntypically

resolvew

ithin

7to

10days

(ii)Th

edefinitio

nof

PCSgivenby

theW

orld

Health

Organizationinclu

desa

histo

ryof

traumaticbrain

injury

and3or

mores

ymptom

s(iii)Nocogn

itive

testing,exclu

sionof

otherd

isorders,

orsymptom

thresholdexistsfor

thed

iagn

osisof

PCS

(iv)P

atientsw

ithPC

Shadas

ymptom

-limitedrespon

seto

exercise,and

thetreadmill

testwas

apotentia

llyuseful

toolto

mon

itorthe

recovery

from

PCS

Kristjanssonand

Trele

aven

[29]

Thep

urpo

seisto

review

dizzinessinneck

pain:

implications

fora

ssessm

entand

managem

ent

Adult

Review

(i)Disturbances

tothea

fferent

inpu

tfrom

thec

ervical

region

inthosew

ithneck

pain

may

beap

ossib

lecause

ofsymptom

ssuchas

dizziness,un

steadiness,andvisual

distu

rbances,as

wellassigns

ofalteredpo

stural

stability,cervicalproprioception,

andhead

andeye

movem

entcon

trol

Ledd

yetal.[27]

Theo

bjectiv

ewas

tocompare

symptom

sinpatie

ntsw

ithph

ysiologicp

ostcon

cussion

disorder

(PCD

)versus

cervicogenic/vestib

ular

PCD

128adults

Retro

spectiv

ereview

Questionn

aire

(i)Clinicians

shou

ldconsider

specifictestin

gof

exercise

tolerancea

ndperfo

rmap

hysic

alexam

inationof

the

cervicalspinea

ndthev

estib

ular/ocularsystemsto

determ

inethe

etiology

ofpo

stcon

cussionsymptom

s(ii)C

oncomitant

injury

tothec

ervicalspine

resembling

whiplashmay

occura

saresultof

thea

cceleration,

deceleratio

nforces

sustainedin

concussiv

etraum

a(iii)Structuralandfunctio

nalinjuryto

thec

ervical

spinec

anbe

associated

with

prolon

gedsymptom

ssuch

asheadache,dizziness,blurred

visio

n,andvertigo


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

Ledd

yetal.[44

]Th

isreview

focuseso

nrehabilitationof

concussio

nand

postc

oncussionsynd

rome

Adult

Child

ren

Review

(i)Ea

rlyeducation,

cogn

itive

behavioraltherapy,and

aerobice

xercise

therapyhave

show

neffi

cacy

incertain

patie

ntsb

uthave

limitatio

nsof

study

desig

n

Lesliea

ndCr

aton

[25]

Basedon

thec

urrent

medical

evidence,w

ewou

ldsuggestthat

thec

onste

llatio

nof

symptom

spresently

defin

edas

concussio

ndo

esno

thavetoinvolvethe

brain

Adult

Edito

rialcom

ment

(i)Con

cussionsymptom

scan

emanatefrom

the

cervicalspine

(ii)W

hiplashmechanism

sofinjuryareidenticalto

the

“impu

lsive

forces”d

escribed

inconcussiv

einjuries

(iii)Notably,

symptom

ssuchas

headache,n

eckpain,

distu

rbance

ofconcentrationor

mem

ory,dizziness,

irritability,sle

epdistu

rbance,and

fatig

uehave

been

describ

edin

both

concussio

nandwhiplashpatie

nts

(iv)C

ervicalzygapop

hysia

ljointsh

aveb

eenim

plicated

asgeneratorsof

headache

anddizziness

(v)Th

eoverla

pwith

neck/w

hiplashinjurie

sise

vident

Lucas[19]

Thisarticlereview

sthe

literature

onheadache

managem

entin

concussio

nandmTB

I

Adult

Pediatric

UnitedStates

Literature

review

(i)Re

portso

fheadachea

fterc

oncussionor

mTB

Iin

child

renrang

edfro

m72%to

93%

(ii)H

eadacheiso

neof

them

ostcom

mon

symptom

saft

erTB

Iand

PTHmay

bepartof

acon

stellatio

nof

symptom

sthatisseenin

thep

ostcon

cussives

yndrom

e

Makdissietal.[8]

Theo

bjectiv

esof

thec

urrent

papera

reto

review

theliterature

regardingdifficultconcussio

nandto

provider

ecom

mendatio

nsfora

napproach

tothe

investigationandmanagem

ento

fpatie

ntsw

ithpersistent

symptom

s

Adult

Sport

Qualitativer

eview

(i)Cases

ofconcussio

nin

sportw

here

clinicalrecovery

falls

outside

thee

xpectedwindo

w(i.e.,

10days)sho

uld

bemanaged

inam

ultid

isciplin

arymannerb

yhealth

care

providersw

ithexperie

nceinsports-

related

concussio

n

Marshall[11]

Thispaperisa

review

ofrecent

literatureo

nthetop

icof

concussio

n,consistingof

biom

echanics,patho

physiology,

diagno

sis,and

sideline

managem

ent

Athletes

UnitedStates

Narrativ

ereview

(i)Th

ecervicalspine

noto

nlyisap

otentia

lsou

rceo

finjury

thatwem

ustb

eawareo

fbut

also

isim

plicated

asafactorinthec

oncussionitself

(ii)S

igns

andsymptom

sofcon

cussionfro

mthe

Associationof

SportC

ollege

ofMedicine(AC

SM)

updatedconsensusstatement

Maugans

etal.[22]

Theg

oalofthisinvestig

ationwas

toexplorec

erebralblood

flow

fluctuatio

naft

erpediatric

sport-r

elated

concussio

n

Twelv

echildren

Ages11to15

years

Con

trolgroup

Clinicalstu

dy

(i)Statisticallysig

nificantalteratio

nsin

cerebralbloo

dflo

wwered

ocum

entedin

thes

port-rela

tedconcussio

ngrou

p,with

redu

ctionin

cerebralbloo

dflo

wpredom

inating.Im

provem

enttow

ardcontrolvalues

occurred

inon

ly27%of

thep

artic

ipantsat14

days

and

64%at>30

days

after

sport-r

elated

concussio

n


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

McC

rory

etal.[4]

Then

ew2012

Zuric

hCon

sensus

statem

entisd

esignedto

build

onthep

rinciples

outlinedin

the

previous

documentsandto

developfurtherc

onceptual

understand

ingof

thisprob

lem

usingaformalconsensus-based

approach

International

consensus

(i)Ad

ults

(ii)P

ediatric

Internationalcon

sensus

Sportcon

cussion

(i)Aninitialperio

dof

restmay

beof

benefit

(ii)M

ultim

odalph

ysiotherapytreatmentfor

individu

als

with

clinicalevidenceo

fcervicalspine

and/or

vestibular

dysfu

nctio

nmay

beof

benefit

(iii)Persistentsym

ptom

s(>10

days)a

regenerally

repo

rted

in10–15%

ofconcussio

ns.Ingeneral,

symptom

sare

notspecific

toconcussio

nanditis

impo

rtanttoconsider

otherp

atho

logies

(iv)P

CSshou

ldbe

managed

inam

ultid

isciplin

ary

mannerb

yhealth

care

providersw

ithexperie

ncein

sportsconcussio

n

Mihaliketal.[39]

Theo

bjectiv

ewas

toevaluatethe

effecto

fcervicalm

uscle

strength

onhead

impactbiom

echanics

37volunteerice

hockey

players

Age

=15.0±1.0

years

Prospectivec

ohortstudy

(i)Th

ehypothesis

thatplayersw

ithgreaterstatic

neck

streng

thwou

ldexperie

ncelow

erresultant

head

acceleratio

nswas

notsup

ported

(ii)Th

ereisstilln

onem

piric

alsupp

ortfor

ther

olen

eck

musculature

may

play

inredu

cing

ther

iskof

mild

TBI

thatisworthyof

investigationin

ayou

ngat-risk

sample

Moser

etal.[21]

Theo

bjectiv

eofthisa

rticleisto

evaluatethee

fficacy

ofcogn

itive

andph

ysicalrestforthe

treatmento

fcon

cussion

Highscho

oland

collegiatea

thletes

(𝑁=49)

Range=

14–23yo

Mean=15.0yo

67%male

33%female

Retro

spectiv

eanalysis

(i)Participantsshow

edsig

nificantly

improved

perfo

rmance

onIm

mediatePo

st-Con

cussion

Assessmentand

Cognitiv

eTestin

ganddecreased

symptom

repo

rtingfollo

wingprescribed

cogn

itive

and

physicalrest

(ii)Th

esep

relim

inarydatasuggestthata

perio

dof

cogn

itive

andph

ysicalrestmay

beau

sefulm

eans

oftre

atingconcussio

n-relatedsymptom

s,whether

applied

soon

after

acon

cussionor

weeks

tomon

thslater

Pelletie

r[18]

Thep

urpo

seof

thispaperisto

presenta

review

ofthed

iagn

osis

andtre

atmento

fthe

potentially

catastroph

icneck

andhead

injurie

scausedby

spearin

gin

Canadian

amateurfoo

tball

Amateurfoo

tball

UnitedStates

and

Canada

Literature

review

(i)Associatedcervicaltraumaw

ithconcussio

nmay

inclu

deon

eorseveralof

neck

pain,reduced

cervical

rangeo

fmovem

ent,cervicogenicheadache,

cervicogenicvertigo,andoccipitaln

euralgia

(ii)S

everalmanualtechn

iquesfor

thetreatmento

fpo

sttraum

aticconcussio

nsynd

romeh

aveb

een

describ

edas

either

“dire

ct”o

r“indirect”

Reid

etal.[37]

Thisstu

dyaimed

todeterm

ine

thee

fficacy

ofsustainednatural

apop

hysealglides

(SNAG

s)in

the

treatmento

fthisc

onditio

n

34adults

17SN

AGs

17Placebo

Dou

ble-blind

rand

omized

controlled

clinicaltria

l

(i)Th

eSNAG

treatmenth

adan

immediateclinically

andsta

tistic

allysig

nificantsustained

effectinredu

cing

dizziness,cervicalpain,and

disabilitycaused

bycervicaldysfu

nctio

n


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

Schm

idtetal.[42]

Thep

urpo

seof

thisstu

dywas

tocompare

theo

ddso

fsustaining

high

ermagnitude

in-seasonhead

impactsb

etweenathletes

with

high

erandlower

preseason

perfo

rmance

oncervicalmuscle

characteris

tics

49high

scho

oland

collegiateA

merican

footballplayers

Coh

ortstudy

(i)Th

estudy

finding

ssho

wed

thatgreaterc

ervical

stiffnessandlessangu

lard

isplacementafte

rperturbatio

nredu

cedtheo

ddso

fsustaininghigh

ermagnitude

head

impacts;ho

wever,the

finding

sdid

not

show

thatplayersw

ithstr

ongera

ndlarger

neck

muscle

smitigatehead

impactseverity

(ii)M

alea

thletesa

lsoexhibitg

reater

stiffnessand

capacityto

store

elasticenergy

comparedwith

female

athletes

Schn

eidere

tal.

[26]

Theo

bjectiv

eofthisstudy

was

todeterm

inethe

riskof

concussio

nin

youthmaleh

ockeyplayers

with

preseasonrepo

rtso

fneck

pain,headaches,and

/ord

izziness

3832

males

Iceh

ockeyplayers

(11–14yo)

280team

s

Prospectives

tudy

(i)Preseasonrepo

rtso

fneckpain

andheadache

were

riskfactorsfor

concussio

n(ii)D

izzinesswas

arisk

factor

forc

oncussionin

theP

eeWee

nonb

odychecking

(iii)Acombinatio

nof

any2symptom

swas

arisk

factor

intheP

eeWee

nonb

odychecking

coho

rtandthe

Bantam

coho

rt(iv

)Neckpain

isthethird

mostcom

mon

lyrepo

rted

baselin

esym

ptom

invarsity

athletes

Schn

eidere

tal.[10]

Theo

bjectiv

eofthisstudy

was

todeterm

ineifa

combinatio

nof

vestibu

larrehabilitatio

nand

cervicalspinep

hysio

therapy

decreasedthetim

euntilmedical

clearance

inindividu

alsw

ithprolon

gedpo

stcon

cussion

symptom

s

18males

13females

12–30years

Rand

omized

controlled

trial

(i)Acombinatio

nof

cervicalandvestibular

physiotherapydecreasedtim

etomedicalcle

arance

toreturn

tosportinyouthandyoun

gadultswith

persistentsym

ptom

sofd

izziness,neckpain,and

/or

headachesfollowingas

port-related

concussio

n(ii)Th

ecervicalspine

iscitedas

asou

rceo

fpainin

individu

alsw

ithwhiplash

(iii)Th

eupp

ercervicalspinec

ancausec

ervicogenic

headaches

(iv)A

combinatio

nof

manualtherapy

andexercise

has

been

show

nto

bemoree

ffectivethanpassivetreatment

mod

alities

inindividu

alsw

ithneck

pain

Scorza

etal.[13]

Currentcon

ceptsinconcussio

nCh

ildrenadolescents

Literature

review

(i)Initialevaluatio

ninvolves

elim

inatingcervicalspine

injury

andserio

ustraumaticbraininjury

(ii)S

elected

symptom

sofcon

cussion


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

Sign

orettietal.[15]

Thefollowingreview

represents

thea

utho

rs’effo

rtto

piece

together

thec

urrent

concepts

andthem

ostrecentfi

ndings

abou

tthe

complex

basic

physiology

underly

ingtheinjury

processeso

fthisp

artic

ular

type

ofbraintraumaa

ndto

emph

asize

then

uances

involved

incond

uctin

gresearch

inthisarea

European

coun

tries

UnitedStates

Adult

Literature

review

(i)Po

stcon

cussives

ymptom

smay

beprolon

gedin

asm

allp

ercentageo

fcases,but

thea

cuteclinical

symptom

slargelyreflectafun

ctionaldisturbancer

ather

than

astructuralinjury,which

usually

isconfi

rmed

bythea

bsence

ofabno

rmalities

onsta

ndardneuroimaging

studies

(ii)Th

esym

ptom

sofcon

cussionreflected

afun

ctional

distu

rbance

rather

than

astructurald

amages

uchas

contusion,

hemorrhage,or

laceratio

nof

theb

rain

Smith

etal.[32]

Thispreliminarystu

dyexam

ined

asam

pleo

find

ividualswho

did

anddidno

trespo

ndto

facet

blockas

wellash

ealth

ycontrols

todeterm

inew

hether

therew

ere

differences

intheirp

hysic

aland

psycho

logicalfeatureso

ncethe

effectsof

theb

locksh

adabated

andsymptom

shad

returned

58adults

(18–65

yo)

Calgary,Ca

nada

Cross-sectionalstudy

(i)Fo

llowingFB

procedures,bothWADgrou

psdemon

strated

generalized

hypersensitivity

toall

sensorytests

,decreased

neck

ROM,and

increased

superficialmuscle

activ

itywith

theC

CFTcomparedto

controls

(ii)B

othWADgrou

psdemon

stratedpsycho

logical

distr

ess

(iii)Ch

ronicW

ADrespon

dersandno

nrespo

ndersto

feedback

(FB)

procedures

demon

stratea

similar

presentatio

nof

sensorydistu

rbance,m

otor

dysfu

nctio

n,andpsycho

logicaldistress.H

igherlevelso

fpain

catastroph

izationandgreaterm

edicationintake

werethe

onlyfactorsfou

ndto

differentiatetheseg

roup

s

Spitzer

etal.[28]

Thep

urpo

sewas

toexpo

sethe

clinicalclassificatio

nof

Whiplash-As

sociated

Diso

rders

Adult

Guidelin

e(i)

Grades0

to4(clin

icalpresentatio

n)

Stovnere

tal.[23]

Amainob

jectiveo

fthisstudy

was

toassessthev

alidity

ofthis

diagno

sisby

studyingthe

headache

patte

rnof

concussed

patie

ntsthatp

artic

ipated

inon

ehisto

ric(𝑛=131)a

ndon

eprospectivec

ohort(𝑛=217)

study

200patie

nts

(18–67

yo)

Traumainvolving

LOCof<15min.

Kaun

as,Lith

uania

Questionn

airesstudy

(afte

r3mon

ths&

1year)

(i)Ex

istence

ofpretraum

aticheadache

was

apredictor

ofpo

sttraum

aticheadache,alth

ough

pretraum

atic

headache

seem

stohave

been

underreportedam

ongthe

concussedpatients

(ii)Th

isisnegativ

ecorrelation,

andthelackof

specificityindicatesthath

eadacheo

ccurrin

g3mon

ths

ormorea

fterc

oncussionisno

tcausedby

theh

eador

braininjury

(iii)Ra

ther

itmay

representanepiso

deof

oneo

fthe

prim

aryheadaches,po

ssiblyindu

cedby

thes

tressof

thes

ituation


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

Tatore

tal.[1]

Thisrepo

rtisintend

edto

improveu

nderstanding

ofthe

epidem

iology

ofneurological

cond

ition

sand

thee

cono

mic

impacton

theC

anadianhealth

care

syste

mandsociety

Adult

Child

ren

Canada

Statisticalrepo

rt

(i)Cerebralcon

cussions

arec

ommon

lykn

ownas

mild

traumaticbraininjury

(mTB

I)(ii)B

ycontrast,

StatisticsC

anadae

stim

ated

inrecent

studies

thatthea

nnualincidence

form

TBIis6

00per

100,00

0person

sand

11.4per100,000

inhabitantsfor

atraumaticbraininjury

(TBI)

(iii)How

ever,the

high

estage

grou

pincidenceis

between19

and29

years,representin

gapproxim

ately

one-qu

artero

fpatientsw

ithcranialtraum

a(iv

)Children(18yearsa

ndyoun

ger)representedalmost

45%of

thep

atientsw

ithhead

injury

Tierneyetal.[41]

Thep

urpo

sewas

todeterm

ine

whether

gend

erdifferences

existed

inhead-necksegm

ent

kinematicandneurom

uscular

controlvariables

respon

sestoan

externalforcea

pplicationwith

andwith

outn

eckmuscle

preactivation

20females

20males

Adult

Coh

ortstudy

(i)Genderd

ifferencese

xiste

din

head-necksegm

ent

dynamicstabilizatio

ndu

ringhead

angu

lara

cceleration

(ii)F

emales

exhibitedsig

nificantly

greaterh

ead-neck

segm

entp

eakangu

lara

ccelerationanddisplacement

than

males

despite

initiatingmuscle

activ

ityearlier

(SCM

only)a

ndusingag

reater

percentage

oftheir

maxim

umhead-necksegm

entm

uscle

activ

ity

Trele

aven

etal.[31]

Thisstu

dymeasuredaspectso

fcervicalmusculoskele

tal

functio

nin

agroup

ofpatie

nts

(12)

with

postc

oncussional

headache

(PCH

)and

inan

ormal

controlgroup

8males

(15–48

yo)

4females

(20–

44yo)

Retro

spectiv

estudy

(i)Tw

elveo

fthe

15eligiblepatie

ntsc

onsented

toenter

thes

tudy

(ii)Th

emostfrequ

entm

ajor

symptom

aticsegm

ents

wereC

1-C2,C2

-C3,C0

-C1,andC3

-C4.

Sign

sofcervicalarticular

andmusculard

ysfunctio

ndistinguish

edtheP

CHgrou

pfro

mthec

ontro

lgroup

(iii)Asu

pper

cervicaljointd

ysfunctio

nisafeature

ofcervicogeniccauses

ofheadache,the

results

ofthis

study

supp

ortthe

inclu

sionof

aprecise

physical

exam

inationof

thec

ervicalregionin

differential

diagno

sisof

patie

ntssuff

eringpersistenth

eadache

follo

wingconcussio

n


Table2:Con

tinued.

Authors/sections

Stud

yob

jective

Popu

lation

Metho

dsMainou

tcom

es/find

ings

Watanabee

tal.

[20]

Thes

pecific

goalso

fthisreview

inclu

de(1)d

eterminationof

effectiv

einterventio

nsforP

TH(2)d

evelo

pmento

ftreatment

recommendatio

ns(3)identificatio

nof

gaps

inthe

currentm

edicalliterature

regardingPT

HAtre

atment

(4)sug

gestions

forfuture

directions

inresearch

toim

prove

outcom

efor

person

swith

PTHA

Adult

Child

Literature

review

Thelevelof

evidence:

American

Academ

yof

Neurology

criteria

(i)Headpain

may

berelatedto

directdamagetothe

skullorb

rain

tissue;muscular,tend

inou

s,and/or

ligam

entous

injury

tothec

ervicalspine;and

injurie

sto

perip

heraln

erves.Other

nervou

ssystem

injurie

s,such

asvisualandvestibu

larsystem

damage,also

may

contrib

utetoheadache

synd

romes

(ii)B

iologically

basedinterventio

nsinclu

dedav

ariety

ofbiofeedb

ackmechanism

s,ph

ysicaltherapyand

manualtherapy,immob

ilizatio

ndevices,ice,and

injections

Weightm

anetal.

[17]

Thep

urpo

seof

thisarticleisto

providea

summaryof

the

developm

entp

rocessandto

shares

pecific

recommendatio

nsforP

Tpractic

ewith

service

mem

berswho

sustainMTB

I

Military

andcivilian

popu

latio

ns

Literature

review

MTB

I-related,

evidence-based

review

sandguidelines

(i)Determinethe

disabilityandits

severityrelated

tothen

eck,jaw,

andheadaches

(ii)P

hysic

altherapyinterventio

nswith

thes

trongest

evidence

inthetreatmento

fPTH

inclu

deam

ultim

odal

approach

ofspecifictrainingin

exercise

andpo

stural

retraining

,stre

tching

andergono

miceducation,

and

manipulationand/or

mob

ilizatio

nin

combinatio

nwith

exercise


Table 3: Most common symptoms of mTBI according to their categories [4, 6, 11–13].

References Cognitive Somatic physical Affective emotional Sleep disturbance

Marshall,2012 [11]Hanson et al.,2014 [6]Hynes andDickey, 2006[12]Scorza et al.,2012 [13]McCrory etal., 2013 [4]

(i) Confusion(ii) Retrograde amnesia(iii) Anterograde amnesia(iv) Loss of consciousness(v) Disorientation(vi) Feeling foggy (in a fog)(vii) Vacant stare(viii) Inability to focus(ix) Delayed verbal responses(x) Delayed motor responses(xi) Slurred(xii) Incoherent speech (slurred)(xiii) Excessive drowsiness

(i) Headache(ii) Dizziness(iii) Balance disruption(iv) Nausea(v) Vomiting(vi) Visual disturbances(vii) Phonophobia

(i) Emotional liability(ii) Irritability(iii) Fatigue(iv) Anxiety(v) Sadness

(i) Trouble falling asleep(ii) Decreased sleep(iii) Increased sleep

Hanson et al.,2014 [6]

(i) Feeling slowed down(ii) Difficulty concentrating(iii) Difficulty remembering(iv) Forgetting of recentinformation(v) Confused about recent events(vi) Answers questions slowly(vii) Repeats questions

(i) Balance problems(ii) Visual problems(iii) Fatigue(iv) Sensitivity to light(v) Sensitivity to noise(vi) Dazed(vii) Stunned

(i) Nervousness (i) Drowsiness

Hynes andDickey, 2006[12]

(i) Dysphagia(ii) Seeing stars

(i) Deafness(ii) Ringing in the ears(iii) Temporomandibular

Scorza et al.,2012 [13]

(i) Disorientation(ii) Stunned(iii) Vacant stare

(i) Blurred vision(ii) Convulsions(iii) Light-headedness(iv) Numbness(v) Tingling(vi) Tinnitus

(i) Clinginess(ii) Depression(iii) Personality changes

Table 4: Summary table of the Whiplash-Associated Disorder(WAD) classifications and concussion symptoms that can manifestthemselves in any grade of WAD [6, 20, 27, 28].

WAD classification Symptoms0 No neck complaints

I Complaint of neck pain, stiffness, ortenderness

II Neck complaint withmusculoskeletal signs

III Neck complaint, musculoskeletalsigns, and neurological signs

IV Fracture and/or dislocation

of the cervical region by a precise physical examination indifferential diagnosis of 12 patients suffering of persistentpostconcussion headache [31].

Following a whiplash, the cervical spine is often thesource of a patient’s pain [4, 10]. The neck received thetransmitted force of the impact and the same acceleration-deceleration mechanism that produces mTBI [28]. Duringthe whiplash, the cause of cervicogenic and brain inducedsymptoms could be caused by either the mTBI or the cervicalspine involvement or both at the same time [10]. There are

similarities between the symptoms of neck disorders and thesymptoms of mTBI [19]. The most common posttraumaticsymptom is headache [4]. Cervicogenic headache and post-traumatic headache are well-known conditions [4, 13, 19, 33].In fact, those upper cervical impairments, if not diagnosedand treated, can lead to chronicity of postconcussion head-aches [10].

Cervicogenic headaches are common after a whiplashinjury [16, 34]. Different studies showed that 3 to 4.6% ofpatients will develop chronic daily headaches after whiplashand 2% will be permanently disabled [34]. Upper cervicalspine pain can arise from various anatomical structures suchas muscles, joints, ligaments, and nerves [34]. Tensions incervical muscles (trigger points) are the most common diag-nosed type of headache [16, 23]. Becker (2010) explained thatheadaches related to cervical spine disorders (CGH) remainone of the most controversial areas of headache medicine[34]. Dysfunctions of the craniocervical zygapophysial (C0 toC4) joints can also cause headaches [16, 30]. In patients withheadaches following a whiplash injury, dysfunctions of theC2-C3 zygapophysial joint are highly prevalent, particularlyif there is tenderness over the C2-C3 facet joint [34]. Cer-vicogenic headaches may be unilateral or bilateral with thedominance depending on one or more of the structures thatare affected [16]. Pain location usually begins in the occipital


region of the neck [34]. After awhiplash injury, zygapophysialjoints are clinically identified as the single most commonsource of pain in at least 50% of neck pain. Furthermore,facet joints appear to be the most common source of painin the neck, with or without headache [34]. King et al.(2007) showed in their retrospective study, which included173 patients, that manual examination had a high degree ofsensitivity during zygapophysial joint pain evaluation [35].Tension in the cervical muscles has the potential effect ofreducing neck movement and generating local pain [16, 18].A bad posture or sleeping position as well as physical activityperformed with a faulty motor strategy can lead to neckpain and pain irradiating to the head [19]. In 2013, theCervicogenic Headache International Study Group (CHISG)developed the diagnostic criteria for CGH [33] (see thefollowing).

Summary of the Cervicogenic Headache (CGH)Diagnostic Criteria [33]

Unilaterality of pain, although it is recognized thatbilateral cervicogenic headache may occur.Restriction in range of motion in the neck.Provocation of usual head pain by neck movement orsustained awkward neck positions.Provocation of usual head pain with external pressureover the upper cervical or occipital region on thesymptomatic side.Ipsilateral neck, shoulder, or arm pain, usually of avague nonradicular nature, occasionally radicular.

Posttraumatic headaches are a serious contributor todisability following cranial, cerebral, and cervical injury.Therefore, evaluating the cervical region after a head traumais recommended [4]. This recommendation will highly con-tribute to limiting morbidity of mTBI and, furthermore, tohelp clinicians identify the International Headache Society(IHS) cervicogenic characteristics on mTBI patients. One ofthe improvements of SCAT3 and Child-SCAT3 compared tothe SCAT2 is the introduction of the cervical assessment inposttrauma evaluation [4]. Knowing that the mechanism ofmTBI is an external force transmitting energy to the head,it is possible that the neck, supporting the head, can also beinjured during such an external force [11, 12, 16]. The Zurichconsensus for concussion in sports (2012) recommended amultidisciplinary approach for patients who suffer PCSsymptoms, such as headaches lasting longer than 6 weeks [4].

6.3. Treatments. Themajority of articles in the literature cur-rently focus on the diagnosis of mTBI, but few are dedicatedto its management and treatments [7]. The 2012 Zurich con-sensus on concussion in sport suggested physical and cogni-tive rest until the end of the acute symptoms after trauma anda multidisciplinary approach involving experienced healthcare professionals when treating mTBI [4]. In their retro-spective analysis, Moser et al. (2012) analyzed 49 high schooland collegiate athletes (mean = 15.0 years old) and suggested

that a period of cognitive and physical rest may be a usefulmean of treating concussion-related symptoms [21]. Thisrecovery time allows for a period of 7 to 10 days before theathlete returns to competition [2]. During this period, thesymptoms should be evaluated daily and all activities thatincrease these symptoms should be stopped [4]. A Cochranestudy mentioned that, based on present literature, no acutelyinitiated intervention has been clearly associated with apositive outcome for patients who sustain mTBI [36].

Return-to-play is allowed when athletes are symptom-free at rest, are able to do a full practice with contactwithout symptoms, no longer take anymedications, and havereturned to their baseline levels of cognitive functioning andpostural stability [6].

The evaluation of the cervical region has been included asa new part of the SCAT3/Child-SCAT3, and a full clearanceis essential before return-to-play [4]. According to someauthors, post-mTBI subjects must have no pain in the neck,full mobility, and an adequate bilateral general strength torestart their sporting activities [12].

Treatments such as vertebral manual therapy, cervicaltractions, manipulations, and exercises can relieve neck pain[16]. Brolinson (2014) has demonstrated that interventionsof spinal manual therapy, physiotherapy, and neuromo-tor/sensorimotor training are more effective for mTBI recov-ery compared to a program of rest and exercises [7]. Anotherstudy demonstrated that the physical status of individualswith neck pain is improvedwith an exercise programcombin-ingmanipulation, proprioceptive neuromuscular facilitation,acupressure on trigger points, and range of motion exercises,along with proprioceptive exercises compared to a neck paincontrol group of similar patients treatedwith information andadvice [29]. Treatment of the cervical spine (sustained naturalapophyseal glides) has been shown to be effective in 17 indi-viduals with suspected cervicogenic dizziness compared to acontrol group (17 adults) [37]. Schneider et al. (2014) estab-lished that a significantly higher proportion of post-mTBIindividuals (more than 3 weeks after trauma) were medicallycleared to return to sport within 8 weeks of initiating treat-ment if they were treated in physiotherapy with cervical spineand vestibular rehabilitation compared to a control group[10]. Another study recruited 128mTBI adultswith either PCSor cervicogenic/vestibular symptoms [27], who completedthe 22-symptom postconcussion symptoms scale question-naire. Their results demonstrated that the questionnaire doesnot reliably discriminate between both types of patients.Theyconcluded that clinicians should consider specific testing ofexercise tolerance and perform a physical examination of thecervical spine and the vestibular/ocular systems to determinethe etiology of postconcussion symptoms and to considertreating these accordingly [27]. Assessment and treatment ofthe cervical spine and vestibular system in the presence ofpersistent dizziness, neck pain, and/or headaches may facili-tate functional and symptomatic improvements and shortenrecovery in post-mTBI subjects [7, 10].

There is little evidence in clinical trials on the treatmentof PTH. A study by Bonk et al. (2000) has shown that physio-therapy treatments decrease pain and increase cervical rangeof motion compared to a control group in a cervical collar for


a period of 6 and 12 weeks after trauma [38]. The physiother-apy programs consisted of active and passive mobilizations,postural strengthening, the application of ice, and exercisesthat are efficient for PTH.

Regarding the cervical muscular system, several changesare observed following a trauma such as mTBI or whiplash.There is still nonempirical support that stronger neckmusclescould reduce the risks of mTBI on the field [11, 39]. In fact,Mihalik et al. (2011) evaluated the effect of cervical strengthonhead impact in 37 hockey players (average 15 years old) andthey concluded that the hypothesis of neck strength decreas-ing head accelerationwas not supported [39]. Recent publica-tions identify the importance of neck musculature in the pre-vention of concussions. Two hypotheses are presently underdebate in the literature.The potentiallymodifiable risk factorsfor concussion are neck strength and impact anticipation[40]. Tierney et al. (2005) demonstrated that males have abetter head-neck segment dynamic stabilization than femaleswhen angular acceleration is sustained by the head in astudy including 20 males and 20 females [41]. Furthermore,a descriptive study demonstrated that greater neck strengthand anticipatory cervical muscle activation (bracing forimpact) can reduce the magnitude of the head’s kinematicresponse in a population of 46 contact sport athletes (maleand female) aged between 8 and 30 years [40]. Another studyon a group of 49 football players (high school/collegiate) hasshown that the odds of sustaining higher magnitude headimpacts are reduced with better cervical strength and lowerangular displacement following impact [42]. However, theirfindings did not show that stronger and larger neck musclesin players decreased head impact severity [42]. Meanwhile,Collins et al. (2014) concluded, in their study, which included6704 high school athletes, that neck strength can be a valuablescreening tool to prevent concussion [43]. Further research isneeded to clarify these hypotheses and the actual role of neckstrength in reducing risk of concussion.

A study by Leddy et al. (2012) for mTBI subjects slowto recover shows that a lightweight level of exercise can bebeneficial [44]. Kozlowski et al. (2013) recently published across-sectional study about the exercise impact on 34 patientswith PCS and a control group of 22 patients [3]. Conclusionsshowed that patients with PCS had a symptom-limitedresponse to exercise, and the treadmill test was a potentiallyuseful tool to monitor the recovery from PCS [3].

Other physiotherapy treatments, such as vestibular reha-bilitation, visual training, cardiovascular training, and thetreatment of cervical dysfunctions, have shown some promis-ing avenues, but further studies are needed [4, 10, 14, 17, 20].

7. Conclusion

In conclusion, mTBI is a complex injury and needs to betaken care of by differentmedical specialists working togethertoward the same goal, recovery [4]. The evidence of cervicalspine involvement in mTBI is becoming apparent, but thereis a lack of sound evidence in the literature [25]. Our findingshave implications for further research. The hypothesis ofcervical spine involvement in post-mTBI symptoms and inPCS is supported by increasing evidence and largely accepted.

Health professionals should consider assessing the cervicalspine of patients affected bymTBI. Some original data articlessupport this theory and show that persistent headache andpostconcussion syndrome are often related to musculoskele-tal pathology of the cervical spine. For themTBImanagementand treatment, few articles in the literature are available, butwell-defined studies showed interesting results about manualtherapy (cervical and vestibular) and exercises as effectivetools for health care practitioners. Further studies are neededto establish an adequate evaluation and determine guidelinesfor treatments. The evaluation and treatment of the cervicalregion are a major step to improve mTBI rehabilitation.

Appendix

See Figure 1 andTables 1, 2, 3, and 4, and also see “Summary ofthe Cervicogenic Headache (CGH) Diagnostic Criteria [33]”in Section 6.2.

Abbreviations

mTBI: Mild traumatic brain injuryICL: Index to Chiropractic LiteraturePEDro: SportDiscus, Physiotherapy Evidence DatabaseCINAHL: Cumulative Index to Nursing and Allied Health

LiteratureCDC: Centers for Disease Control and PreventionTBI: Traumatic brain injuryPCS: Postconcussion syndromeMRI: Magnetic Resonance ImagingWAD: Whiplash-Associated DisorderIHS: International Headache SocietyPTH: Posttraumatic headacheCGH: Cervicogenic headacheGCS: Glasgow Coma ScoreSAC: Standardized Assessment of ConcussionBESS: Balance Error Scoring System.

Competing Interests

The authors declare that they have no competing interests.

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