Post-Concussion Syndrome

Case Study

Post-Concussion Syndrome

By Conor Collins

I sit across from a young lady who has been struggling for months with the symptoms of post-concussion syndrome. She is frustrated and tears up as she explains how she feels lost, helpless and has received little guidance on how to get better. She’s been told to sit in a dark room, not exercise and “rest”. When her symptoms don’t get any better, she’s told to rest more and the cycle repeats itself.

I

have heard this story plenty of times. As the field of concussion continues to evolve, massage therapists are becoming an integral part of the health care team managing this often complicated injury. Years ago, I had a very poor understanding of this injury when I began to see more concussions in practice. What I discovered is that I was not alone, the entire medical community was struggling to manage patients appropriately. This has caused practitioners of all disciplines to learn more about the role they play in managing a concussion, whether they are a sole provider treating a patient or part of a complementary medical care team.

A concussion is defined as “any transient neurological dysfunction resulting from a biomechanical force” (Giza C., Hovda D., 2001). In simplest terms, the brain gets injured at a microscopic level which can lead to a host of symptoms. The vast majority of these symptoms resolve within 30 days. A small percentage of patients will have symptoms between 30-90 days (known as “post-concussive syndrome”) and an even smaller group will experience symptoms lasting over 90 days, placing them into the persistent symptom category.

As with anything overwhelming, establishing a process can help simplify things. The more thorough an exam the more time the massage therapist will save in treatment. A thorough health history should be performed in order to identify “red flags” before beginning any physical exam. Red flags can include, but are not isolated to: persistent vertigo, resting double vision, unrelenting severe headache, persistent vomiting or continued neurological decline. These symptoms require immediate attention by a physician.

Depending on the therapist’s experience, a full neurological exam should be performed, including assessment of the central and peripheral nervous systems as well as the cranial nerves. This allows the therapist to catch discrete symptoms that might go overlooked during initial health history intake. The assumption should also be made that none of these assessments have been done by any other practitioner. In my experience, many massage therapists expect that another discipline has performed these exams which is not always the case. Approach each patient with a clean slate and it will allow you to understand them more thoroughly.

Following a neurological exam, assessment of the cervical spine should be performed and include: range of motion, strength, proprioception and indicated special orthopaedic tests. Pay close attention to the symptoms felt by the patient during the assessment and whether or not the evaluation re-creates any familiar symptoms. If a patient has suffered a concussion, there is almost always a concurrent whiplash-associated injury. The force by which a whiplash injury occurs is substantially less than that of a concussion. If a patient is coming into a clinic with a previously diagnosed concussion, it is safe to assume that they have exceeded the force required for a whiplash-associated disorder. In particular, the massage therapist should address the sub-occipital, scalene, and sternocleidomastoid muscles. Injuries to the ligaments and joint capsules of the cervical and upper thoracic spine are also very common, depending on the mechanism of injury.

Pay close attention to the symptoms felt by the patient during the assessment and whether or not the evaluation recreates any familiar symptoms.

The massage therapist is often asked to field a number of questions regarding concussion following treatment. This is mainly due to the frustration of the patient, as well as the significant amount of misinformation being communicated about the injury. Having a baseline understanding of the current evidence

post-concussion syndrome

surrounding concussion injuries assists the massage therapist in communicating with the patient effectively. Some of these topics include appropriate rest, exercise and screen use. Gone are the days of pure rest and sitting in a dark room. The evidence is very clear that total rest beyond 4872 hours is not favourable to recovery in concussion patients. In fact, cardiovascular training that is heart rate guided and within sub-symptom threshold has been shown to be very beneficial for the healing process (Leddy et al., 2018). With respect to screens, patients may want to monitor their symptoms during screen use and limit themselves accordingly, but do not need to remove screens entirely. The most important thing during the healing process is that the patients try to remain at or below their symptom threshold for the day. Of the symptoms requiring management following a concussion, there are three that are considered a priority. It’s important for the massage therapist to understand these symptoms thoroughly and provide sound evidence-based advice to ensure patients are making appropriate progress through each stage of the injury. Sleep helps assist in breaking the acute cycle of injury, is brain saving, and helps regulate the stress response of the autonomic nervous system following a concussion. Structured sleep hygiene practices will help manage symptoms. This is done by developing a fixed bedtime, minimizing sleep-altering substances 2 hours before bed (caffeine, sugar, and alcohol) and removing all electronics from the bedroom.

Regulating sleep can also help with the second priority symptom following a concussion, which is headache. The massage therapist should begin by classifying headache symptoms as there are many types of headache, each requiring its own treatment. Many therapists assume that the majority of headaches are cervicogenic in nature. Cervicogenic headaches arise from the muscles, joints and/or ligaments of the cervical spine and are often recreated through movement of the neck, or palpation of the structures in the cervical spine. While these headaches are prominent there are also several other types of headaches commonly suffered post-concussion.

post-concussion syndrome

The massage therapist should have a thorough understanding of a patient’s headache history to better predict outcomes following injury. For example, if a patient has a prior history of migraines, they may experience an increase in frequency of migraine headache following a concussion. Tension headaches are the most common type of headache suffered during the acute phase of concussion. These headaches are driven by an imbalance in the autonomic nervous system as it tries to manage the metabolic changes occurring within the brain. Understanding that these headaches are driven by the nervous system rather than the soft tissue can help the massage therapist develop treatment plans that provide the patient with relief during these periods. Lastly, medication overuse headaches are common as patients struggle to manage symptoms. Overuse of medication can perpetuate symptoms without the patient’s knowledge. Patients should be questioned regarding the frequency of medication use. Those patients using medication for 15+ days out of the month should be referred to a physician to help progressively reduce medication use under medical guidance (International Headache Society, 2018). Lastly, the development or resurgence of mood disorder is also of high importance following a concussion. Understanding a patient’s mental health history prior to injury will help determine the need for a referral. Validated questionnaires can be used to help quantify often ambiguous symptoms of anxiety and/or depression. Those patients suffering from mental health concerns following a concussion should be referred back to a physician. While it’s important for the massage therapist to recognize when patients need help managing their mental health, it is not within their scope of practice to manage them directly. Resources that may help manage a patient’s mental health symptoms include, but are not isolated to: medication, cognitive behavioral therapy, sleep, and exercise. Those patients resorting to self-medicating are at increased risk of developing persistent mental health disorders and should take immediate action to avoid such an outcome. A concussion is often a scary diagnosis to receive. As research continues, it is becoming increasingly evident that active care programs are of benefit to patient progress. As is true for many medical conditions today, gone are the days of sitting and waiting. Scarier than the diagnosis itself are practitioners that provide advice to patients based on theory rather than evidence. As massage therapists are becoming an integral part of the patient management team, being at the forefront of the concussion research allows them to provide patients with the best opportunity for recovery.

Conor Collins is a Canadian massage therapist and has been practicing and teaching in Ontario for 13 years. As both a massage therapist and sports injury therapist, Conor provides a unique approach to clinical practice by combining disciplines of manual therapy and movement-based rehabilitation strategies.

Conor shares a special interest in concussion management. His passion is to help massage therapists better understand the nervous system and its role following a concussion injury. Conor’s goal is to help educate massage therapists worldwide and help them to become leaders in the concussion management space. Conor is the owner of a private multidisciplinary clinic just outside of Toronto, Ontario. While not in clinical practice, he is on faculty at Mohawk College in the massage therapy program. He is also the producer of the podcast, “The Concast”, where he discusses the manual therapy industry from an evidence-based perspective.

Throughout his career, Conor has had the pleasure of working major sporting events such as the Pan Am games, as well as managing athletes and consulting for national-level and club teams in both the NHL and NCAA.

Website - www.conorpcollins.com Facebook - www.facebook.com/conorpaulcollins Instagram - www.instagram.com/conorpaulcollins Podcast - www.anchor.fm/concast

Roman Chamomile

Roman chamomile flowers have a daisy like appearance. The plant is native to Europe and is mainly cultivated in England, Belgium, France and Hungary. The essential oil is pale yellow in colour, with a warm, sweet, hay-like, often dry odour, reminiscent of tea. This plant should not be confused with other chamomiles, as each has its own unique chemical composition. Latin Name: Anthemis Nobilis L./ Chamamaelum nobile (L.) All

Family: Asteraceae (Compositae) Method of Extraction: Steam distillation of the flowering tops of the plant. Historical Use: The Egyptians were said to use Roman chamomile for treating fevers whilst the Romans used it for intestinal or rheumatic issues. In herbal medicine, Roman chamomile flowers have long been associated with curing digestive disorders such as nausea and vomiting. For massage: Roman chamomile essential oil can be blended with a carrier oil such as sweet almond oil, however care should be taken with this essential oil and the correct dosage guidelines should be followed. The essential oil should only used for massage by qualified therapists. Therapeutic Properties: Roman chamomile essential oil has been proven to be highly antiinflammatory. It is also sedative, anxiolytic and anti microbial. A very gentle and versatile oil, it is most commonly used to treat the digestive and nervous systems, to alleviate PMS and reproductive issues, and can be used to help soothe sensitive skin. Other Uses: Roman chamomile essential oil can be used to treat insomnia, in combination with essential oils such as lavender or neroli. Its unique aroma lends itself to use in perfumery and beauty products as well. Contra-indications: None known, it is non-toxic, non-irritant, non-sensitising and suitable for use on children at the appropriate dilutions. Do not use in the rare case of allergy to Roman chamomile or other Asteraceae plant. Avoid using old or oxidised oils.

Oil profile written by Nana Mensah