Case report: Manual therapies promote resolution of persistent post-concussion symptoms in a 24-year-old athlete

Abstract

This case report illustrates the treatment outcomes of a collegiate athlete presenting with an 18-month history of post-concussion syndrome who received a series of mixed manual therapies in isolation of other therapy. Persistent symptoms were self-reported as debilitating, contributing to self-removal from participation in school, work, and leisure activities. Patient and parent interviews captured the history of multiple concussions and other sports-related injuries. Neurological screening and activities of daily living were baseline measured. Post-Concussion Symptom Checklist and Headache Impact Test-6™ were utilized to track symptom severity. Treatments applied included craniosacral therapy, manual lymphatic drainage, and glymphatic techniques. Eleven treatment sessions were administered over 3 months. Results indicated restoration of oxygen saturation, normalized pupil reactivity, and satisfactory sleep. Post-concussion syndrome symptom severity was reduced by 87% as reflected by accumulative Post-Concussion Symptom Checklist scores. Relief from chronic headaches was achieved, reflected by Headache Impact Test-6 scores. Restoration of mood and quality of life were reported. A 6-month follow-up revealed symptoms remained abated with full re-engagement of daily activities. The author hypothesized that post-concussion syndrome symptoms were related to compression of craniosacral system structures and lymphatic fluid stagnation that contributed to head pressure pain, severe sleep deprivation, and multiple neurological and psychological symptoms. Positive outcomes over a relatively short period of time without adverse effects suggest these therapies may offer viable options for the treatment of post-concussion syndrome.

Introduction

Serious awareness over the past decade of the short- and long-term effects of traumatic head trauma leading to concussion has prompted rigorous diagnostic and clinical management endeavors.^1,2 Sources report the number of sports-related concussions receiving medical attention in the United States ranged between 1.6 million and 3.8 million annually.^3,4 Persistent symptoms following concussions may not reflect a single pathophysiological entity and likely describes individualized patterns of non-specific, post-traumatic symptoms that may be linked to coexisting and/or confounding issues.^1,5 Subtypes of post-concussion syndrome (PCS) are now recognized by physiological, cervicogenic, and neuropsychological manifestations.^2,4,6–9

A fluid model: glymphatic and meningeal lymphatic systems

The existence of a cerebral fluid-exchange system (different than blood vessels) has been long debated but new discoveries have intensified research into fluid dynamics within the brain parenchyma.¹⁰ Glial cells have been shown to create a possible architectural system among the microvasculature which appears to match blood flow with neuronal firing.¹¹ Pathways formed by glial cells and endothelial walls of penetrating blood vessels have been suggested to serve as a physiological cleansing mechanism called the “glymphatic system.”^10,12,13 These pathways appear to form perivascular channels by astroglia end-feet where monitoring and active clearing of the neuronal terrain may occur.^14–16 Furthermore, it is theorized that this cellular transportation network also serves to distribute nutritional compounds and neuromodulators.¹⁵ Brain-wide perivascular pathways, believed to facilitate cerebrospinal fluid (CSF) flow through the parenchyma and the movement of interstitial solutes, have been captured by contrast-enhanced magnetic resonance imaging (MRI) scan.¹³ The theoretical function then of this proposed glymphatic system serves to support perfusion of CSF and interstitial fluids as a means of pseudo-lymphatic function of the nervous system, elucidating a possible mechanism of how the brain cleans itself through elimination of soluble proteins and metabolites.^{10,13,17–19}

However, there are also proponents who argue a glymphatic system as proposed needs to be re-evaluated, accounting for more specifics to cerebrovascular fluid transport.²⁰ Regardless, there is within the brain a mechanism that moves fluids through a cleansing process, shown to be active during restorative sleep and rather inactive during wakefulness.¹⁵

Lymphatic system discovery

In addition, a recent identification of lymphatic projections into meningeal membranes within the cranial vault suggests a functional proximity and/or connection between the brain pseudo-lymphatic and the whole-body lymphatic network.^21,22 Furthermore, lymphatic vessels were discovered lining the dura sinuses of the meninges and in turn have been shown to carry both fluid and immune cells from the CSF, connecting to deep cervical lymph nodes and into the peripheral venous return system.^17,21 Magnetic resonance images provide supporting evidence of glymphatic drainage from human brain to cervical lymph nodes.²³ Other emerging data from both animal models and human studies support this theory that the brain fluid-exchange and body lymphatics system share an intimacy and work together for homeostasis, though we are only at the beginning of understanding how this works.^12,22–24

Structural impact and pathology of fluid transport systems

Chronic symptoms associated with PCS have been theorized to be a result of “gliopathy,” a dysregulation of glial function and drainage in the central and peripheral nervous system.²⁵ Murine models of glial and glymphatic system function following head injury has begun to shed light on the effect of brain trauma upon astrocytes and the effect upon intracranial edema and resolution.^26,27 Impaired functioning of the meningeal lymphatic vessels has been theorized to accelerate the accumulation of toxic amyloid beta protein in the brain parenchyma.²⁸

Upledger illuminated and confirmed the existence of the function and physiology of the craniosacral system (meninges housing the brain, spinal cord, and cerebral spinal fluids).^29,30 Bodywork professionals are guided by the premise that structural compressions such as osseous and/or fascial restrictions can impede fluid movement and exchange, leading to an array of symptomology.^30–34 It is understood that vertebral bone compression into spinal cord space will create various neurological symptoms theorized, in part, by the obstruction of cerebral spinal fluid.^35,36 One animal model has demonstrated that blocking the normal physiologic cerebral spinal fluid drainage sites in the cribriform plate increases resting intracranial pressure.³⁷

Manual therapies for the central nervous system

Craniosacral therapy

Manual therapies such as craniosacral therapy (CST) emerged from the science that explored the physiological motion of the central nervous system.^30,38,39 The core intent of CST is the theoretic interactions with connective tissue at osseous sites and, using a sustained low-force stretch, elicit a softening or relaxation response of soft tissues. In turn, a positive effect upon fluid exchange and the body’s self-correcting actions can occur.³⁰ Studies have illuminated the natural motion of cranial bones, organ movement, and fluid exchange, depicting and measuring the dynamic nature of the physiology of the craniosacral system.^33,40,41 Based on observations of one animal study on the structural effects of applying CST, no discernible length difference was found at cranial bone sutures. However, this study concluded that perhaps a different biological basis for such treatment could be at play.⁴² In a now classic study, changes in the length of the intracranial falx cerebri membrane were demonstrated with the application of CST on an embalmed cadaver skull. Recorded relative change in tissue length ranged between .28 and 1.44 mm at different sites of the membrane with different CST techniques applied. This study offers some validation that sustained, gentle, and external forces have a measurable effect upon the intracranial membrane system.⁴³

Manual lymphatic drainage

Various methods of manual lymphatic drainage (LD) exist, but a contemporary version aligns with discoveries of anatomical pathways and lymph tissue mapping, the depths of lymph flow throughout the body, and using specific rhythms in fluid evacuation.⁴⁴ Hand pressure used in the Chikly method is extremely light, matching the tissue dynamics unique to each patient, and only enough to stimulate the movement of fluid to enhance flow through specific lymph pathways. This is theorized to activate contractions of the functional unit of lymph vessels, called lymphangions, which assist fluid exchange without increasing blood filtration or lymph node collapse from too great of manually imposed pressure. There exists extensive innervation from the autonomic nervous system of these contractile units of the lymphatic system and the conceptualization of the movement of lymphatic fluids.^45,46 LD is believed to influence the whole-body system through gentle manual evacuation, creating a system-wide siphoning effect to enhance fluid exchange in multiple systems.⁴⁵

The use of manual LD by qualified professionals is a treatment option for lymphedema, sports injuries, and fibromyalgia.^44,47–49 Manual LD was first suggested as a specific treatment of post-contusion and PCS for its anti-edematous effects.⁵⁰ The evolution and addition of glymphatic treatment methods have only recently emerged and are based on the practical application of the combination of methods such as CST, LD, and non-invasive intention of therapeutic touch.^16,45

Existing studies on manual therapies for concussions and brain injuries

In clinical application, CST has been shown to have positive effect for a number of chronic syndromes that parallel PCS subtypes, but the body of data is limited to observational designs and low to moderate quality of randomized controlled methods.^51,52 The credibility of a sham control protocol for future study of CST was reported.⁵³ A recent study of former pro-football players with PCS showed statistically greater improvements in range of motion, pain, sleep, and cognitive function after a series of combined manual therapies.⁵⁴ A pilot study of 10 active military members had a reduction of symptoms of post-traumatic stress and head injury through the application of mixed light touch manual therapies.⁵⁵ A single blind case series measured clinical outcomes of soldiers with combat-related head injuries receiving CST and other manipulation techniques. Results showed statistically greater improvements in objective and subjective measurements pre- and post-treatment.⁵⁶ Case studies report positive outcomes of varied uses of manual therapies for the treatment of PCS.^57,58 One case of an athlete with PCS compared brain scans before and after 15 isolated CST treatments using quantitative electroencephalogram comparing symptom reduction to changes in neurological activity.⁵⁹

Headaches

Headaches are a common symptom of concussion and PCS.^7,60 CST and other manual methods have been shown to have positive effect in the treatment of headaches, migraines, and trigeminal neuralgia.^61–64

Sleep

Sleep has a critical function in ensuring metabolic homeostasis and clearance of metabolites and is but one important way for the nervous system to heal from trauma and injury.^13,18,65 The glymphatic system functions mainly during sleep and is largely disengaged during wakefulness. Sleep debt and a glymphatic system disruption have been proposed as a mediator of brain trauma, chronic traumatic encephalopathy, and other neurological disorders.^15,66,67

Concussion symptom assessments

Subjective data —from patient

Self-reporting symptom scales are vital for assisting in the medical management of PCS. Several tracking tools hold substantial overlap with one another in capturing various pains and neurological infirmaries, functional impairment, and quality of life.^68–70 Although only some have been empirically studied, clinical users need to be aware that these scales have evolved rather than being developed scientifically.⁷¹ Nonetheless, patient reports of subjective levels of pain, sensory, and psychological symptoms are crucial to aid in the clinical search for effective treatments.

Post-Concussion Symptom Checklist (PCSC)

The PCSC was utilized to track outcomes and re-administered periodically throughout the treatment process with care given to avoid coaching the patient on symptom manifestations.^70,72 Symptoms were also tracked through open-ended self-reporting by the patient at the onset of each session if he wished to share them.

Headache Impact Test™ (HIT-6)

The HIT-6 was designed to screen and monitor patients’ severity of headache pain and the impact on function and quality of life.⁷³ Utilizing six items with a severity rating scale, the HIT-6 has been shown to be a reliable and valid tool for discriminating the effect of headache on daily living.^74,75 A possible point range of 36–78 reflects the severity of impact that headaches are interfering with daily quality of life and function. The HIT-6 was chosen for this particular patient to track headache symptoms which was also a chief complaint, second only to sleep disturbances.

Measurement of sleep

Sleep function was tracked through a sleep diary and the patient’s perception of restfulness and daily energy.

Subjective data —from the clinician

Neurological screenings occurred each session per standard of care, including pupil and oculomotor status, balance reactions, and general cognitive assessments conducted through observations of behavior. Palpation findings from full body assessment of musculoskeletal, fascia and fluid fields were conducted at the beginning of each treatment session. Inquiry about mood and stress were made at the beginning of each session.

Objective data

Quantifiable neurological soft sign and biomarkers not captured on the PCSC included fixed and dilated pupils, oxygen saturation, and frequency of urination and thirst.

Case report

The subject, a 24-year-old male, presented with an 18-month history of persistent neurological and behavioral symptoms reportedly related to one sports-induced concussion. Onset was in October 2017, following a head injury while playing in a collegiate-level sport. He reported being screened by an athletic trainer and having a follow-up medical assessment. No hospitalization was required. Prolonged rest was prescribed and adhered to for several months. An eventual referral to a local academic-medicine concussion clinic was made several months post-injury due to escalation of unresolved symptoms where psychological services addressing anxiety and depression and medications for pain and concentration were prescribed. Medications reported on patient intake included Prozac, Xanax, and Adderall. He reported his ability to focus on job tasks improved by the Adderall but the medications generally worsened “brain fog” and memory. He also participated in a physical therapy program for vestibular rehabilitation. Symptoms persisted to the point of full debilitation by sleep deprivation, increasing dizziness, sensory overload, and brain fatigue. Suicidal ideation prompted his parents to seek other recommendations and services.

In the interview with the patient and one of his parents, it was discovered that he sustained a total of six sports-related concussions dating back several years. History also included several orthopedic injuries long since healed (fractures to a foot and nose, and several bone contusions). The patient affirmed that a whiplash occurred with the most recent concussion and had originally sought chiropractic care for neck pain post-injury.

Since symptoms began to intensify, he was forced to take a medical leave from attending school and working a job that required much traveling. He stated he could perform job duties, enjoyed them, and felt capable of the job. However, the sensory intolerances created significant anxiety and began to reduce his confidence in his job performance. His tolerance and engagement in favorite activities were at 10% of normal participation level. He frequently isolated himself to cope with the sensory overload which added to a sense of helplessness.

Based upon client report and clinical observations, functional problems were noted on intake (see Figure 1). Initial clinical findings were also noted (see Figure 2).

Figure 1.

Post-concussion symptoms (18 month duration) reported on intake questionnaire by patient and in personal and parent interviews.

Figure 2.

Initial clinical findings.

Treatment methods employed included the following: (incorporated into each session as the need arose).

• Manual LD techniques (Chikly).⁴⁵

• CST techniques (Upledger).³⁰

• Glial and Glymphatic system techniques (Wanveer).¹⁶

Goals for series of therapy encounters

• Reduce and eliminate stagnant and congested edema of spine, neck, and head.

• Soft tissue mobilization and fascial release methods to increase general soft tissue flexibility and subtleness through body to reduce sympathetic tone (through CST).

• Facilitate exchange of fluid through all body fluid systems; reduce interstitial congestion to promote healing and self-correction of nervous system (through LD).

• Neurological rehabilitation strategies to reduce and adapt to sensory challenges; environmental structuring. (These methods were not required due to the speed in which positive changes were experienced and observed with manual therapies.)

• Achieve freedom from pain and neurological dysfunction, restore/raise quality of life.

• Community and work re-entry, adaptations, and modifications assistance where needed.

• Patient and family education on the concepts of manual therapies.

• Client stated just one personal goal: “I just want to be able to sleep.”

Treatment process

Treatment was conducted in isolation of any other (new) therapy over the course of three months. The patient participated in eleven, 1-h sessions. Scheduling sessions were recommended at 2–3 times per week initially. Following the first session, he requested daily treatment but was advised to allow his system to acclimate and integrate treatment effects. The first four sessions were scheduled 3 days apart. After the fourth session, scheduling was left to his discretion. Six more appointments were scheduled with 1 week spacing, and the eleventh session was as a follow-up at the patient’s discretion 5 weeks later. Each session was an improvisational process of applying the various manual therapies and techniques, based upon whole-body assessment of primary and secondary structural and fluid findings.

Results and treatment outcomes

Quantitative data were collected through self-reporting of severity of symptoms using the PCSC, the HIT-6, and clinical observations. Sessions began most often with an invitation for him to report whatever symptom(s) felt most pressing. Quality of life measurements were self-reporting of sleep function, brain fog, ability to “get through the day,” ability to tolerate sensory aspects of daily events, and endurance for mental and physical activities. All were recorded in the daily notes. A total of five recordings of the PCSC and three recordings of the HIT-6 were captured over the course of the treatment series (see Figure 3). Based upon both verbal responses from the patient as well as observation, some particular treatment techniques demonstrated a direct correlation to a reduction of a specific symptom (see Figure 4).

Figure 3.

Self-reported changes of persistent concussion symptoms related to treatment intervention; measured through symptom tracking methods.

Figure 4.

Based upon patient’s verbal responses and direct observation in treatment, several techniques had a direct correlation to a reduction of specific symptoms.

Sleep was restored following the first treatment as he reported sleeping 12 h each night between session one and two. Sleep continued to remain at normalized levels throughout the treatment process.

Sessions were not based upon following specific protocol sequence. A narrative summary of this improvisational and experiential treatment process is reflected in a summary of the daily notes (see Figure 5).

Figure 5.

Treatment Progression Depicted through Daily Notes. Abbreviated daily notes to reflect the full therapeutic process of applying CST and LD to treat symptoms of concussion. See KEY for term definitions.

Six month follow-up

A 6-month follow-up (via telephone conversation) revealed sustained abatement of PCS symptoms and the patient resumed educational pursuits and gainful employment. His parents recommended that he continue to receive maintenance therapy but he voiced concerned over his mounting financial debt. He denied that symptoms were interfering with daily activities and quality of life. The patient’s perspective about these therapies was highly positive.

Discussion

This article offers a hypothesis that persistent symptoms of PCS could be, in part, a result of compromised glymphatic and lymphatic pathway flow stemming from restrictions of movement and balanced position of osseous and soft tissue structures. The theoretical constructs of CST suggest when fascial membranes such as the dura and other meningeal layers and/or cranial plates and vertebral column may be in a compressive state, leading to neurological and/or behavioral symptoms.^30,32,76 The theoretical constructs of LD is that gentle, manual evacuation of lymphatic channels following anatomical mapping enhances a whole-body fluid exchange and removal of cellular wastes between interconnecting fluid systems.^45,49

Only through whole-body palpation assessment was the first clinical discoveries made in this patient. Asymmetrical rib cage alignment, with sub-optimal breath expansion and lowered oxygen saturation, was subjectively assessed and CST techniques were immediately employed. The second discovery was persistent edema through anterior and lateral cervical chains, over the expanse of scalp lymphatics, and engorged in bilateral occipital nodes at the cranial base. It is a reasonable assumption that edema may have occurred at the time of injury but after 18 months, edema and interstitial fluid stagnation would be expected to have resolved. That was not the case for this athlete. Palpation for (chronic) edema is a skill set learned through specific LD training methods.

Sleep was the first of the chronic symptoms to demonstrate an effect from treatment, after just one, 1-h treatment session. It could be suggested that fluid stagnation in and around the central nervous system contributed to the adverse head pressure pain with impact on the lack of restorative sleep (as surmised by the patient’s insights). It could be suggested that quality of breathing function may also have had a negative effect upon sleep. It is apparent through the stream of daily notes that the first treatment in and around the thoracic body and rib cage (consisting of fascia mobilization following CST methods) produced immediate elevation in oxygen saturation. It was also immediately apparent that LD through the central spinal lymph node confluences and pathways produced an immediate response of head pressure relief. Sleep resolved to satisfactory levels for the patient and remained so for the remainder of the treatment series, and at the 6-month follow-up.

Other neurological symptoms resolved at different, but steady rates, as reflected on the periodic scoring of the PCSC. To avoid or minimize effects of coaching or influencing the patient on symptom reporting, freely expressed symptom declarations were documented prior to the administration of repeated PCSC scoring. It is with a high rate of certainty that the PCSC yielded an accurate expression of the patient’s self-reported experiences in symptom status through the treatment process.

Therapeutic touch and emotional support are aspects of most forms of manual therapies. It is possible that any placebo or autonomic calming effect of therapeutic touch contributed to the reduction of symptoms. However, resolution of certain chronic symptoms did correlate with the application of only specific treatment techniques (see Figure 4). Mood, cognitive function, and emotional well-being improved and the patient attributed this to reduction and elimination of head pain, brain fatigue, and sensory sensitivities. Quality of life improved and he returned to his occupational tasks of completing college and finding a less stressful, yet meaningful, job.

The literature supports interventions for PCS which include psychological, cervical, and vestibular rehabilitation.⁵ The differential methods of CST and LD as distinct manual therapies have yet to be fully explored as options for PCS, though emerging studies indicate CST being used clinically with functional PCS subtypes. One contraindication for CST is not to apply during acute stages of brain injury when increased intracranial pressure is present.³⁰ Contraindications for LD have been cited and include acute infection or inflammatory disease process, thrombosis or phlebitis, acute hemorrhage, active malignant ailments, and acute heart problems as LD increases cardiac load.^44,45

Future study could possibly isolate the impact CST and LD modalities have upon sleep in PCS. Research of the fluid exchange models of the nervous system could explore possible correlations to persistent symptoms of PCS. Furthermore, efficacy studies into therapies such as CST and LD might be aided by advancements of proving and measuring the exchange of fluids where glymphatic and lymphatic structures merge.

Conclusions

This case report reflects one collegiate athlete’s unique constellation of PCS and the self-reported reduction of persistent symptoms through the experiential process of CST and LD intervention. There is little published evidence of the efficacy of CST and/or LD on the symptoms of PCS, though both have been utilized in clinics internationally for over 3 decades. Rest allowance and other therapy interventions had been previously trialed for 18 months, though no concussion symptom tracking was completed or available from previous records for comparative purposes. Previous pharmacologic treatment and vestibular rehabilitation for this patient were self-reported to have reduced symptoms of attention deficits and balance in climbing stairs, respectively. Other psychology and physical medicine endeavors had been trialed over the year and a half, and per his declaration, “Did not help heal me. Medications only helped me get through the work day; they did not take away the symptoms.”

The author, an occupational therapist with 20 years of experience applying CST and LD in clinical practice, admits to a strong inherent bias. The strength of this case study, however, is that treatment was provided in isolation of any intervention other than his established medication usage. It could be said that placebo effect had been controlled for where specific treatment techniques clearly resolved some specific symptoms, but not all. Other symptoms resolved over time and may reflect effects of the restoration of sleep and elevation of mood. Though generalization of the findings in this case cannot be applied to the greater population of patients with concussions and brain injuries, this case does suggest that CST and LD are valuable treatment options for PCS and worthy of future study.