ABSTRACT
Objective: To describe individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment as part of multidisciplinary concussion care. A secondary objective is to report on how participants describe the outcomes of neck treatmentMethods: Long-term follow-up for a subgroup of participants in a prospective case series (n = 11). Data were collected at initial assessment, completion of neck treatment, 6 and 12 months including standard questionnaires (Rivermead post-concussion symptoms questionnaire, neck disability index, dizziness handicap inventory); patient-reported measures of headache, dizziness and neck pain and participant descriptions of the effects of neck treatmentResults: Grouped measures of post-concussion symptoms were further improved or sustained at 6 and 12 months. Ten of the 11 participants reported neck treatment as a beneficial part of their care and described the effects on the neck, multiple symptoms and their overall recovery. However, seven participants experienced recurrent headache, neck pain or dizziness at 6- or 12-month follow-up.Conclusion: Long-term follow-up of individuals receiving neck treatment shows improvement across a range of patient reported outcomes, yet highlights frequent recurrence of symptoms. Neck treatment can play a valuable role in people’s recovery that extends beyond local effects on the neck.
KEYWORDS: Brain concussion, cervical spine, physiotherapy
Introduction
Concussion is increasingly recognized as a health priority internationally, with the potential for long-term impact on people’s health and wellbeing [1,2]. A concussion event can lead to dysfunction in a wide range of systems that are challenging for clinicians to identify and manage. Current definitions describe concussion as a brain injury [3], yet numerous publications highlight the potential for a concussion to affect the neck as well as underlying vestibular, oculomotor and visual systems [4–8] while also having a wider psychosocial impact [2,9]. This complexity is reflected in recommended practices for the assessment and management of concussion [8,10]. However, the long-term effects of many recommendations, such as neck treatment where indicated, are unclear.
The potential for the neck to contribute to symptoms following a concussion event is widely accepted, yet the frequency and nature of neck involvement in concussion injuries has required clarification. Recent evidence showed that in a multidisciplinary service for people with persistent symptoms post-concussion, neck treatment was recommended in over half (54%) of cases [11]. This highlights the frequency of concurrent neck injury in those with persistent symptoms. The nature of concurrent neck injury has been described as involving the upper cervical spine [6,12], and identified with common physical examination techniques [6,8,12–14]. The effects of neck treatment as part of post-concussion management are not well understood. Evidence indicates that the combination of neck and vestibulo-ocular rehabilitation can decrease time to medical clearance to return to sport in people with concussion [15], yet the contribution of neck treatment remains unclear. Emerging research suggests that neck treatment aids concussion recovery [6,10,12,16–18], with potential to affect symptoms of neck pain, headaches and dizziness [6,10]. This is supported by randomized controlled trials demonstrating the benefits of physical therapy treatment in neck pain [19], cervicogenic headaches [20] and cervicogenic dizziness [21,22].
Long-term outcomes from neck treatment in concussion have received little attention. Neck pain is understood to be episodic, recurrent and persistent [23] highlighting the value of longer-term follow-up to better appreciate the outcomes of neck-related treatment. Beneficial effects of manual neck treatment on neck pain, cervicogenic headache and dizziness have been shown to be sustained at 12-month follow-up [20,22], indicating potential utility for people with similar symptoms post-concussion. Understanding outcomes for symptoms that are potentially episodic and recurrent is challenging with grouped data, where overall improvements in outcome measures can mask individual variation. In this relatively emerging field of research, an examination of the long-term outcomes of neck treatment at an individual level could give valuable insight into the impact it may have on people’s recovery from persistent symptoms post-concussion.
The purpose of this report is to describe the individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment within a multidisciplinary concussion service. A secondary aim is to report how participants describe the outcomes of neck treatment.
Methods
This study was conducted within a multidisciplinary concussion service, and represents further analysis and long-term follow-up of a subgroup receiving neck-treatment from a published case series [6]. Ethical approval for this research was received from the University of Otago Human Ethics Committee (H16/089) and Accident Compensation Corporation Ethics Committee (#314). This study was prospectively registered with the Australian New Zealand Clinical Trials Register, registration number ACTRN12616001183471.
Clinical setting
Participants were prospectively recruited from two providers of a multidisciplinary concussion service. This service is nationally funded, and provided by local contract holders nationwide. It is designed to provide further assessment and care for people with persistent symptoms post-concussion, who are at risk of a prolonged recovery. The service accepts referrals from medical practitioners (most commonly general practitioners). The concussion service provides a multidisciplinary assessment to confirm the diagnosis, evaluate the source(s) of symptoms, consider any barriers to recovery and develop an individual management plan. All patients in the concussion service receive basic support from a key worker (an occupational therapist or physical therapist) including education about concussion, advice on how to manage a graduated return to daily activities and case management. Other treatment varies based on the assessment findings, such as vestibular and/or oculomotor rehabilitation, neck treatment, return to work planning, medical management etc.
Participants
Participants received neck assessment and subsequent treatment from one of the three experienced physical therapists with postgraduate training in orthopedic manual therapy. A detailed description of the assessment findings and initial response to treatment has been published [6].
Selection criteria
Key workers in the concussion service screened consecutive patients for eligibility. Patients were eligible to participate if they had persistent (>10 days) headaches, dizziness and/or neck pain; a history suggesting the neck might contribute to their symptoms and attended neck assessment and treatment with a study physical therapist. Patients were excluded if they had contraindications to manual neck assessment (e.g. fracture, inflammatory joint conditions and infection), other significant neurological conditions, or were under 16 years. All participants provided written informed consent and their rights were protected.
Data collection
Data were collected at initial assessment, completion of neck treatment, and 6 and 12 months from initial assessment. At initial assessment and on completion of neck treatment data collected included demographic data, the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Neck Disability Index (NDI), the Dizziness Handicap Inventory (DHI), patient-reported findings and physical assessment using a standard assessment form [6]. Follow-up at 6 and 12 months involved a phone meeting with participants where the researcher (EK) followed a standardized data collection form (Appendix A), and asked participants to complete and return the RPQ, NDI and DHI questionnaires. Data collected were the same as previous time points with the exception of the physical examination and additional questions, in particular: If the participant overall considered neck treatment beneficial; and what the main outcomes/effects of neck treatment were (if any). The researcher recorded responses as close to verbatim as possible.
The RPQ measures the severity of a range of post-concussion symptoms [24], and is recommended as a core measure of traumatic-brain-injury-related symptoms [25]. Scores ≥2 indicate that the symptom has increased since the concussion injury. In addition, the RPQ-3 and RPQ-13 subscales are reported [26]. The NDI and DHI measure the impact of neck disability [27], and dizziness [28] on daily activities. Subjective and physical examination findings were recorded on a standard assessment sheet developed in collaboration with the clinicians and reflecting their routine clinical practice, with attention to headaches, dizziness and neck pain.
Clinicians provided treatment to match patient impairments and preferences without influence from the research team. Upon completion, patient notes from study physical therapists were reviewed and techniques used broadly classified as selective manual therapy (including various types of joint mobilization), specific exercises (e.g. posture, retraction, craniocervical control) and/or soft-tissue techniques. Further details were retrieved from the multidisciplinary concussion service reports, including details of comorbidities and other treatment received. Where the multidisciplinary team recommended and included specific follow-up treatment, this was recorded as ‘other treatment received’. Adverse effects from treatment were monitored.
Data analysis
In line with recommendations for case series design [29,30], the majority of results are presented individually as descriptive statistics – frequency (percentage) for categorical data or mean (standard deviation) for continuous data. Median values are presented where appropriate.
The documented responses to the question ‘What were the main outcomes of neck treatment?’ at 6 and 12 months were analyzed using a general inductive approach [31], to establish major themes and integrate these into a model representing the outcomes/effects experienced.
Results
After inclusion/exclusion, 11 participants with persistent symptoms post-concussion received neck assessment and treatment with the study physical therapists (Figure 1). A summary of participant demographic information is shown in Table 1. For a more detailed summary of assessment findings refer to participants 1–11 in a previous report [6]. At 6 and 12-month follow-up all 11 participants were followed up by phone. At 6 months, two participants did not send in the completed questionnaires, while at 12 months, one participant did not send in the completed questionnaires.
Figure 1.
Participant flowchart
Table 1.
Demographic, injury and treatment characteristics (n = 11)
| ID | Age | Gender | Ethnicity | Weeks since injury | Cause of concussion | Past history | Type of neck treatment | Neck treatment sessions | Treatment timespan (weeks) | Comorbidities identified | Other treatment received | Overlap in neck and vestibulo-ocular treatment |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 19 | Female | NZ European | 4 | Exposure to mechanical force | Nil of note | MT | 4 | 1 | Vestibular, balance, sleep, fatigue | Vestibular rehab, Neuropsychology screen and advice, OT support and education | No overlap |
| 2 | 26 | Male | NZ European | 4 | Exposure to mechanical force | Nil of note | MT | 5 | 2 | Oculomotor, balance, vestibular, fatigue | Vision rehab, vestibular rehab | No overlap |
| 3 | 21 | Male | Other – European | 4 | Exposure to mechanical force | Nil of note | MT, specific ex | 4 | 3 | Oculomotor, vestibular, motion sensitivity, postural intolerance, fatigue | OT support (primarily return to work), vestibular rehab | 2 sessions |
| 4 | 40 | Female | NZ European | 4 | Fall | Nil of note | MT, specific ex | 6 | 5 | Fatigue, balance, vestibular | Vestibular rehab, OT support (primarily return to work) | 2 sessions |
| 5 | 31 | Female | Other – European | 2 | Exposure to mechanical force | Migraines. Previous concussion 2 months ago. | MT, specific ex, soft tissue | 6 | 4 | Vestibular, oculomotor, blurred vision | Vestibular rehab, OT support | ≥3 sessions |
| 6 | 46 | Female | NZ European | 5 | Fall | Nil of note | MT | 5 | 2 | Oculomotor, vestibular | Vestibular rehab | No overlap |
| 7 | 66 | Female | NZ European | 42 | Transport accident | Multiple previous concussions. Previous neck injury 1 y ago. | MT, specific ex | 5 | 3 | Oculomotor, vestibular, fatigue | Vestibular rehab, increasing physical activity | ≥3 sessions |
| 8 | 23 | Male | NZ European | 10 | Assault | Nil of note | MT, specific ex | 3 | 1 | Vestibular, fatigue | Vestibular rehab | 1 session |
| 9 | 44 | Female | NZ European | 2 | Exposure to mechanical force | Nil of note | Soft tissue, specific ex | 3 | 2 | Vestibular | Vestibular rehab | 2 sessions |
| 10 | 62 | Male | Other – Irish | 3 | Transport accident | Nil of note | MT, specific ex | 3 | 3 | Balance, fractured finger requiring surgery | OT support, vestibular rehab | 1 session |
| 11 | 19 | Female | NZ European | 5 | Exposure to mechanical force | Migraines | MT, specific ex, soft tissue | 5 | 9 | Oculomotor, vestibular, background psychological | Vestibular rehab | ≥3 sessions |
| Mean (SD)/% | 36 (17) years |
64% female 36% male |
73% NZ European 27% Other |
8 (12) weeks Median = 4 |
4.5 (1.1) sessions Median = 5 |
3.2 (2.3) weeks Median = 3 |
ID = identifier; NZ = New Zealand; OT = Occupational therapy; MT = Manual therapy; Specific ex = Specific exercises (e.g. posture, control); Soft tissue = Soft-tissue techniques
Grouped measures of post-concussion symptoms improved at follow-up, and were further improved or sustained at 6- and 12-month follow-up (Table 2). At 6-month follow-up, improvements are seen in the number of participants reporting symptoms, although RPQ scores flatten and are more variable (Table 2). From 6- to 12-month follow-up progress is more mixed: a small improvement in mean RPQ scores is seen, yet an increasing proportion of participants with four or more scores ≥2 (Table 2). The number of people reporting headaches, neck pain and dizziness slightly increases (Table 2). Across a range of measures, headaches, neck pain and dizziness reported at 12 months are improved compared to baseline measures, but not always improved compared to post-neck-treatment (Table 3). A further breakdown of RPQ by symptom for participants over time is shown in Appendix B.
Table 2.
Patient-reported outcomes for participants over time (n = 11)
| Baseline | Post-neck-treatment | 6-month follow-up | 12-month follow-up | |
|---|---|---|---|---|
|
Rivermead post-concussion symptoms questionnaire* (0–64 scale) RPQ-3 (0–12 scale) RPQ-13 (0–52 scale) Participants with four or more items >2 |
35.4 (7.2) 6.9 (2.6) 28.5 (5.5) 11 (100%) |
14.1 (8.7) 2.2 (1.5) 11.9 (7.5) 4 (36%) |
14.1 (10.7) 1.9 (1.5) 12.2 (9.3) 5 (56%) |
10.5 (8.4) 2.0 (2.3) 8.5 (6.6) 6 (60%) |
|
Neck pain present Numeric pain rating scale (0–10 scale) Neck Disability Index (0–100 scale) |
10 (91%) Yes 3.5 (1.5) 32.9 (7.3) |
4 (36%) Yes 2.1 (1.4) 12.5 (7.5) |
2 (18%) Yes 4.0 (0.0) 22.0 (17.0) |
3 (27%) Yes 3.9 (0.2) 18.0 (6.9) |
|
Dizziness present Frequency (0–5 scale) Duration (0–5 scale) Severity (0–10 scale) Dizziness Handicap Inventory† Total score (0–100 scale) Function (0–36 scale) Emotion (0–36 scale) Physical (0–28 scale) |
10 (91%) Yes 4.5 (0.7), Median 5 1.8 (1.0), Median 1.5 4.7 (2.0) 51.8 (15.4) 21.0 (8.7) 14.6 (7.1) 16.2 (3.5) |
4 (36%) Yes 4.8 (0.5), Median 5 1.0 (0.0), Median 1 4.3 (1.9) 38.0 (13.4) 17.0 (6.2) 6.5 (3.8) 14.5 (5.3) |
2 (18%) Yes 3.0 (1.4), Median 3 2.5 (0.7), Median 2.5 4.5 (0.7) 16 6 4 6 |
4 (36%) Yes 2.5 (1.0), Median 2 3.0 (2.3, Median 3 5.3 (1.9) 26.0 (17.1) 11.3 (6.1) 5.3 (5.0) 9.3 (9.2) |
|
Headache present Provoked by neck movement/position? Yes No Unsure Sidedness Bilateral Unilateral with side shift Unilateral without side shift Frequency (headache days per week) Duration (hours) Severity (0–10 scale) |
11 (100%) Yes 4 3 4 7 1 3 5.8 (2.1) 7.6 (10.6) 4.3 (2.2) |
6 (55%) Yes 0 4 2 3 2 1 3.8 (2.5) 0.6 (0.7) 2.8 (1.2) |
2 (18%) Yes 0 0 2 2 0 0 1.5 (2.1) 13.0 (15.6) 3.8 (1.8) |
2 (18%) Yes 1 0 1 0 0 1 3.5 (3.5) 3.5 (0.7) 2.5 (2.1) |
| Physiotherapist considered neck Rx beneficial |
- |
11 Yes |
- |
- |
| Client considered neck Rx beneficial | - | - | 10 Yes 1 Unsure |
10 Yes 1 Unsure |
RPQ = Rivermead post-concussion symptoms questionnaire; Rx = Treatment
* Rivermead post-concussion symptoms questionnaire data were missing for two participants at 6-month follow-up & one participant at 12-month follow-up
† Dizziness handicap inventory data were missing for one participant at both 6- and 12-month follow-up
Table 3.
Patient-reported outcomes for individual participants over time (n = 11)
| |
Baseline |
Post neck treatment |
6-month follow-up |
12-month follow-up |
||||||||
| ID |
RPQ (0–64) |
Number items ≥2 |
RPQ (0–64) |
Number items ≥2 |
RPQ (0–64) |
Number items ≥2 |
RPQ (0–64) |
Number items ≥2 |
||||
| 1 | 25 | 10 | 7 | 1 | 2 | 0 | 5 | 0 | ||||
| 2 | 35 | 12 | 18 | 4 | Missing | 12 | 4 | |||||
| 3 | 36 | 13 | 16 | 3 | 26 | 11 | 17 | 5 | ||||
| 4 | 42 | 14 | 9 | 1 | 21 | 6 | 18 | 4 | ||||
| 5 | 42 | 12 | 30 | 11 | 15 | 4 | 19 | 4 | ||||
| 6 | 31 | 12 | 20 | 6 | 26 | 9 | 10 | 5 | ||||
| 7 | 42 | 15 | 8 | 0 | 19 | 9 | 22 | 5 | ||||
| 8 | 29 | 11 | 9 | 1 | 18 | 2 | 0 | 0 | ||||
| 9 | 26 | 9 | 0 | 0 | 0 | 0 | 0 | 0 | ||||
| 10 | 34 | 11 | 13 | 2 | 0 | 0 | 2 | 0 | ||||
| 11 |
47 |
15 |
25 |
10 |
Missing |
Missing |
||||||
| Neck pain and disability | ||||||||||||
| |
Baseline |
Post neck treatment |
6-month follow-up |
12-month follow-up |
||||||||
| ID |
Y/N |
NPRS |
NDI % |
Y/N |
NPRS |
NDI % |
Y/N |
NPRS |
NDI % |
Y/N |
NPRS |
NDI % |
| 1 | N | - | N | - | - | N | - | - | N | - | - | |
| 2 | Y | 0.7 | 26 | Y | 1 | 10 | N | - | - | N | - | - |
| 3 | Y | 4.7 | 30 | Y | 4 | 14 | N | - | - | Y | 4 | 22 |
| 4 | Y | 2.3 | 31 | N | - | - | Y | 4 | 10 | Y | 4 | 10 |
| 5 | Y | 4.3 | 34 | N | - | - | N | - | - | N | - | - |
| 6 | Y | 3.7 | 36 | N | - | - | Y | 4 | 34 | Y | 3.7 | 22 |
| 7 | Y | 3 | 42 | Y | 1 | 4 | N | - | - | N | - | - |
| 8 | Y | 2.7 | 42 | Y | 2.3 | 22 | N | - | - | N | - | - |
| 9 | Y | 6 | 40 | N | - | - | N | - | - | N | - | - |
| 10 | Y | 2.7 | 28 | N | - | - | N | - | - | N | - | - |
| 11 |
Y |
4.7 |
20 |
N |
- |
- |
N |
- |
- |
N |
- |
- |
| Headache | ||||||||||||
| |
Baseline |
Post neck treatment |
6-month follow-up |
12-month follow-up |
||||||||
| ID |
Y/N |
Freq |
Sev |
Y/N |
Fre |
Sev |
Y/N |
Fre |
Sev |
Y/N |
Freq |
Sev |
| 1 | Y | 7 | 5 | Y | 7 | 1 | Y | 0 | 2.5 | N | - | - |
| 2 | Y | 7 | 9 | Y | 7 | 2 | N | - | - | Y | 6 | 1 |
| 3 | Y | 7 | 6 | Y | 3 | 3 | N | - | - | N | - | - |
| 4 | Y | 7 | 3 | N | - | - | N | - | - | N | - | - |
| 5 | Y | 7 | 4 | Y | 2 | 4 | N | - | - | N | - | - |
| 6 | Y | 4 | 6 | Y | 2 | 4 | Y | 3 | 5 | Y | 1 | 4 |
| 7 | Y | 3 | 2 | N | - | - | N | - | - | N | - | - |
| 8 | Y | 7 | 4 | Y | 2 | 3 | N | - | - | N | - | - |
| 9 | Y | 7 | 3 | N | - | - | N | - | - | N | - | - |
| 10 | Y | 1 | 1 | N | - | - | N | - | - | N | - | - |
| 11 | Y | 7 | 4 | N | - | - | N | - | - | N | - | - |
| Dizziness | ||||||||||||
| Baseline |
Post neck treatment |
6-month follow-up |
12-month follow-up |
|||||||||
| ID |
Y/N |
Fre |
Sev |
DHI |
Y/N |
Fre |
Sev |
DHI |
Y/N |
Fre |
Sev |
DHI Y/N Fre Sev DHI |
| 1 | N | - | - | - | N | - | - | - | N | - | - | - N - - - |
| 2 | Y | 5 | 6 | 60 | Y | 5 | 3 | 56 | N | - | - | - N - - - |
| 3 | Y | 5 | 3 | 62 | N | - | - | - | N | - | - | - N - - - |
| 4 | Y | 5 | 5 | 36 | Y | 5 | 3 | 34 | N | - | - | - Y 1 4 10 |
| 5 | Y | 5 | 5 | 42 | Y | 5 | 7 | 38 | N | - | - | - Y 1 5 44 |
| 6 | Y | 5 | 4 | 58 | N | - | - | - | N | - | - | - N - - - |
| 7 | Y | 4 | 7 | 60 | N | - | - | - | Y | 2 | 4 | 16 Y 2 8 24 |
| 8 | Y | 4 | 4 | 40 | Y | 4 | 4 | 24 | N | - | - | - N - - - |
| 9 | Y | 3 | 4 | 26 | N | - | - | - | N | - | - | - N - - - |
| 10 | Y | 4 | 1 | 56 | N | - | - | - | N | - | - | - N - - - |
| 11 | Y | 5 | 8 | 78 | N | - | - | - | Y | 4 | 5 | Miss Y 4 4 Miss |
ID = Identifier; RPQ = Rivermead post-concussion symptoms questionnaire; Y/N = Yes/No; NPRS = Numeric Pain Rating Scale (average of recent best, worst and current pain scores from 0 to 10); NDI = Neck Disability Index; Fre = Frequency (Headache = headache days in the past week; Dizziness = 0–5 scale); Sev = Severity; DHI = Dizziness Handicap Inventory; Miss = Missing
A review of individual data reveals that 7 of the 11 participants experienced recurrent headache, neck pain or dizziness at 6- or 12-month follow-up (Table 3). Recurrent symptoms are further observed in an increasing number of participants with four or more scores >2 on the RPQ at 6 and 12 months (Table 2). Post-neck-treatment, all participants showed reductions in RPQ scores, reduced neck pain and/or disability, reduced headaches and either resolved or similar dizziness. Considering the post-neck treatment scores as a reference point: At 6-month follow-up, all residual neck pain and dizziness had resolved, while headaches in four of the six participants had resolved. Five participants had an increase in RPQ score, two participants had a recurrence of neck pain, one participant had increased headaches and two participants had a recurrence of dizziness. At 12-month follow-up three participants still had a higher RPQ score than at post-neck-treatment, one further participant had a recurrence of neck pain (while the two with a recurrence at 6 months continued to have neck pain), one participant had a recurrence of headaches and further two participants had a recurrence of dizziness (while the two with a recurrence at 6 months continued to have dizziness).
Participant descriptions of main outcomes of neck treatment
Ten of 11 participants considered neck treatment beneficial, and one was unsure. Participant descriptions of the main effects of neck treatment were conceptualized into three main themes reflecting the range of effects described: 1. Effects on the neck; 2. Effects on multiple symptoms and 3. Effects of overall recovery (Figure 2). Local effects on the neck were typically related to neck pain and/or movement. Wider effects on symptoms were described as reductions in specific symptoms such as headaches or dizziness, but also reducing nonspecific symptoms such as fatigue or ‘fogginess’. Several participants described neck treatment as helping all their symptoms reduce or become more manageable. More broadly, participants described neck treatment as helping their overall recovery in different ways: for example, by giving them insight into their problem, providing reassurance, reducing anxiety about their problem or improving their sleep. One participant (p8) described neck treatment as a turning point in their recovery, allowing them to function and make progress in other areas of their recovery.
Figure 2.
Conceptual model based on participant descriptions of the effects of neck treatment
Discussion
This study describes individual long-term outcomes of people with persistent symptoms post-concussion who have received neck treatment, and provides some preliminary insight into patient perspectives on the role neck treatment can play in their recovery. The prospective descriptive case series design enables reporting of individual outcomes over an extended follow-up period.
The findings indicate improvements across a wide range of patient-reported outcomes at 6 and 12 months. This is seen in the number of people reporting symptoms over time as well as RPQ scores. Symptom data at 6 and 12 months were improved compared to baseline scores, yet not always better than post-neck-treatment scores. This reflects improvements from the baseline that were sustained over the follow-up period. This positive outcome is tempered by a lack of progress between 6 and 12 months for many participants, seen in an increase in participants reporting symptoms between 6 and 12 months (Table 2), and in individual data (Table 3). The only measure indicating progress over this period was the overall RPQ score which reduced from a mean of 14.1 (10.7) at 6 months to a mean of 10.5 (8.4) at 12 months. A review of individual RPQ data (Table 3) reveals changes in symptoms between 6 and 12-months varied considerably between individuals. These long-term data are consistent with reports of nearly half of people with mild traumatic brain injury experiencing persistent symptoms at 12 months post-injury, based on RPQ data [2] while revealing that symptoms may not be experienced consistently over the follow-up period. In this study, headache, dizziness and neck pain symptoms reported at 12-month follow-up were often reported as resolved post-neck-treatment or at 6-month follow-up (Table 3). Just one participant reported a symptom (headache) at all follow-up points (p6, see Table 3). This indicates that persistent symptoms are not as consistent as one might assume, instead coming and going, affecting different people at different times during their recovery.
The individual case reporting highlights that while group data indicate that patient reported outcomes tend to improve, this does not necessarily reflect the experience of individuals. In this case series of 11 participants, seven experienced a recurrence of headache, neck pain or dizziness at 6 or 12 months. This includes one participant with recurrent headache, three with recurrent neck pain and four with recurrent dizziness. These recurrences are not readily apparent in grouped data, yet could have different implications to persistent symptoms. The single case of a mild recurrent headache is difficult to draw conclusions from. Outcome measurements of neck pain indicate recurrences were not milder than baseline, instead reflecting moderate pain (NPRS ~4/10) and mild-moderate disability (NDI 10–34%). These data are consistent with epidemiological descriptions of neck pain as recurrent and episodic [23,32]. Recurrent dizziness also reflected moderate severity (4–8/10) and mild-moderate disability (DHI 10–44). Recurrent symptoms present a challenge to concussion service providers that may differ from persistent symptoms. The multidisciplinary concussion service described in this study provides a comprehensive assessment and recommendations for care, but is not designed to monitor potentially changing needs for services over time. At 6- and 12-month follow-up several participants with recurrent symptoms reported being unsure about how to access further care after ‘completion’ of the concussion service. Further management may not be required in cases where recurrent symptoms are manageable and do not negatively affect people’s function in everyday life, but is likely to be beneficial in some cases. While the potential for persistent symptoms post-concussion is widely appreciated [2,3,9,33], the individual data presented in this study highlight that recovery from persistent symptoms can be non-linear. Ensuring that appropriate services remain accessible after providing an initial package of care is likely to help reduce the impact of recurrent symptoms. For example, planned follow-up could be arranged at the end of initial care.
Participant descriptions of the main effects of neck treatment emphasize that neck treatment has a range of effects on concussion recovery not limited to local effects on the neck. While preliminary and limited in scope, the data provide some insight into the role of neck treatment from a patient perspective. Ten of the 11 participants considered neck treatment beneficial (one was unsure, this participant indicated that their main problem was not neck-related). While local effects on the neck are expected, wider effects were well described by multiple participants. The data are consistent with the systems-based biopsychosocial model of health proposed by Engel [34,35]. This reflects a wider perspective acknowledging that neck treatment may impact on multiple levels, from local tissues to the person and their community. This also supports the whole encounter with the physical therapist [36], not just physical neck treatment. Another perspective is that these findings highlight the potential to explore neck treatment as a mechanism for effecting change in multiple systems that may extend beyond simple local effects on the neck [37–39]. Future studies might explore these mechanisms further, including the potential effects of neck treatment on people without obvious neck dysfunction. More broadly, these findings provide some insight into how people experience and might recover from a wide range of symptoms. Persistent symptoms post-concussion are known to affect a wide range of systems with impacts on physical, mental and social health [2,8]. Systems-based approaches advocated by Ellis et al. [5] and Schneider [10] target specific impairments, including cervical spine dysfunction. While system-based approaches may appear reductionist, these research findings highlight that identifying and addressing specific issues – in this case, cervical spine injury – remains consistent with a biopsychosocial model [36].
Limitations
As reported previously, this study has limitations as an observational case series designed for descriptive reporting [6]. Participants represent a subset of individuals who received neck treatment with the study's physical therapists, not all patients accessing a concussion service. The relative contribution of neck problems toward participant symptoms in comparison with other systems is unknown. The contribution of multidisciplinary concussion services and changes over time to outcomes should be taken into account when interpreting results. As a secondary aim of this study, the qualitative analysis of participant perceptions of the outcomes of neck treatment is preliminary and limited in scope. Patient perspectives on neck and other treatments would benefit from further qualitative investigation with more tailored methods and richer data sources.
Conclusion
This prospective descriptive case series describes the individual long-term outcomes of people with persistent symptoms following a concussion who received neck treatment within a multidisciplinary concussion service. Improvements across a range of patient reported outcomes were observed at 6 and 12 months. Neck treatment is a valued part of care with effects on the neck, other symptoms and their overall recovery. However, recurrent symptoms were commonly observed – especially neck pain and dizziness – within 12 months. Researchers and providers of concussion services – including but not limited to those providing neck treatment – should be aware of the potential for recurrent symptoms and consider how people might access services beyond an initial package of care.
Biography
This case series was registered with the Australian New Zealand Clinical Trials Register, reference ACTRN12616001183471.
APPENDIX A. Standard concussion neck assessment at 6/12-month follow-up.
Name: _______________________________________________Date: ____________________
Physiotherapist: _______________________________________
Brief current status: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Headaches: Yes/No
Description: __________________________________________________________
Provoked by neck movements or positions? Yes/No/Don’t know
Location: Unilateral without side-shift Unilateral with side-shift Bilateral
Notes: _______________________________________________________________
Frequency:_____headache days in the past week
Duration:_____minutes/hours (typically)
Severity:_____/10 (typically)
Dizziness: Yes/No
Description: __________________________________________________________
Provoked by neck movements or positions? Yes/No/Don’t know
Frequency:_____per day/week/month (circle) Constant
Duration:_____seconds/minutes (typically)
Severity:_____/10 (typically)
Neck pain: Yes/No
Description: __________________________________________________________
Constancy: Constant/Intermittent
Severity:_____/10 current_____/10 best last 24 h_____/10 worst last 24 h
Other relevant issues: (describe):
__________________________________________________________________________________________
Brief summary/analysis
Overall consider neck treatment beneficial? Yes/No/Unsure
Main outcomes of neck treatment: (e.g. symptom, functional, work/social changes)
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________ _________________________________ __________________________
Any remaining symptoms/problems
__________________________________________________________________________________________
APPENDIX B. Rivermead post-concussion symptoms questionnaire results breakdown by symptom for participants over time.
| Baseline (n = 11) |
Post-neck-)treatment (n = 11) |
6-month follow-up (n = 9) |
12-month follow-up (n = 10) |
|||||
|---|---|---|---|---|---|---|---|---|
| Mean (SD) | Score ≥2 (%) | Mean (SD) | Score ≥2 (%) | Mean (SD) | Score ≥2 (%) | Mean (SD) | Score ≥2 (%) | |
| Headache | 2.6 (0.5) | 11 (100%) | 1.1 (0.9) | 5 (45%) | 0.9 (1.1) | 2 (22%) | 0.6 (0.7) | 1 (10%) |
| Feelings of dizziness | 2.6 (1.1) | 9 (82%) | 0.7 (0.6) | 1 (9%) | 0.7 (0.7) | 1 (11%) | 1.0 (1.5) | 3 (30%) |
| Nausea and/or vomiting | 1.6 (1.5) | 5 (45%) | 0.4 (0.5) | 0 (0%) | 0.3 (0.5) | 0 (0%) | 0.4 (0.8) | 2 (20%) |
| Noise sensitivity | 2.5 (1.4) | 8 (73%) | 0.8 (1.0) | 2 (18%) | 1.2 (1.2) | 3 (33%) | 0.9 (1.1) | 3 (30%) |
| Sleep disturbance | 2.3 (0.6) | 10 (91%) | 1.0 (1.0) | 3 (27%) | 0.9 (0.9) | 3 (33%) | 0.5 (0.7) | 1 (10%) |
| Fatigue, tiring more easily | 3.1 (0.8) | 11 (100%) | 1.7 (1.2) | 5 (45%) | 1.3 (1.1) | 5 (55%) | 1.0 (1.1) | 3 (30%) |
| Being irritable, easily angered | 2.2 (1.2) | 9 (82%) | 1.0 (1.0) | 3 (27%) | 0.7 (0.9) | 2 (22%) | 0.6 (0.7) | 1 (10%) |
| Feeling depressed or tearful | 1.8 (1.3) | 7 (64%) | 0.6 (0.8) | 2 (18%) | 0.7 (0.9) | 2 (22%) | 0.3 (0.5) | 0 (0%) |
| Feeling frustrated or impatient | 2.5 (0.7) | 10 (91%) | 1.1 (1.1) | 3 (27%) | 0.7 (0.9) | 2 (22%) | 0.6 (0.7) | 1 (10%) |
| Forgetfulness, poor memory | 2.7 (1.2) | 10 (91%) | 1.1 (0.7) | 3 (27%) | 1.3 (1.0) | 4 (44%) | 1.2 (0.9) | 3 (30%) |
| Poor concentration | 2.9 (1.1) | 10 (91%) | 1.2 (0.6) | 3 (27%) | 1.1 (0.9) | 4 (44%) | 1.0 (1.1) | 3 (30%) |
| Taking longer to think | 2.7 (0.9) | 10 (91%) | 1.2 (0.6) | 3 (27%) | 1.3 (0.9) | 5 (55%) | 1.0 (0.9) | 4 (40%) |
| Blurred vision | 1.5 (1.0) | 7 (64%) | 0.6 (0.8) | 2 (18%) | 0.9 (0.9) | 3 (33%) | 0.3 (0.5) | 0 (0%) |
| Light sensitivity | 2.5 (0.8) | 10 (91%) | 0.7 (0.6) | 1 (9%) | 1.0 (0.9) | 3 (33%) | 0.5 (0.7) | 1 (10%) |
| Double vision | 0.6 (0.8) | 2 (18%) | 0.2 (0.6) | 1 (9%) | 0.6 (0.7) | 1 (11%) | 0.0 (0.0) | 0 (0%) |
| Restlessness | 1.3 (1.0) | 5 (45%) | 0.6 (1.0) | 2 (18%) | 0.6 (0.7) | 1 (11%) | 0.6 (1.0) | 1 (10%) |
Note: Data are presented as mean (standard deviation), and number of scores ≥2 (percentage). The Rivermead Post-Concussion Symptoms Questionnaire is based on symptoms now compared to before the accident, and scored as 0=not experienced at all, 1=no more of a problem, 2=a mild problem, 3=a moderate problem, 4=a severe problem 20
Funding Statement
This research was supported by a Postdoctoral Fellowship in Orthopaedic Manual Therapy at the School of Physiotherapy, University of Otago, New Zealand and held by Dr Ewan Kennedy. This Postdoctoral position was enabled by a generous bequest from the Alumni of the University of Otago in America, Inc. The authors affirm that they have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript.
Ethical approval
This case series received ethical approval from the University of Otago Human Ethics Committee (H16/089) and Accident Compensation Corporation Ethics Committee (#314).
Disclosure statement
No potential conflict of interest was reported by the authors.
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