Presence of Neck or Shoulder Pain Following Sport-Related Concussion Negatively Influences Recovery

The Diagnostic Utility of Cervical Spine Proprioception for Adolescent Concussion

OBJECTIVE

Cervical spine proprioception may be impaired after concussion. Our objective was to determine the diagnostic utility of cervical spine proprioception for adolescent concussion.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Adolescents ≤18 days of concussion and uninjured controls.

INTERVENTIONS

N/A.

MAIN OUTCOMES

Head repositioning accuracy (HRA) testing, a measure of cervical spine proprioception. The HRA test involved patients relocating their head back to a neutral starting position with eyes closed after maximal cervical spine flexion, extension, and right and left rotations. The overall HRA error score was the mean error (distance from the starting point to self-reported return to neutral) across 12 trials: 3 trials in each direction. We used t -tests to compare group means and logistic regression (outcome = group, predictor = HRA, covariates) to calculate odds ratios. We used a receiver operator characteristic curve to evaluate area under the curve (AUC) and calculate the optimal HRA cutpoint to distinguish concussion from controls.

RESULTS

We enrolled and tested 46 participants with concussion (age = 15.8 ± 1.3 years, 59% female, mean = 11.3 ± 3.3 days postconcussion) and 83 uninjured controls (age = 16.1 ± 1.4 years, 88% female). The concussion group had significantly worse HRA than controls (4.3 ± 1.6 vs 2.9 ± 0.7 degrees, P < 0.001, Cohen d = 1.19). The univariable HRA model AUC was 0.81 (95% CI = 0.73, 0.90). After adjusting for age, sex, and concussion history, the multivariable model AUC improved to 0.85 (95% CI = 0.77, 0.92). The model correctly classified 80% of participants as concussion/control at a 3.5-degree cutpoint.

CONCLUSIONS

Adolescents with concussion demonstrated worse cervical spine proprioception than uninjured controls. Head repositioning accuracy may offer diagnostic utility for subacute concussion.

Cervical spine sensorimotor deficits persist in people post-concussion despite minimal symptoms

BACKGROUND

The mechanisms of a concussion place stress on the cervical spine like that of a whiplash event, which can result in cervical spine dysfunction. This study aimed to determine if underlying cervical spine mobility and sensorimotor function deficits occur in individuals who are post-concussion with near resolution of symptoms.

METHODS

Twenty-five participants with a self-reported concussive event within a year (PC group: post-concussion 157 + 120 d, 9 men, age: 25 ± 8 yr) and 26 comparable peers (Peer group, 9 men, age: 25 ± 7 yr) were tested. The Post-Concussion Symptom Scale (PCSS) quantified residual concussion symptoms. Participants completed cervical joint position error (JPE) and cervical spine joint mobility tests blinded from each other. Group mean differences were analyzed using t-tests.

RESULTS

The PC group had minimal symptoms (PCSS = 6.8 ± 6.5) but substantial differences in JPE tests compared to the Peer group (PC = 7.4 ± 1.8 cm; PG = 5.6 ± 1.1 cm; p < .001). Those PC participants with pain during joint testing (n = 15) had worse JPE (Painful = 8.1 ± 1.8 cm, No-pain = 6.3 ± 1.6 cm; p = .02) and less averaged lower cervical spine joint mobility compared to PC participants without pain (Painful = 0.66 ± 0.22, No-pain = 0.87 ± 0.19; p = .02, Normal motion = 1.0).

CONCLUSION

Following a concussion, it is a reasonable recommendation to screen the cervical spine to identify impairments in joint mobility and JPE that contribute to neck dysfunction.

Concussion Incidence, Mechanism, and Perspectives Among Australian Elite Surfers: Implications for Medical Support and Safety Protocols

OBJECTIVE

The primary objective was to investigate the incidence of concussion and the associated mechanisms of injury in elite Australian surfers. The secondary objective was to investigate the current perspectives and behaviors related to experiencing concussion in surfing.

DESIGN

A cross-sectional, retrospective, descriptive survey.

SETTING

Surfing Australia high-performance program.

PARTICIPANTS

Forty nationally identified elite Australian surfing athletes.

INTERVENTION

A retrospective survey collected information pertaining to participant demographics, concussion history, potential concussive symptoms, such as headache, neck pain, dizziness, or unusual fatigue, following a wipeout, and participants' perspectives on concussion.

MAIN OUTCOME MEASURES

Investigating concussion incidence among elite Australian surfers compared with potential undiagnosed concussive episodes.

RESULTS

Surfers with a history of diagnosed surfing-related concussion (DC) were compared with those with no history of a diagnosed surfing-related concussion (NDC). A total of 13 of 40 surfers had a DC, with "contact versus the water surface" identified as the primary mechanism. Both DC and NDC groups had a high frequency of concussive symptoms after a surfing wipeout with a total of 447 and 573 concussive symptom occurrences reported in the DC and NDC groups, respectively. Concern regarding the long-term impacts of concussion were reported in 25 of 40 surfers.

CONCLUSIONS

The number of concussive symptoms reported by surfers who had not previously been diagnosed with concussion suggests that concussion may be underreported and underdiagnosed in elite surfing. This underscores the need for increased medical support, education, and improved safety protocols.

Gender differences in female and male Australian football concussion injury: A prospective observational study of emergency department presentations

OBJECTIVE

To examine gender differences in Australian football (AF)-related concussion presentations to EDs in regional Australia.

METHODS

A prospective observational study of patients presenting to 1 of the 10 EDs in Western Victoria, Australia, with an AF-related concussion was conducted. Patients were part of a larger study investigating AF injuries over a complete AF season, including pre-season training and practice matches. Information regarding concussion injuries was extracted from patient medical records, including clinical features, concurrent injuries, mechanism and context of injury. Female and male data were compared with chi-squared and Fisher's exact tests. P < 0.05 was considered significant.

RESULTS

From the original cohort of 1635 patients with AF-related injuries (242 female and 1393 male), 231 (14.1%) patients were diagnosed with concussion. Thirty-eight (15.7%) females had concussions versus 193 (13.9%) males (P > 0.05). Females over the age of 16 were more likely to be concussed than males in the same age range (females n = 26, 68.4% vs males n = 94, 48.7%; P = 0.026). Neurosurgically significant head injury was rare (one case). Similar rates of concurrent injury were found between females 15 (39.5%) and males 64 (33.2%), with neck injury the single most common in 24 (10.3%) concussions. Sixty-nine patients (29%) were admitted for observation or to await the results of scans. The majority of concussions occurred in match play (87.9%). Females were more likely injured in contested ball situations (63.2% vs 37.3%; P < 0.05).

CONCLUSION

Concussion rates for community-level AF presentations to regional EDs were similar between genders. Serious head injury was rare, although hospital admission for observation was common. Concurrent injuries were common, with associated neck injury most often identified. Match play accounted for the majority of head injuries.

The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium

BACKGROUND

Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes.

HYPOTHESIS

New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018.

RESULTS

A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592).

CONCLUSION

This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

Early Identification and Management of Cervical Impairments in Pediatric Patients With Concussion May Reduce Risk of Delayed Recovery

OBJECTIVE

Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury.

DESIGN

Prospective cohort study.

SETTING

Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019.

PATIENTS

One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion).

INDEPENDENT VARIABLES

Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness).

MAIN OUTCOME MEASURES

Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS.

RESULTS

Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340).

CONCLUSIONS

We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery.

Neck Symptoms and Associated Clinical Outcomes in Patients Following Concussion

OBJECTIVE

To examine the frequency and association of neck pain symptoms in patients with a concussion.

STUDY SETTING AND PARTICIPANTS

Three-hundred and thirty-one consecutively enrolled patients aged 9 to 68 years with a diagnosed concussion 1 to 384 days post-injury were enrolled at a concussion clinic from a single integrated healthcare system in Western Pennsylvania between 2019 and 2021.

DESIGN

Retrospective cohort analysis of prospectively collected concussion screening tool intake survey responses and clinical outcomes data. The primary outcome was self-reported neck pain or difficulty with neck movement on the Concussion Clinical Profiles Screening (CP Screen) tool, recovery time, and incidence of treatment referral. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) composite scores, Vestibular/Ocular Motor Screening (VOMS) item scores, type and severity of neck symptoms, mechanism of injury, time from injury to clinic presentation, medical history, and concussion symptom profile were secondary outcomes.

RESULTS

Of the 306 consecutively enrolled eligible patients in the registry, 145 (47%) reported neck pain, 68 (22.2%) reported difficulty moving their neck, and 146 (47.7%) reported either symptom. A total of 47 (15.4%) participants reported more severe neck symptoms, and this group took longer to recover (40 ± 27 days) than those not reporting neck symptoms (30 ± 28 days; U = 8316, P < .001). Stepwise logistic regression predicting more severe neck symptoms was significant (Nagelkerke R2 = 0.174, χ 2 = 9.315, P = .316) with older age ( P = .019) and mechanism of injury including motor vehicle collisions (MVCs) ( P = .047) and falls ( P = .044) as risk factors. MVCs and falls were associated with over 4 times and 2 times greater risk, respectively, for reporting more severe neck symptoms.

CONCLUSION

Neck pain and stiffness symptoms are common in patients with a concussion following high-energy mechanisms of injury including MVCs or falls from height. These symptoms are associated with prolonged recovery. Providers should evaluate neck symptoms and consider targeted treatment strategies to limit their effects in patients with a concussion.

Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes

OBJECTIVES

To explore the prevalence of acute neck pain in high school athletes following sports-related concussion (SRC) and to examine the role of acute neck pain in modifying or amplifying concurrent concussive symptoms.

DESIGN

Retrospective observational.

SETTING

High school sporting events.

PARTICIPANTS

High school athletes who suffered a sports-related concussion between the 2011 and 2019 academic years academic years from the National Athletic Treatment, Injury and Outcomes Network (NATION) Study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence of neck pain (yes/no) along with 33 other commonly reported concussion symptoms, number of symptoms reported, mechanism of injury (contact with person/surface or object), sport type (contact/noncontact), and injury history (first time/repeated injury).

RESULTS

One hundred thirty-eight of 401 athletes (33.9%) indicated acute neck pain following SRC. Those with neck pain reported significantly more symptoms overall (M = 13.53, SD = 6.89) relative to their non-neck pain counterparts (M = 8.46, SD = 5.68; t [191.35] = 7.11, P < 0.001). Athletes with SRC due to contact with a surface were significantly less likely to report neck pain than those reported contact with a person. Neck pain, repeated injury, and female sex were significantly associated with a greater number of concussion symptoms in the acute phase.

CONCLUSIONS

Our data suggest that acute neck pain is a frequent acute symptom following SRC and signals the necessity for additional screening to seek and identify comorbid cervical pathology. Prospective studies should seek to access the benefit of cervical therapy in the early stages in SRC patients with neck pain to reduce the risk of persistent postconcussion symptoms.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion

OBJECTIVE

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.

DESIGN

Cross sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients ≤14 days post concussion.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.

RESULTS

We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).

CONCLUSIONS

In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Incidence of Neck Pain in Patients With Concussion in a Pediatric Emergency Department

OBJECTIVES

The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use.

METHODS

This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables.

RESULTS

Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic.

CONCLUSIONS

Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.

The Nocebo Effect and Pediatric Concussion

While placebo effects are well recognized within clinical medicine, "nocebo effects" have received much less attention. Nocebo effects are problems caused by negative expectations derived from information or treatment provided during a clinical interaction. In this review, we examine how nocebo effects may arise following pediatric concussion and how they may worsen symptoms or prolong recovery. We offer several suggestions to prevent, lessen, or eliminate such effects. We provide recommendations for clinicians in the following areas: terminology selection, explicit and implicit messaging to patients, evidence-based recommendations, and awareness of potential biases during clinical interactions. Clinicians should consider the empirically grounded suggestions when approaching the care of pediatric patients with concussion.

The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review

BACKGROUND

Patients with cervicogenic symptoms following a concussion have shown a disproportionate rate of delayed symptom resolution. However, the prevalence of cervicogenic symptoms in the acute stages following a concussion and the percentage of those patients who continue on to suffer delayed symptom resolution is poorly described in the literature.

OBJECTIVES

To provide a comprehensive report on the clinical prevalence, diagnostic methods, and potential treatment options for cervicogenic symptoms that are elicited during acute and chronic phases following a concussion.

METHODS

Electronic searches were conducted in PubMed, SPORTDiscus, ICL, CINAHL and PEDro, from inception to May 2020, to identify original research articles on concussion involving cervicogenic symptoms. We assessed each included article for risk of bias, methodological quality, level of evidence and evidence quality. The articles were categorized into three topics: (1) prevalence of post-concussion cervicogenic symptoms; (2) diagnostic testing for cervicogenic symptoms, and (3) treatment techniques for cervicogenic symptoms.

RESULTS

The initial review resulted in 1443 abstracts, of which 103 abstracts met the inclusion criteria of our research. After the review of full text, 80 articles were excluded, which resulted in a total of 23 articles for this systematic review. Prevalence of cervicogenic symptoms in the acute stages ranged from 7 to 69% and increased to 90% in patients experiencing persistent post-concussive symptoms. Neck pain at initial evaluation increased risk of developing persistent post-concussive symptoms (PPCS) by 2.58-6.38 times. Patient-reported outcome measures (e.g., Neck Disability Index, Dizziness Handicap Inventory, and Rivermead Post-Concussion Questionnaire) can identify patients with cervicogenic symptoms that should be further differentiated by clinical testing. Lastly, treatment using graded cervical manual therapy has shown to reduce time to symptom resolution and medical clearance.

CONCLUSIONS

Cervicogenic symptoms are prevalent in the acute and chronic stages following concussion, which if not diagnosed appropriately increase the likelihood of PPCS. Several clinical tests are available to help differentiate cervicogenic symptoms; however, lack of awareness and hesitation by practitioners limits their use. More randomized controlled trials are necessary to evaluate the effectiveness of cervical specific treatment programs for PPCS.

Does interprofessional concussion management improve recovery in varsity athletes? A year to year effectiveness-implementation hybrid study

OBJECTIVES

The main purpose of this study was to explore the effectiveness of an integrated interprofessional management (IPM) concussion care approach in varsity athletes.

SETTING

The study was completed in a university environment with varsity athletes.

DESIGN

Data analysis was quantitative, as compared between seasons, in this observational cohort study.

MAIN OUTCOME MEASURES

The metrics for the effectiveness of the IPM team were: time spent in treatment and post-concussion symptom severity scores. These measures were compared for each season year and both sexes for the primary concussive domain they were initially diagnosed with.

PARTICIPANTS

University varsity athletes from various in-season teams.

RESULTS

A Kruskal-Wallis revealed that 2017/18 athletes spent a significantly shorter amount of time in treatment between the two seasons, median 29 days in the 2016/17 season year (IQR = 29) versus 13 days in the 2017/18 season year (IQR = 11), for both sexes (p = 0.009). It appears women tended to recover more quickly than men, particularly in the 2016/2017 season first year.

CONCLUSIONS

A highly communicative interprofessional management (IPM) strategy was shown to lead to reduced return to play (RTP) and return to learn (RTL) times. Increased experience as an IPM team may be a factor contributing to the effectiveness in IPM strategies as well as overall concussion treatment.