Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review

The safety and feasibility of transcranial direct current stimulation and exercise therapy for the treatment of cervicogenic headaches: A randomized pilot trial

OBJECTIVE

Our primary objective was to evaluate the safety and feasibility of transcranial direct current stimulation combined with exercise therapy for the treatment of cervicogenic headache. Our exploratory objectives compared symptoms of headache, mood, pain, and quality of life between active and sham transcranial direct stimulation combined with exercise therapy.

BACKGROUND

Cervicogenic headache arises from injury to the cervical spine or degenerative diseases impacting cervical spine structure resulting in pain, reduced quality of life, and impaired function. Current standard-of-care treatments such as radiofrequency ablation, pharmacotherapy, manual therapy, and exercise therapy lack efficacy for some patients. Transcranial direct current stimulation is a neuromodulation technique that has shown promise in treating chronic pain conditions by positively altering neuronal activity but has not been evaluated as treatment for cervicogenic headache.

METHODS

This double-blind, sham-controlled, randomized, feasibility trial recruited 32 participants between the ages of 18 and 65 years that met the International Classification of Headache Disorders third edition criteria for cervicogenic headache. Participants were randomized to receive either active or sham transcranial direct current stimulation both combined with daily exercise therapy over 6 weeks. Transcranial direct current stimulation was applied over the primary motor cortex ipsilateral to worse pain for 20 min at 2 mA with a 30 s ramp up/down period. Recruitment, retention, and adherence were evaluated for feasibility. Safety was assessed through serious and minor adverse events and an adverse effect questionnaire. Clinical outcome measures assessed headache, pain, quality of life, and mood symptoms at pre-treatment, post-treatment, and 6- and 12-weeks post-treatment.

RESULTS

A total of 97 participants were contacted to participate with 32 recruited, 16 randomized into each group, and 14 completing the treatment protocol in both groups. Within each group 12 (active) and nine (sham) completed treatment within the proposed 6 weeks (three sessions per week), others received 18 sessions but took longer. Exercise therapy was completed on an average of 87% of days for both groups. Transcranial direct current stimulation was safe, with no serious adverse events and one minor adverse event in the active group. Itching was a more common post-intervention complaint in the active group (64% active vs. 43% sham). Exploratory analysis revealed significant group × time interactions for average headache pain from pre- to post-treatment (β = -1.012, 95% confidence interval [CI] -1.751 to -0.273; p = 0.008), 6-weeks (β = -1.370, 95% CI -2.109 to -0.631; p < 0.001), and 12-weeks (β = -1.842, 95% CI -2.600 to -1.085; p < 0.001) post-treatment, and for neck pain from pre- to post-treatment (β = -1.184, 95% CI -2.076 to -0.292; p = 0.010) and 12-weeks (β = -1.029, 95% CI -1.944 to -0.114; p = 0.028) post-treatment favoring active vs. sham. There were no significant group × time interactions for quality of life or mood.

CONCLUSION

The combination of transcranial direct stimulation and exercise therapy is safe and feasible for treating cervicogenic headache. While some promise has been shown for reducing headache and neck pain, larger scale trials with adequate power are needed to confirm these findings.

The Treatment of Cervicogenic Headache with Transcranial Direct Current Stimulation and Exercise Therapy: A Randomized Control Trial Evaluating Functional Outcomes

ObjectiveThe objectives of this study were to evaluate functional outcomes of cervical motor control, strength and endurance following active transcranial direct current stimulation (tDCS) with exercise therapy (ET) compared to sham tDCS/+ET in patient with cervicogenic headache (CGH),DesignThis was a pilot sham-controlled, participant and assessor blinded, randomized controlled trial.MethodsThirty-two participants with CGH were randomized to active tDCS/+ET or sham tDCS/+ET. Participants completed 6-weeks of daily ET concurrently combined with 3 sessions per week of tDCS. Assessments included: craniocervical flexion test (mmHg), cervical isometric strength (N), cervical flexor and extensor endurance (seconds), and range of motion (degrees) pre-treatment, post-treatment, 6-weeks and 12-weeks post treatment. Linear mixed effect models evaluated group-time interactions at each follow-up while accounting for exercise program adherence and sex.ResultsThere were significant group-time interactions for activation scores on the craniocervical flexion test from pre-treatment to post-treatment (β = 1.571; 95%CI[0.155, 2.988]; p = 0.030), 6-weeks (β = 1.571; 95%CI[0.155, 2.988]; p = 0.030), and 12-weeks (β = 1.954; 95%CI[0.465, 3.443]; p = 0.011) favoring the active tDCS/+ET group.ConclusionsActive tDCS/+ET demonstrated significant benefits in deep cervical flexor motor control compared to sham tDCS/+ET that remained improved up to 12 weeks post-treatment. This suggests tDCS/+ET may improve of functional outcomes for patients with CGH.

Exploring the Link Between Traumatic Brain Injury and Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, characterized by brief episodes of vertigo triggered by changes in head position. While idiopathic cases are frequent, post-traumatic BPPV has been increasingly recognized, particularly in individuals who have experienced traumatic brain injury (TBI). TBI, ranging from mild concussions to severe head trauma, is a significant cause of neurological morbidity and is often associated with vestibular dysfunction. The pathophysiology of post-traumatic BPPV is thought to involve direct mechanical disruption of the otolithic organs, alterations in endolymph dynamics, or vascular compromise affecting inner ear structures. Compared to idiopathic BPPV, post-traumatic cases tend to have a more prolonged and refractory course, often requiring multiple repositioning maneuvers for symptom resolution. Additionally, concurrent vestibular pathologies, such as vestibular migraine, post-concussive dizziness, or central vestibular dysfunction, may complicate diagnosis and treatment. Early identification and appropriate management of post-traumatic BPPV are crucial in reducing disability and improving the quality of life in affected patients. This review explores the epidemiology, pathophysiology, clinical characteristics, and treatment considerations of post-traumatic BPPV, emphasizing the importance of a multidisciplinary approach. Understanding the relationship between TBI and BPPV can enhance clinical decision-making and optimize rehabilitation strategies for individuals with vestibular dysfunction following head trauma.

Clinical Trajectories of Comorbidity Associated With Military-Sustained Mild Traumatic Brain Injury: Pre- and Post-Injury

BACKGROUND AND OBJECTIVE

In the US military, traumatic brain injury (TBI) is of distinct importance, at home and in the deployed setting, and is considered a "signature injury of the wars in Afghanistan and Iraq." Since 2000, an estimated 468 424 service members (SMs) have been diagnosed with at least one TBI. We examined the clinical trajectories of a group of 18 comorbidities before and after a military-sustained mild TBI (mTBI).

METHODS

Without making assumptions on causality, a group of 18 conditions often co-occurring with mTBI were identified through literature review and TBI subject matter workgroup consensus. Using data from Military Health System Data Repository, we identified SMs whose first lifetime military mTBI occurred between October 1, 2016, and October 30, 2019. Correlation analyses were used to determine the linear relationship between comorbidities prior to and after mTBI diagnosis. Changes in the period prevalence of comorbidities was calculated.

RESULTS

We identified 42 018 SMs with a first lifetime military mTBI, of which 77.6% had at least one comorbidity. Identified SMs were mostly young (46.1% ages 18-24 years), male (81.4%), and White (64.1%). Up to 180 days prior to an mTBI, the most frequently identified conditions were sleep-related conditions (21.7%), headaches (19.4%), posttraumatic stress disorders (PTSDs) (17.8%), anxiety disorders (11.3%), and cervicogenic disorders (eg, cervicalgia) (10.9%). In the period following mTBI diagnosis, the prevalence of diagnosed conditions increased, especially for visual disturbances (327.2%), cognitive conditions (313.9%), vestibular conditions (192.6%), those related to headache (152.2%), and hearing (72.9%). Sleep-related conditions showed moderate positive correlation with a group of co-occurring conditions, led by cognitive conditions ( ϕc = 0.50), anxiety disorders ( ϕc = 0.42), PTSDs ( ϕc =0.43), and headaches and related conditions ( ϕc = 0.38).

CONCLUSION

Results indicate that caring for SMs with mild TBI requires a holistic approach, one that considers the complex nature of SM conditions, prior to sustaining their mTBI, as well as after injury. We found a complex correlation of conditions that suggest SMs with mTBI are undergoing a multifaceted experience, one that may require the development of a targeted multidimensional clinical practice recommendation and practice.

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.

Prevalence of Neck Pain in Soldiers as a Result of Mild Traumatic Brain Injury-Associated Trauma

INTRODUCTION

Many of the injury mechanisms that cause mild traumatic brain injury (mTBI) also create forces commonly associated with whiplash, resulting in cervical pain injury. The prevalence of associated neck pain with mTBI is not well established. There is a strong indication that injury to the cervical spine may aggravate, cause, and/or impact recovery of symptoms and impairments associated with the concussive event and its primary effect on the brain. The purpose of this study is to help identify the prevalence of ensuing cervical pain within 90 days of a previously documented mTBI and to examine the role of neck pain during concurrent concussive symptoms, in a military population stationed at a large military installation.

MATERIALS AND METHODS

This retrospective design utilized a de-identified dataset using predetermined search and filter criteria, which included male active duty service members (SMs), 20 to 45 years of age, who received medical care at any clinic on Fort Liberty (Fort Bragg, NC) during fiscal year (FY) 2012 to FY 2019, with documented cervicalgia and mTBI (via the International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes), verified using electronic medical records. The final dataset served as the basis for subject sampling and was analyzed to determine the total number of documented cervicalgia and mTBI diagnoses. Results are presented as descriptive statistics. Approval for this study was received from the Andrews University Office of Research (18-097) and the Womack Army Medical Center Human Protections Office.

RESULTS

Between FY 2012 and FY 2019, 14,352 unique SMs accessed a Fort Bragg, NC health care facility, at least once (Table I). Overall, 52% of SMs diagnosed with cervicalgia were found to have a previously diagnosed mTBI during the 90 days before the cervicalgia diagnosis. In contrast, the prevalence of same-day cervicalgia and mTBI diagnosis was <1% (Table IV). The prevalence of isolated cervicalgia diagnosis at any time during the reporting period was 3%, whereas isolated mTBI diagnosis was 1% (Table III).

CONCLUSIONS

Over 50% of SMs diagnosed with cervicalgia had sustained a documented mTBI within 90 days prior, whereas less than 1% were diagnosed with cervicalgia at the time of initial primary care or emergency room encounter following the mTBI event. This finding suggests that the close anatomical and neurophysiological connections between the head and the cervical spine are both likely to be impacted through the same mechanism of injury. Delayed evaluation (and treatment) of the cervical spine may contribute to lingering post-concussive symptoms. Limitations of this retrospective review include the inability to assess the causality of the relationship between neck pain and mTBI, as only the existence and strength of the prevalence relationship can be identified. The outcome data are exploratory and intended to identify relationships and trends that may suggest further study across installations and across mTBI populations.

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.

The Implementation of a Return-to-Play Protocol with Standardized Physical Therapy Referrals in a Collegiate Football Program: PT's Role in Return-to-Play, A Clinical Commentary

Sport-related concussions (SRCs) are multi-faceted injuries requiring coordinated care for return-to-play (RTP). Although the number of concussions in collegiate football is increasing annually, there is poor standardization among RTP protocols. Recent evidence suggests there is an increased risk of lower extremity injury, neuropsychiatric consequences, and re-injury after SRC, and risk factors for a prolonged recovery from SRC have also been identified. Evidence demonstrates a faster RTP and improved outcomes with early physical therapy intervention; however, this is not yet common practice in the treatment of acute SRC. There is little guidance available on the development and implementation of a multidisciplinary RTP rehabilitation protocol for SRC that incorporates standardized physical therapy. By describing an evidence-based RTP protocol with standardized physical therapy management, and measures taken to implement this protocol, this clinical commentary aims to identify steps in treating SRC that can be used to improve recovery. The purpose of this commentary is to: a) survey the current state of standardization of RTP protocols in collegiate football; b) highlight the development and implementation of a RTP protocol with standardized physical therapy referral and management in an NCAA Division II collegiate football program; and c) describe results of a full-season pilot study, including time to evaluation, time to RTP, rate of re-injury or lower extremity injury, and the clinical significance of protocol implementation.

Level of Evidence

Level V.

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Towards defining biomarkers to evaluate concussions using virtual reality and a moving platform (BioVRSea)

Current diagnosis of concussion relies on self-reported symptoms and medical records rather than objective biomarkers. This work uses a novel measurement setup called BioVRSea to quantify concussion status. The paradigm is based on brain and muscle signals (EEG, EMG), heart rate and center of pressure (CoP) measurements during a postural control task triggered by a moving platform and a virtual reality environment. Measurements were performed on 54 professional athletes who self-reported their history of concussion or non-concussion. Both groups completed a concussion symptom scale (SCAT5) before the measurement. We analyzed biosignals and CoP parameters before and after the platform movements, to compare the net response of individual postural control. The results showed that BioVRSea discriminated between the concussion and non-concussion groups. Particularly, EEG power spectral density in delta and theta bands showed significant changes in the concussion group and right soleus median frequency from the EMG signal differentiated concussed individuals with balance problems from the other groups. Anterior-posterior CoP frequency-based parameters discriminated concussed individuals with balance problems. Finally, we used machine learning to classify concussion and non-concussion, demonstrating that combining SCAT5 and BioVRSea parameters gives an accuracy up to 95.5%. This study is a step towards quantitative assessment of concussion.

Misconceptions About Traumatic Brain Injuries in Five Sub-Saharan African Countries

Background Traumatic Brain Injury (TBI) remains a significant problem in certain regions of the world but receives little attention despite its enormous burden. This discrepancy could consequently lead to various misconceptions among the general public. This study evaluated misconceptions about TBI in five African countries. Methods Data for this cross-sectional study were collected using the Common Misconception about Traumatic Brain Injury (CM-TBI) questionnaire, which was electronically disseminated from January 16 to February 6, 2021. Associations between the percentage of correct answers and independent variables (i.e., sociodemographic characteristics and experience with TBI) were evaluated with the ANOVA test. Additionally, answers to the question items were compared against independent variables using the Chi-Square test. A P-value <0.05 was considered statistically significant. Results A total of 817 adults, 50.2% female (n=410), aged 24.3 ± 4.3 years, and majoritarily urban dwellers (94.6%, n=773) responded to the survey. They had received tertiary education (79.2%, n=647) and were from Nigeria (77.7%, n=635). Respondents had few misconceptions (mean correct answers=71.7%, 95% CI=71.0-72.4%) and the amnesia domain had the highest level of misconception (39.3%, 95% CI=37.7-40.8%). Surveyees whose friends had TBI were more knowledgeable about TBI (mean score difference=4.1%, 95% CI=1.2-6.9, P=0.01). Additionally, surveyees whose family members had experienced TBI had a better understanding of brain damage (mean score difference=5.7%, 95% CI=2.1-9.2%, P=0.002) and recovery (mean score difference=4.3%, 95% CI=0.40-8.2%, P=0.03). Conclusion This study identified some misconceptions about TBI among young adult Africans. This at-risk population should benefit from targeted education strategies to prevent TBI and reduce TBI patients' stigmatization in Africa.

Head and Body Dyskinesia During Gait in Tactical Athletes With Vestibular Deficit Following Concussion

Background: Vestibular deficit is common following concussion and may affect gait. The purpose of this study was to investigate differences in head and pelvic center of mass (COM) movement during gait in military tactical athletes with and without concussion-related central vestibular impairment.

Material and Methods: 24 patients with post-concussion vestibular impairment (20 males, 4 females; age: 31.7 ± 7.9 years; BMI: 27.3 ± 3.3) and 24 matched controls (20 males, 4 females; age: 31.8 ± 6.4 years; BMI: 27.2 ± 2.6) were included in the analyses. Three-dimensional head and pelvic displacement and velocities were collected at a 1.0 m/s standardized treadmill walking speed and assessed using Statistical Parametric Mapping t-tests. Maximum differences (d_max) between groups were reported for all significant kinematic findings.

Results: The Vestibular group demonstrated significantly diminished anteroposterior head excursions (d_max = 2.3 cm, p = 0.02) and slower anteroposterior (d_max = 0.37 m/s, p = 0.01), mediolateral (d_max = 0.47 m/s, p = 0.02) and vertical (d_max = 0.26 m/s, p < 0.001) velocities during terminal stance into pre-swing phases compared to the Control group. Vertical pelvic excursion was significantly increased in midstance (d_max = 2.4 cm, p = 0.03) and mediolaterally during pre- to initial-swing phases (d_max = 7.5 cm, p < 0.001) in the Vestibular group. In addition, pelvic velocities of the Vestibular group were higher mediolaterally during midstance (d_max = 0.19 m/s, p = 0.02) and vertically during post-initial contact (d_max = 0.14 m/s, p < 0.001) and pre-swing (d_max = 0.16 m/s, p < 0.001) compared to the Control group.

Significance: The Vestibular group demonstrated a more constrained head movement strategy during gait compared with Controls, a finding that is likely attributed to a neurological impairment of visual-vestibular-somatosensory integration.

Changes in White Matter of the Cervical Spinal Cord after a Single Season of Collegiate Football

The involvement of the central nervous system (CNS), specifically the white matter tracts in the cervical spinal cord, was examined with diffusion tensor imaging (DTI) following exposure to repetitive head acceleration events (HAEs) after a single season of collegiate football. Fifteen National Collegiate Athletic Association (NCAA) Division 1 football players underwent DTI of the cervical spinal cord (vertebral level C1–4) at pre-season (before any contact practices began) and post-season (within 1 week of the last regular season game) intervals. Helmet accelerometer data were also collected in parallel throughout the season. From pre-season to post-season, a significant decrease (p < 0.05) of axial diffusivity was seen within the right spino-olivary tract. In addition, a significant decrease (p < 0.05) in global white matter fractional anisotropy (FA) along with increases (p < 0.05) in global white matter mean diffusivity (MD) and radial diffusivity (RD) were found. These changes in FA from pre-season to post-season were significantly moderated by previous concussion history (p < 0.05) and number of HAEs over 80 g (p < 0.05). Despite the absence of sports-related concussion (SRC), we present measurable changes in the white matter integrity of the cervical spinal cord suggesting injury from repetitive HAEs, or SRC, may include the entirety of the CNS, not just the brain.

Vanishing White Matter Disease Diagnosis After Athletic Concussion in an Adolescent Male Patient

We report the recognition of a diagnosis of leukoencephalopathy with vanishing white matter, also known as vanishing white matter disease in an adolescent male patient after a sports-related concussion. The patient's atypical symptoms after the concussion led to imaging and subsequent neurological consultation. The objective of this clinical case is to highlight the importance of considering imaging in patients who present with atypical symptoms that may be present after a concussion and to raise awareness of this rare disorder which can present after head trauma.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM

Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two.

METHODS

Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ).

RESULTS

Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013).

CONCLUSIONS

It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

Osteopathic manipulative medicine in the management of headaches associated with postconcussion syndrome

CONTEXT

Previous studies have demonstrated the effectiveness of osteopathic manipulative treatment (OMT) for various headache types, with limited evidence of its use for headaches related to mild traumatic brain injury (MTBI). No studies prior studies were found regarding OMT for headaches in patients with postconcussion syndrome (PCS), defined as symptom persistence for longer than 3 months after MTBI.

OBJECTIVES

To evaluate OMT for headaches in patients with PCS.

METHODS

A controlled pilot study was conducted of patients with PCS who presented to an outpatient interdisciplinary rehabilitation clinic; patients with symptoms lasting longer than 3 months were enrolled and randomly assigned to an OMT treatment group or a control group. Primary outcome measures were immediate change in headache scores according to a Visual Analog Scale (VAS) and change in the six item Headache Impact Test (HIT-6) between baseline and follow up visits. The participants in the control group completed the HIT-6 between baseline and follow up visits but did not receive OMT and did not complete the VAS. Mean immediate VAS score change for the treatment group and mean improvement in HIT-6 scores for both groups between baseline and follow up were analyzed for statistical significance.

RESULTS

A total of 26 patients were included in this study: 13 (50%) in the treatment group and 13 (50%) in the control group. Six patients (23.1%), three from each group, did not complete the study, so 10 subjects in each group were included in the final analysis. Statistically significant improvement in VAS scores was seen immediately after OMT in the treatment group (mean change, 2.1;p=0.002). Mean HIT-6 scores showed improvement in the treatment group compared with the control group, although the change was not statistically significant (p=0.15) from baseline to follow up visit. No adverse effects from treatments were noted.

CONCLUSIONS

Patients with headaches secondary to PCS showed immediate benefit in headache pain intensity after OMT. However, no sustained benefit was found on the follow up visit compared with the control group.

Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms

CONTEXT

Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS.

EVIDENCE ACQUISITION

PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value.

CONCLUSION

Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes.

STRENGTH OF RECOMMENDATION TAXONOMY

2.

The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report

BACKGROUND AND PURPOSE

Less than half of patients discharged from the emergency department post-concussion receive patient education or follow-up care, and 10-20% of individuals will develop symptoms that last longer than six months. Current research on interventions for post-concussion syndrome (PCS) shows inconsistent results, and recommendations for effective physical therapy treatment for patients with chronic PCS are lacking. The purpose of this case report is to highlight a successful, multi-system approach to physical therapy examination and treatment of a patient with chronic PCS.

CASE DESCRIPTION

This case describes a 21-year-old male who sustained a concussion 356 days prior to evaluation. He received no follow-up treatment and reported periods of worsening symptoms since the injury. Impairments in cervical range of motion and accessory mobility, vestibular and vestibulo-ocular function, and postural stability were identified. Both cognitive and emotional symptoms were also present. The patient attended eight, sixty-minute sessions over a five-week period in an outpatient setting. Comprehensive physical therapy interventions included manual therapy, vestibular rehabilitation, and neuromotor retraining aimed at restoring proper sensory integration and midline postural orientation.

OUTCOMES

Outcomes included cervical spine goniometric measurements and accessory mobility assessments. Objective measures of postural stability included the Modified Clinical Test of Sensory Interaction in Balance (m-CTSIB) and the Fukuda Step Test. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used to subjectively assess symptom severity. At discharge, goniometric measurements returned to within normal limits except left cervical rotation active range of motion (ROM), and both the m-CTSIB and Fukuda Step Test were within normal ranges. The RPQ score reduced from 20 to 2 demonstrating symptom resolution in all items but "headache."

DISCUSSION

PCS can affect multiple systems, necessitating a comprehensive approach to examination and intervention. Manual therapy was used to restore cervical spine ROM, vestibular rehabilitation was utilized to improve gaze stability and visual motion sensitivity, and neuromotor retraining was implemented to improve postural stability and sensory integration. Physical therapists have the ability to treat multiple systems impacted with PCS, with the potential to reduce the longevity and severity of impairments for patients.

LEVEL OF EVIDENCE

Level V.

Physician Medical Assessment in a Multidisciplinary Concussion Clinic

Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.

Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum: a prospective multicentre cohort study

BACKGROUND

Acute neck pain (ANP) has recently been demonstrated to be a predictor of persistent posttraumatic complaints after mild traumatic brain injury (mTBI). The aim of this study was to determine specific characteristics of patients with ANP following mTBI, their posttraumatic complaints and relationship with functional outcome.

METHODS

Data from a prospective follow-up study of 922 mTBI patients admitted to the emergency department (ED) in three level-one trauma centres were analysed. Patients were divided into two groups: 156 ANP patients and 766 no acute neck pain (nANP) patients. Posttraumatic complaints were evaluated 2 weeks and 6 months post-injury using standardized questionnaires and functional outcome was evaluated at 6 months with the Glasgow Outcome Scale Extended (GOSE).

RESULTS

ANP patients were more often female (p < 0.01), younger (38 vs. 47 years, p < 0.01) with more associated acute symptoms at the ED (p < 0.05) compared to nANP patients. More motor vehicle accidents (12% vs. 6%, p = 0.01) and less head wounds (58% vs. 73%, p < 0.01) in ANP patients indicated 'high-energy low-impact' trauma mechanisms. ANP patients showed more posttraumatic complaints 2 weeks and 6 months post-injury (p < 0.05) and more often incomplete recovery (GOSE < 8) was present after 6 months (56% vs. 40%, p = 0.01).

CONCLUSIONS

MTBI patients with acute neck pain at the ED constitute a distinct group within the mTBI spectrum with specific injury and demographic characteristics. Early identification of this at risk group already at the ED might allow specific and timely treatment to avoid development of incomplete recovery.

Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms

CONTEXT

Concussion, a type of mild traumatic brain injury, is a disruption in normal brain function due to head injury. New-onset symptoms from concussion vary, likely depending on the areas of the head and neck affected; they can be severe and debilitating. Current treatment options are limited and difficult to individualize. Osteopathic manipulative medicine (OMM) can aid musculoskeletal restrictions that can potentially improve concussion symptoms.

OBJECTIVE

To assess concussion symptom number and severity in participants with concussion who received either OMM or an educational intervention.

METHODS

A randomized controlled trial was conducted at the New York Institute of Technology Academic Health Care Center. Patients presenting to the center with concussion-like symptoms due to recent head injury within the previous 7 days provided consent and were randomized into 2 intervention groups, receiving either 1 OMM treatment (n=16) or 1 concussion education intervention (n=15). Participants were assessed before and after the intervention with the validated Symptom Concussion Assessment Tool fifth edition (SCAT-5) for quantification of number of symptoms and their severity. Collected data were analyzed using the Mann-Whitney U test and the repeated-measures analysis of variance.

RESULTS

Thirty-one participants were enrolled in the study; after 1 control participant was excluded due to incomplete data, 30 patient records were analyzed. The OMM intervention group had a significant decrease in symptom number (P=.002) and symptom severity (P=.001) compared with the concussion education group.

CONCLUSION

When used in the acute setting, OMM significantly decreased concussion symptom number and severity compared with concussion education. This study demonstrates that integration of OMM using a physical examination-guided, individualized approach is safe and effective in the management of new-onset symptoms of uncomplicated concussions. (Clinicaltrials.gov No. NCT02750566).

Association of artificial turf and concussion in competitive contact sports: a systematic review and meta-analysis

Objective

To determine the incidence of head injuries and concussion in contact sports, comparing natural grass with artificial turf surfaces.

Design

Systematic review and meta-analysis via the RevMan V.5.3 software.

Eligibility criteria for selecting studies

All studies describing competitive contact sports played on both natural grass and artificial turf. The primary outcome measured was occurrence of head injury and concussion.

Data sources

The databases include PubMed, Embase, Cochrane, Medline and Sport Discus. The last search took place on 23 May 2019. The Newcastle-Ottawa Quality Assessment Scale evaluated the methodological quality of the selected studies with a funnel plot designed to determine publication bias. Study screening and data extraction were performed by two independent reviewers.

Results

Initial screening generated 42 publications, with 12 meeting criteria for inclusion. Eight studies described concussion only. The rate ratio (RR) of head injury and concussion was less on artificial turf compared with natural grass (RR=0.89, 95% CI 0.77 to 1.04) as was the rate ratio of concussion only (RR=0.72, 95% CI 0.58 to 0.89).

Conclusion

Analysis of published data demonstrates a decreased incidence of head injury and concussion when contact sports are played on artificial turf. This difference was most marked for sports such as rugby and American football. However, artificial turf has no association with the incidence of head injury or concussion while playing soccer.

Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol

Background

Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated.

Objective

To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week).

Methods

In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used.

Discussion

Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations.

Trial registration

ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.

Re-conceptualizing postural control assessment in sport-related concussion: Transitioning from the reflex/hierarchical model to the systems model

Background: While postural control impairment is common following sport-related concussion, few investigations have studied the physiological basis for this impairment. Both the Reflex/Hierarchical Model and the Systems Model are commonly used to characterize the physiological basis of postural control.Purpose: To discuss the physiological basis of postural control impairment resulting from sport-related concussion based on these models and suggest directions for future research.Methods: Narrative literature review.Findings: Postural control impairment seen with sport-related concussion is a multifaceted construct that can result from deficits in numerous systems that underlie postural control as described by the Systems Model, rather than a unidimensional construct that stems from the central nervous systems' inability to integrate sensory input to control posture as per the Reflex/Hierarchical Model.Conclusion: We recommend a transition away from the Hierarchical/Reflex Model of postural control towards the Systems Model in the conceptualization of sport-related concussion. Future research on postural control following sport-related concussion should account for the multifaceted nature of the resulting postural control impairment based on the Systems Model. Clinically, there is a need for a clinical postural control test that allows examination across the affected systems under single-task, dual-task, and sport-specific paradigms.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BACKGROUND

Concussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important.

OBJECTIVES

To determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery.

DESIGN

Longitudinal observational study.

METHODS

Pre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments.

RESULTS

There was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation.

CONCLUSIONS

While no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.

Concussion - Part I: The need for a multifaceted assessment

INTRODUCTION

Concussion is among the most commonly occurring sport and recreation injuries in today's society. An understanding of the heterogenous nature of concussion will assist in directing a multifaceted and comprehensive interdisciplinary assessment following injury.

PURPOSE

The purpose of this masterclass article is to summarize the current state of the evidence in the area of concussion, describe typical symptom presentations and assessment techniques that may assist in directing appropriate management following concussion.

IMPLICATIONS

A comprehensive assessment including a thoughtful differential diagnosis will assist the clinician to direct care appropriately and efficiently in individuals who have suffered a concussion.

Unstable Cervical Spine Fracture in a Surfer Presenting as Concussion With Associated Low Grade Neck Pain: A Case Report

Objective

The purpose of this study is to describe the evaluation and management of a surfer who presented with concussion-like symptoms and was eventually diagnosed with an unstable cervical spine fracture.

Clinical Features

A young man presented to a chiropractic clinic 5 weeks after a surfing injury. He had mild lower cervical spine pain and complaints of cognitive disturbance. He was previously evaluated by his primary care provider who diagnosed cervical sprain and strain injuries. There was no prior imaging or follow-up concussion management.

Intervention and Outcome

After a history, exams were performed of the cervical spine, thoracic spine, shoulder, and head, including a modified Sport Concussion Assessment Tool, Third Edition, concussion evaluation. Cervical spine radiographs were taken, which demonstrated a right C6 pillar fracture grade 2 anterior spondylolisthesis. These findings were confirmed with a CT scan. The patient was referred to an orthopedic spine specialist for further consultation, which resulted in cervical fusion of the C6/7 motor unit.

Conclusion

The use of clinical guidelines for head and neck injury assisted in the appropriate management of this patient with cervical spine injury presenting with concussion symptoms.

CHARACTERIZATION OF CERVICAL SPINE IMPAIRMENTS IN CHILDREN AND ADOLESCENTS POST-CONCUSSION

BACKGROUND

Patients with concussion may present with cervical spine impairments, therefore accurate characterization of cervical post-concussion impairments is needed to develop targeted physical therapy interventions.

PURPOSE

To characterize the type, frequency and severity of cervical impairments in children and adolescents referred for physical therapy after concussion.Study design: Retrospective, descriptive study.

METHODS

A retrospective analysis was conducted for 73 consecutive children and adolescents who received cervical physical therapy following a concussion. Data was classified into six broad categories. The frequency and intensity of cervical impairments within and across the categories was reported.

RESULTS

Ninety percent of patients demonstrated impairments in at least three out of five assessment categories whereas 55% demonstrated impairments in at least four out five assessment categories. Of the five assessment categories, posture (99%) and myofascial impairment (98%) demonstrated highest impairment frequency followed by joint mobility (86%) and muscle strength (62%). Cervical joint proprioception was the least commonly evaluated assessment category.

CONCLUSION

High prevalence of cervical spine impairments was observed in the subjects included in this study with muscle tension, joint mobility, and muscle strength being most commonly affected. The categories of impairments examined in this cohort were consistent with the recommendations of the most recent clinical practice guidelines for neck pain. This study provides preliminary data to support the framework for a cervical spine evaluation tool in children and adolescents following concussion.

LEVEL OF EVIDENCE

Level 4.

Neck Injury Comorbidity in Concussion-Related Emergency Department Visits: A Population-Based Study of Sex Differences Across the Life Span

BACKGROUND

The cervical spine region can be especially vulnerable to concurrent injury in concussion, with research suggesting that females may be at greater risk due to their weaker and anatomically distinct necks. The main objective of our research was to study sex differences in the rate of neck injury comorbidity across the life span among patients with a concussion diagnosis in the emergency department (ED) setting, by cause of injury (motor vehicle collisions [MVC] and sports).

MATERIALS AND METHODS

All patients with a first concussion-related ED visit between fiscal years 2002/2003 and 2011/2012 (inclusive) in Ontario were identified in population-based health administrative data using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) codes. Age-dependent odds ratios of comorbid neck injury for sex were estimated using polynomial multivariable logistic regression models, adjusting for sociodemographic characteristics.

RESULTS

Females with a concussion had significantly higher odds of sustaining a comorbid neck injury between the ages of 5-49 years for all concussion-related ED visits, 15-49 years for MVC-related concussion ED visits, and 10-39 years for sports-related concussion ED visits, holding all other covariates in the model constant.

CONCLUSIONS

These results support the consideration of increased screening for comorbid neck injuries, particularly for females, to allow for early intervention. Furthermore, the increased risk of comorbid neck injury in females with a concussion-related ED visit was age-dependent, with the interaction between sex and age following a nonlinear trend. As such, future studies on concussions should consider linear and nonlinear sex and age interactions.

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review

BACKGROUND

Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms.

OBJECTIVE

This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning.

METHODS

The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN.

RESULTS

Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations.

CONCLUSIONS

The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.

Moving concussion care to the next level: The emergence and role of concussion clinics in the UK

Concussion is a worldwide issue in sports medicine at present, and in recent years has evolved into a major consideration for sports in the United Kingdom (UK). Governing bodies, sports clinicians, and indeed athletes themselves are dealing with the implications that this injury brings. In parallel with this, innovative means of managing this condition are emerging. The creation of specialized concussion clinics (which mirror those present in the United States and Canada) is one means of enhancing concussion care in the UK. In this chapter, the emergence of concussion clinics in the UK will be discussed. The specific roles of the multidisciplinary teams working in these clinics will be outlined (including the disciplines of sports medicine, radiology, neurology, physiotherapy, and psychology/psychiatry), and the approaches used in the management of concussion in this setting will be explored. Future recommendations for the growth and development of clinic-based concussion care in the UK will also be discussed.