Cervicogenic Contributions to Persistent Post-Concussion Symptoms

As clinicians, we're seeing more patients with persistent symptoms after a concussion, and it's clear that a one-size-fits-all approach doesn't work. The evidence strongly suggests that for many of these patients, the neck is a major, often overlooked, contributor to their ongoing symptoms. A 2024 study in the *Annals of Medicine* highlights that the mechanisms of a concussion often involve a whiplash-like trauma to the cervical spine, leading to dysfunction that can mimic or exacerbate concussion symptoms. This is a crucial paradigm shift for our practice – we need to be looking at the neck in every concussion patient. The research shows that up to 85% of patients with persistent post-concussion symptoms have moderate to severe pain with manual mobility testing of the upper cervical spine. This isn't just a simple neck strain; we're talking about underlying sensorimotor deficits. The 2024 Kinney et al. study found significant impairments in joint position error (JPE) in post-concussion patients, even when their primary concussion symptoms had nearly resolved. This tells us that even when patients feel better, their cervical spine might still be dysfunctional, setting them up for chronic problems down the road. So, what does this mean for our clinical practice? It means we need to be assessing the cervical spine in every concussion patient, not just those with obvious neck pain. A thorough assessment should include manual segmental mobility testing of the upper and lower cervical spine, as well as an evaluation of cervical proprioception using JPE testing. For JPE testing, you can use a head-mounted laser and a target to measure the patient's ability to return to a neutral head position with their eyes closed. An error of greater than 7cm is considered abnormal and indicates a proprioceptive deficit. Once we've identified these cervical impairments, we can target them with specific interventions. The evidence supports a multimodal approach that combines manual therapy, cervical proprioception training, and other modalities. Manual therapy techniques like mobilizations and manipulations of the upper cervical spine (C0-C3) have been shown to reduce pain and improve mobility. For proprioception, exercises that challenge the patient's head and neck awareness are key. This can include things like laser-guided head movements to trace patterns on a wall, or gaze stability exercises while moving the head. When it comes to dosing, the research provides some guidance. For manual therapy, we're looking at 1-2 sessions per week for 4-6 weeks. For proprioceptive training, daily exercises are often recommended, with a focus on quality of movement over quantity. A typical program might involve 3-5 exercises, with 10-15 repetitions each. It's important to start with a low level of challenge and gradually progress as the patient's symptoms allow. We also need to be mindful of contraindications and precautions. Red flags for manual therapy include signs of vertebral artery insufficiency, spinal cord compression, or fracture. For patients with severe irritability, it's best to start with gentle, pain-free techniques. Patient selection is also critical. Patients with a history of whiplash-like injury, neck pain, dizziness, or cervicogenic headaches are prime candidates for this approach. However, given the high prevalence of cervical dysfunction in this population, it's worth screening all concussion patients for these impairments. By addressing the cervical spine, we can help our patients break the cycle of persistent symptoms and get back to their lives. The integration of these principles into our practice is not just an option, but a necessity for providing the best possible care to our patients. The evidence is clear: a happy neck means a happy head.