The Clinical Coach: Persistent Post-Concussion Syndrome in Non-Athletes

Happy Friday !

Welcome to another Clinical issue of The Performance Doctor!

In this issue we are talking all things post concussion syndrome.

Save this page for future references!

Let’s get to it.

First of all…

This is not an assessment tool for concussions. This is an evidence based guide on helping patients with persistent post-concussion syndrome.

If you are unfamiliar with identifying concussions or managing concussions at this time - feel free to email me for resources. 

For now let’s deal with PPCS.

What is PPCS?

Persistent post-concussion syndrome is also known just as post concussion syndrome.

I really like the addition of “persistent” as this differentiates the “common” resolution of post-concussion syndrome. Typically recorded as 2-3 months for recovery.

Persistent post-concussion syndrome can last 6 months to a year, or even longer.

The longest case I have treated was that of a patient who’d been dealing with post-concussion syndrome symptoms for 18 months.

Can you imagine the frustration?

If you were in the room, you would’ve felt it.

What type of symptoms will PPCS present with?

It can be different for every person. Majority of the symptoms will include a mix of:

• Headaches.

• Migraines

• Dizziness.

• Fatigue.

• Irritability.

• Anxiety.

• Depression.

• Trouble falling asleep or sleeping too much.

• Poor concentration and memory.

• Cognitive decline

• Ringing in the ears.

• Blurry vision.

• Noise and light sensitivity.

• Nausea or vomiting.

• Neck pain.

They can present with one or all of these symptoms to various degrees.

And any of these symptoms can exacerbate others. Creating a beautiful chain reaction of negative symptoms for the patient, feeding into some negative habits from the patient.

What do we treat first?

By the time a patient with PPCS arrives at your office they might have already tried a variety of professionals. From neurologists, psychiatrists, neuropsychologists, physical therapists, chiropractors, and more.

You might become overwhelmed and think there’s nothing you can do. However, as a fitness-forward professional you have something all other professionals didn’t have — this guide.

Before we get to treating, we have to do our assessment and it should include:

• Cranial Nerves and Gaze

• Gait, Balance, Coordination

• Blood Pressure and Resting Heart Rate

• Ranges of Motion (P.A.R.) and Orthopedics

• Medications

• Supplementation.

Gaze and Cranial Nerves

Gaze stability involves the vestibuloocular system. Which may be involved in recurring headaches, migraines and other symptoms. The vestibuloocular system is usually assessed with the patient maintaining their gaze on an object while nodding or shaking their head to see if symptoms are provoked.

We use the King-Devick Test to assess rapid eye movement. You can read more about this test here.

Gait, Balance, Coordination

Gait is assessed to detect deficits in dynamic balance. In most cases deficits in gait will not be noticed until the patient is challenged during gait, e.g. walking backward with their eyes closed.

Balance is assessed with Romberg’s test or with the BESS test, whichever one you are most familiar with.

Coordination is assessed with fingertip to nose test. Speed deficits are usually present in early concussion. Dysmetria may be present in PPCS.

Blood Pressure and Resting Heart Rate.

In most patients with PPCS, blood pressure may remain within their normal. However, someone experiencing PPCS may have an elevated resting heart rate. Make sure to record the patients resting heart rate as this will be used in the rehab program of your patient.

Ranges of Motion and Orthopedics

Get your hands on the patient.

The most common complaint I have heard from patients suffering from PPCS or PCS has been that the doctors never touched them.

As manual therapists you should be aware of the amount of information you can gather from simple palpation of bony prominences, muscles, tendons and joints.

You have the experience and ability to assess muscle tone for imbalances, painful areas, and swollen areas that may negatively impact the patient.

Assessing P.A.R. ranges of motion allows you to assess the mobility, stability and strength the patient possesses.

Your orthopedic examination will give you more information about wether or not there may be additional concerns that may aggravate the PPCS symptoms.

There are two special tests that we complete with our patients dependent of what we have available in the clinic.

• The Buffalo Concussion Treadmill Test

• The Buffalo Concussion Bike Test

• Read on them here.

Once we have all of our information, it’s time to develop our treatment plan.

Literature will tell you that in most cases a 4-12 week program will help patient return to sports. This information is based on youth athletes, and I haven’t come across any standards for non-athletic population.

In my experience, the non-athletic population can take up to twice as long as an athlete as they are untrained, and at this stage even deconditioned.

Building The Treatment Plan

As I mentioned earlier there’s little evidence on how long a patient will need to undergo care before symptoms resolve. In some cases symptoms can be permanent. Manageable, but permanent - and this is a conversation you should be ready to have with your patients.

One of the reasons we perform either the Buffalo Treadmill or the Buffalo Bike Test is because there is significant evidence that has demonstrated that in adult patients with prolonged symptoms, a progress aerobic exercise rehabilitation program improves clinical outcomes.

Knowing the heart rate at which symptoms develop, allows us to develop a progressive HR-based rehabilitation program for our patients without aggravating our patients symptoms constantly.

This is key as most patient’s frustrations tend to be linked with physical or mental fatigue.

Additionally you have various treatments available at your disposal to manage and treat their physical limitations.

For muscle tightness and tenderness, joint stiffness, and referred pain, you have the ability to perform a variety of in-office soft tissue and manipulation treatments to improve these conditions. From dry needling and ART, to spinal manipulation, mobilization and soft tissue care.

For vestibuloocular symptoms, you have oculomotor exercises that can be utilized during your rehabilitation program in office and at home.

How often should you see a patient?

Don’t fall into the trap of undertreating.

It’s real.

We expect our patients to do their homework.

They expect us to fix them when they are in the office.

Even with the right expectations. Only about 5% of your patient population will do their exercises at home as you prescribed. Maybe… maybe 10%.

I fell into this trap as well early on my career. Thinking people would do their homework.

Now, they still get homework, but now I see them more often. Specially for cases like this one, which require more maintenance and supervision.

Typically I still won’t see a patient more than twice a week, unless their symptoms get aggravated.

How long should you see a patient?

The current literature states that most PCS symptoms can spontaneously resolve in 4-12 weeks. In my opinion, for patients suffering from PPCS longer than a year, a 10 week initial progressive treatment plan should be the minimum.

It should be aimed at:

• increasing aerobic (cardiovascular) asymptomatic threshold

• reducing muscle hypertonicity and joint fixation

• improving brain metabolic health

• reducing ANS sensitivity

What kind of supplements are good for the patient?

Current evidence suggests that creatine monohydrate and omega-3 fatty acids (DHA and EPA) help decrease inflammation, reduce neural damage and maintain adequate energy supply to the brain following injury.

Similarly, melatonin supplementation may improve some of the sleep disturbances often experienced post-TBI. However, not all PPCS patients have sleep disturbances.

Currently the main supplements that we recommend our patients are:

• Creatine Monohydrate

• Omega-3

• Vitamin D

• Vitamin E

The dosage is where every person will respond differently. Typically we start at the recommended doze on the label for 21 days and increase as needed up to 45 days.

As of today the highest Creatine monohydrate recommendation we’ve given has been 12g with successful improvement in symptoms, while everything else has been 1.5x of what is recommended in the bottle.

Keep in mind that none of our patients have had kidney or GI complaints to begin with.

Every patient responds differently to care. However, changing your treatment plan every three days, will also not yield results.

When you are developing a treatment plan think about what is the minimum effective dose that will stimulate a positive adaptation to your patient.

Keep good records and make sure to note regressions and fast progressions as you see them.

TL;DR: The management of persistent post-concussion syndrome is unique to every individual. However, a 10 week minimum progressive rehabilitation program including subthreshold aerobic exercises, supplementation, oculomotor therapies and manual therapies should be baseline in your care.

If you have further questions on post-concussion care, send me an e-mail.

If you found this issue helpful, help other doctors improve their care by sharing this issue with them!

Until our next issue!

In health and strength,

Ready to take it to the next level? Here are three ways I can help:

1. I have opened my schedule to take calls about starting and growing your practice, schedule your call here. It’s FREE.

2. Join over 270 Certified Dry Needling Practitioners and enroll in an upcoming Dry Needling Course. (SAVE $400 on Early Bird Pricing!)

3. Master diagnosis, treatment and rehab for upper and lower extremity injury and dysfunctions. Enroll in our Extremity Masterclass.