Clinical Neuroscience Applications for Post-Concussion Syndrome and Whiplash Associated Disorders
Concussions can occur anywhere in life. Head injuries are frequent in more intense contactsports (football, boxing, rugby, icehockey etc.) and in sports like cycling, iceskating and horse riding due to falls. Road accidents, whether in the car or on the bike are a common source of mild traumatic brain injuries as well. Falls and hitting the head against a hard surface (i.e. ceiling, table etc) are another frequent cause of such injuries.
Even though the causes of head injury are very diverse, the resulting symptoms and problems are strongly alike in all categories. In the last ten years the neurosciences have progressed our understanding of what happens to the brain in such injuries. More importantly based on these insights newer and evidence based approaches to recovering from mild TBI have come to exist.
Each one of us is a unique human individual and nowhere is this unicity more prominent than in our brains. Brain-based symptomatology and pathology hence needs a very personal approach and cannot be protocolized completely.
Millions of people throughout the world suffer from head injuries each year leading to at least a mTBI (sometimes worse). Estimations for Europe alone are : 2,5 million each year. Around 15-30% of these people suffering from a mTBI will not fully recover and experience residual and often incapacitating symptoms. This is well documented in the scientific literature yet poorly accepted in the medical model.
This 15-30%, some studies even report numbers up to 43%(!), of people with residual symptoms after head injury suffers from a combination of the following symptoms:
Light and sound hypersensitivity, balance and coordination disorders, reading problems, headaches, neck pain and stiffness, cognitive issues (impaired memory, concentration/attention, planning, comprehension), anxiety, fatigue, insomnia and dysregulation of the autonomic nervous system (increased resting heart, poor ventilation skills, increased sweating, palpitations, digestive problems)
Needless to state that this is a tremendous burden for the individual, for his/her direct surroundings (family, friends, work environment) as well as on a broader scale: medical costs for society, loss of productivity, costs for allowances etcetera.
The neuroscientific understanding
Longstanding symptoms after mild traumatic brain injury are also referred to as post-concussion syndrome (PCS). PCS symptoms have been classified in different categories and these subclassifications can guide us to understanding the specific symptomatology per person and to appropriate treatment needed for that individual.
Specific personalized care for PCS demands an in-depth understanding and experience in clinical neurosciences. Nevertheless it is relatively easy to start to comprehend the PCS symptoms when we just look at 4 different systems within the human body.
The current (out-dated) approach
Many people consider the brain to be the organ of thinking, reasoning, and the substrate for our mind, hence of cognitive functions. Little wonder that the current approach often only targets PCS from that perspective: learning how to deal with the symptoms, managing your stresslevels via mindfulness and with little if any focus on one of the above mentioned crucial systems. Even worse, some healthcare practitioners still think that PCS does not exist and everyone who does not recover from a mTBI has psychogenic issues.
1. Vestibular system: AKA our balance system
The vestibular system extends from the sensors in the inner ear (semicircular canals, utricle and saccule) via the vestibular nerves into the central nervous system. There it integrates the head motion signals with the other senses at different levels: brain stem, cerebellum and even at the neocortical level. Dysfunction of the vestibular system leads to problems with balance, dizziness, vertigo, head motion, with eye movements, with appropriate image fusion, with spinal stability and with body position changes. It can even directly contribute to issues with memory and with the autonomic nervous system since there are pathways connecting the vestibular system with the hippocampus (memory, circadian rhythm) and hypothalamus (hormonal production, governor of the sympathetic and parasympathetic branches of the autonomic nervous system).
2. The oculomotor system
Vision does not only rely on light input through the retina. Fine-tuned coordination between the movement of the eyes (i.e. oculomotor skills) are equally important. Precise eye movement coordination is crucially important for our ability to read to shift and/or maintain our attention, to avoid seeing blurry, to assist in pupil response, to judge our distance to our surroundings (e.g. when catching a ball, or walking the stairs), to quickly react to emergency situations.
3. The autonomic nervous system (ANS)
Luckily we don’t have to consciously maintain our blood pressure, decide where we need more or less blood circulation or remind ourselves we need to breathe, sweat, digest an set our muscle tone. Our autonomic nervous system is capable of orchestrating all of these functions and a lot more. Dysregulation of the ANS is very common in PCS and results in increased heart rate, fatigue, digestive problems, poor conditioning, disrupted light and sound regulation and accentuated fight/flight responses as often seen in anxiety. ANS dysregulation can enhance bloodsugar problems and contribute to hormonal imbalances.
4. The neuromusculoskeletal system (NMSK)
The NMSK consists of peripheral nerves (N), muscles (M), bones joints and fascia (SK). In PCS a very important part of the NMSK is obviously the neck region as this areas is often impacted directly at the onset of the head injury. Neck-, shoulder- and arm pain as well as headaches are frequent symptoms. The jaw (temporomandibular joint and muscles) should not be forgotten as it is often involved in headaches. The N part can be crucial since it can be used for interventions that enhance neurological activation.
A state of the art approach
Nearly (?) all of the symptoms of PCS can be traced back to 4 subsystems in the human body. Dysfunction of these 4 subsystems is well-documented in the neuroscientific rehabilitation literature. It would make perfect sense to consider these systems a valid target for treatment of PCS. Both studies and case reports have shown that an integrative approach combining the rehabilitation of those systems can result in improved functionality, decreased symptomatology and even complete recovery.
This is the approach we use for PCS care in the last ten years. We have seen tremendous positive changes that occur with a short intense rehabilitation course combining vestibular and oculomotor exercises, coordination and timing exercises, neurological activation of specific pathways, cardiovascular activation, nutritional strategies, spinal care and some cognitive exercises. We have also experienced that the order in which interventions are done is important and that it is critical to maintain within the borders of the patients metabolic capacity.
- Almost all aspect of PCS can be explained looking at 4 subsystems
- The current biomedical model is out-dated
- Clinical applications of neurosciences offer a new and more comprehensive way for PCS recovery
- Care must be personalized, multifactorial and intense with respect for the individuals capacities