PT Classroom - Game On…. Rehabilitation Strategies for Post Concussion Syndrome by Gail Wetzler PT, DPT, EDO, BI-D

Many victims of concussion injuries report signs and symptoms years after the incidents. In a recent study (2014 and 2015), a team of physical therapists and allied health professionals discovered that specific manual therapy techniques produced significant results toward the future of concussion recovery. The patients in the study were retired professional football players from both the National Football League (NFL) and the Canadian Football League (CFL) with post concussion syndrome. These initial outcomes are inspiring and show real promise for viable treatment options for Traumatic Brain Injury (TBI), concussion, and the secondary compensatory dysfunctions that take place in the days following brain injury.

In 2012, a group of concerned physical therapists were meeting for a common desire to help improve the quality of life that people experience following brain injury or concussive impacts. We wanted to emphasize that the injured person was “not alone” in their road back to recovery. We wondered if the years of study and the specific techniques that we have trained in would benefit patients who had suffered concussions. At that time, our colleagues were devastated by the recent loss of lives due to the severity of symptoms the retired football players were dealing with, and the diagnosis of Chronic Traumatic Encephalopathy (CTE).

As our curiosity grew, so did the desire to design a research project to determine if our techniques and passion to help would prove beneficial. We were aware of the 2011 study that Dr. Amen (et al) had published as the first and largest brain imaging study (SPECT and Quantitative EEG) of 100 active and retired NFL players. They reported consistent damage to the brain’s prefrontal cortex (judgment, impulse control), temporal lobes (memory, mood stability), parietal (spatial orientation), occiput (visual field), and the cerebellum (mental agility, coordination, speed). (1) In 2013, after the death of retired NFL linebacker, Junior Seau, the compassion from fellow colleagues encouraged us to pursue our study.

Could the techniques of Upledger CranioSacral Therapy, Barral Visceral Manipulation, and Barral Neural Manipulation help the biochemical and structural changes that occur after TBI/Concussive injuries?

Could these advanced manual therapy techniques somehow assist the natural healing process that should occur after tissues have been damaged?

Could we assist the brain and nervous system toward recovery, and therefore neuroplasticity (ability for the brain to regain homeostasis via appropriate stimulatory factors)?

Could this method of treatment be an integral step in the rehabilitation strategies of the concussive patient?

Our curiosity prevailed and we were given an opportunity to find out some answers to these questions. The Dr. John E. Upledger Foundation in Palm Beach Gardens, Florida and the Ricky Williams Foundation in Texas provided a platform to begin our Concussion Pilot Program (CPP). The CPP team consisted of a medical director, a research director, a program coordinator, a psychotherapist, and a team of highly qualified therapists who had been selected from around the world by the Upledger Institute International in conjunction with the foundations. We were all there to embrace the spirit of hope and represent a true team approach, which is so vital to recovery.

In the earlier days of sports injuries, there was no clear strategy for treating concussions. Care improved as the medical profession gained more experience with the clinical signs and symptoms. Acute assessment and daily symptom evaluation by the trainers, possible referral to a physician, home management instructions, and abstention from doing any activity that caused the symptoms to increase became the protocol. With the continued complaints from patients in our offices and the continued complaints we read about from other professionals, it was becoming more apparent that this protocol was not enough intervention for the intensity of dysfunction that occurred around a concussive injury.

The professionals involved with this study have had many collective years of experience working with patients having TBI, Autism, PTSD, Anxiety, Depression, Chronic Headache, Chronic Pain, Memory Loss, and Sleep Disorders. The treatment modalities used were developed in the mid 1970’s, so a 40-year history of clinical expertise exists.

Upledger CranioSacral Therapy (CST) is a light touch whole body treatment that works by freeing restrictions within the deeper fascial system that supports and surrounds the central nervous system. CST focuses on glial cells, which are the supporting matrix of the structures of the brain (like fascia), the cranial bones, and the connective tissues inside these bones. (2)

Barral Visceral Manipulation (VM) is a gentle manual therapy that assesses the structural and functional relationship between the organs, and their fascial or ligamentous attachments to the various systems in the body. VM assists the release of restrictions found within these relationships, such as musculoskeletal, vascular, digestive, eliminatory, respiratory, lymphatic, and the autonomic nervous system. (3)

Barral Neural Manipulation (NM) focuses on releasing local nerve restrictions within the central and peripheral nervous systems. It is also a lighter touch manual therapy that examines how the release of these local nerve fixations resolves the more comprehensive (global) dysfunctional patterns. (4)

In summary, these modalities are capable of accessing and addressing the structural, vascular, and neurological tissues of the cranium and brain, as well as the far-reaching ramifications throughout the body.

The CPP design consisted of five consecutive days of treatment. Each participant received a therapy session in the morning and another in the afternoon. Each participant had an initial evaluation in the morning of Day One, a post evaluation in the afternoon of Day Five, and then a follow up evaluation in three months. The testing methods consisted of:
 MD evaluation
 Impact Neurocognitive Test
 Beck II Depression Inventory (BDI)
 SF36 Quality of Life Test
 Headache Impact Test (HIT-6)
 Dizziness Handicap Inventory (DHI)
 Range of Motion tests for the involved joints, as well as the cervical and lumbar regions
 Vestibular testing
 Numeric Pain Scale testing
 Quality/hours of sleep

Our first goal was to explain to the participant what might be happening within their bodies as we became acquainted with their individual patterns of dysfunction. Recent studies in neuroscience have discovered when working with trauma, an important step in the healing process occurs when a person has a better understanding of their personal situation (self awareness/mindfulness). (5)

Our next goal was to calm the threat felt by the nervous system that is overwhelming the coping mechanism for handling trauma. Our final goal was to break the pattern of excessive nerve firing, vascular insufficiency, autonomic responses, anxiety related to these stressors, sleeplessness, inflammation, and muscle tensions. All of these issues were leading to the chronic pain, fatigue, dizziness, headaches, depression, memory loss, and quality of life issues that were complaints of these participants.

The number of concussions for each participant ranged from 3 – 100, with loss of consciousness reported in 6 out of the 11 retired players. We had five participants in the 2014 study and six participants in the 2015 study. Their ages ranged from the mid 20’s to the mid 50’s.

The results show a significant decrease in depression and their overall pain scales. They had a significant increase in the number of hours slept per night and in quality of life issues (general health, bodily pain, energy, emotional well-being, and social functioning). This group did not come in with headaches and dizziness being a major problem.

The range of motion within the cervical and lumbar regions, or with a primary effected joint from previous injuries, improved immediately and continued to gain in the three month evaluation. The balance and vestibular testing was improved, but not as significant as the other findings. In the neurocognitive tests there was a statistically significant increase p=0.0156 in their memory scores.

Beck Depression Inventory II (tests symptoms associated with depression.

SF 36 QoL (Quality of Life)

Numeric Pain Intensity Scale (number given by participant for overall pain)

Average Hours of Sleep Per Night

Cervical Range of Motion – Flexion

Pain Coming from the Neck Area

We are aware of the fact that this was a small number of participants for the Concussion Pilot Program, but we would like to think that the manual therapies presented here may be worth looking into for further studies. Perhaps we are looking toward viable treatment options that can be taken into other clinics for concussion rehabilitation. We are encouraged by the possibilities specific manual therapy may be able to provide for the health and healing of concussive or TBI patients. Perhaps it was the stimulation of increased blood flow (SPECT scan showed a decrease in blood flow to certain areas post concussion, which is consistent with the lasting effects of TBI). (6) Perhaps it was the resolution of fascial restrictions, or changing extracellular electromechanical information through integrins (receptors within the cell membrane). (7) Perhaps it was the increase in proprioception for structural/functional integration, or the bringing together of mind, emotions and body awareness. These initial results are extremely promising, as post concussion syndrome does not seem to be isolated to the brain. Our discoveries during the study found that the autonomic nervous system, the enteric nervous system, and the vascular/lymph/organ systems have secondary compensatory dysfunctions that take place within this syndrome, as well. Each case reported varied and random pain throughout their body, and each case reported previous joint or muscle pain that elevated after the concussion.

Could this method of treatment be an integral step in the rehabilitation strategies for the concussive patient? The results suggest that we are getting one step closer.