Massage and Bodywork Magazine for the Visually Impaired - Postconcussion Syndrome

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September/October 2014 Issue

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Postconcussion Syndrome

The Role of Massage

By Ruth Werner
[Pathology Perspectives]

It could happen to anyone, any time. A bad knock on the head, and suddenly life changes forever.
This year, about 1.3 million people will visit emergency rooms with head injuries. About a million of those injuries will be classified as concussions. And that alarming statistic doesn’t include the number of unreported concussions.
About half the people diagnosed with concussions will still have some symptoms after a month goes by. After six months, about 15 percent will still have symptoms. Those patients will be at risk for a long-term chronic condition with no universally agreed upon definition, and no well-tested and consistently successful treatment protocol: postconcussion syndrome (PCS).

What is a Concussion?
Concussion is defined as a trauma-induced alteration in mental status that may or may not involve a loss of consciousness. The change in mental status reflects damage to the central nervous system, usually the brain, as a result of rapid movement that causes the soft tissues of the central nervous system to forcefully contact the inside of the cranium or spine. If this happens in one direction only, it is called a coup. But if the brain hits one side of the cranium first and then sloshes back and hits the other, multiple areas may experience damage. This injury is referred to as a coup-contrecoup.
Sometimes the term “mild traumatic brain injury” (mTBI) is used synonymously with concussion, but while some overlap does exist between these two types of damage, they are not the same. By definition, concussions do not involve skull fractures or internal bleeds, but traumatic brain injuries might. Readers interested in more on traumatic brain injury may want to read my column, “Potential for Recovery in Central Nervous System Injuries” [Massage & Bodywork, September/October 2008, page 110].

Other Head Injury Complications
Head injuries are common in contact sports among children, amateurs, and professionals. Their potential seriousness has only recently begun to attract widespread attention. While a knock on the noggin is often dismissed as trivial by coaches, it has become increasingly clear that even seemingly small-scale events can cumulatively add up to major problems. One of the most important findings has been that even a very mild concussion or subconcussion injury can increase the risk for much more serious damage if it is followed too soon by another trauma. This has led to some fundamental changes in how sports are taught and played, from guidelines about “heading” in soccer to stricter concussion testing and return-to-play rules in professional football.
The consequence of multiple small-scale head injuries turns out to be more than the sum of its parts. Some evidence shows structural changes in the brain that include a thinning cortex, a shrunken hippocampus, and deterioration of some motor pathways, all of which can contribute to inattention, memory loss and poor memory retention, depression, anxiety, and many other symptoms, depending on which part of the brain sustains the most damage. Some scientists equate the changes seen with multiple small head injuries to those seen in a condition that some boxers (including Mohammed Ali) live with: pugilistic Parkinsonism. In other cases, multiple head injuries may contribute to another brain disorder called chronic traumatic encephalopathy (CTE). CTE is difficult to diagnose in a living person, but it was identified posthumously in many professional football players who committed suicide, including Dave Duerson, Ray Easterling, Terry Long, Junior Seau, and Andre Waters.
Far more common than CTE, however, is PCS.

PostConcussion Syndrome
Although it is a startlingly common condition, PCS has no universally agreed-upon definition. It is considered to be a sequel of minor head injuries, and is marked by the absence of objective neurological findings. Symptoms can persist for months or years after injuries. Experts suggest that anywhere from 29–90 percent of head-trauma patients develop PCS.

Symptoms and Diagnosis
The US Centers for Disease Control describe PCS as a collection of signs and symptoms that occur in four distinct categories.
PCS is typically diagnosed when three or more of these signs or symptoms are present for three weeks or more after a head injury. In the short run, it is necessary to rule out internal brain bleeds for concussion patients, but PCS must also be differentiated from depression, fibromyalgia syndrome, and posttraumatic stress disorder. This becomes especially difficult when we realize these conditions can be present simultaneously, and any one of them can make the symptoms of the others worse.

Demographics    
The vast majority of PCS patients are young men between the ages of 15 and 34—often those who engage in contact or high-risk sports. Women are certainly vulnerable as well, but they experience fewer head injuries overall compared to men. Dealing with PCS is also an issue for many service members returning from Iraq and Afghanistan; various types of brain injuries have become the signature wound of the wars in the Middle East.

Treatment
Treatment for PCS takes a symptom-by-symptom approach, beginning with rest and cessation of any activities that might cause another impact. Psychotherapy and cognitive rehabilitation help restore intellectual function and manage the mood changes that these injuries often bring about. Biofeedback and other stress management strategies are recommended as well: it is important for these patients not to get caught in a cycle of sympathetic reactions that then trigger more sympathetic reactions. Problems with balance, dizziness, and vertigo are addressed with a process called vestibular rehabilitation. Other symptoms, such as depression, headaches, sleep disorders, and so on, are treated pharmacologically.

Living with PCS
Jay Fraga, founder of a concussion advocacy group called The Knockout Project, is the survivor of multiple head traumas, beginning with a life-threatening wreck at age 19, through several crashes as a BMX racer, and culminating with a minor head bump from his 3-year-old child. He struggles with concentration and memory, migraines, sleeplessness, and vertigo that can only be managed with the discipline of a trained athlete.
Vertigo was a serious problem after one of Fraga’s incidents. He went through vestibular rehabilitation—a process which he describes as “the seventh circle of hell.” This is a series of eye and balance exercises developed to help people with a variety of conditions related to vestibular nerve damage, including benign paroxysmal positional vertigo, discussed in Massage & Bodywork, July/August 2010, page 98 (www.massageandbodyworkdigital.com/i/68175/100). At the same time, he consulted a chiropractor specializing in upper-neck issues and found—like many PCS patients—his atlas was subluxated. When that issue was resolved, his vestibular problems were much improved.
Unlike many PCS patients, Fraga was able to continue working throughout his rehabilitation. He still struggles with symptoms that may be with him for the rest of his life, but he is not completely debilitated by them.
Fraga finds that acupuncture is a powerful therapy for him, putting him into a deeply relaxed state. “After my acupuncture treatment they have to sort of pour me into the car,” he says.

Massage for Clients with PCS
The role of massage therapy for clients living with PCS is limited, but helpful.
The initial trauma, be it a sports injury, the result of a violent attack, or a motor vehicle accident, is likely to create other problems connected with a high-velocity event. Temporomandibular joint dysfunction and whiplash are likely, for instance. Injuries to noncentral nervous system structures can respond well to massage therapy, as we work to relieve unnecessary muscular guarding, minimize constricting scar tissue, and promote a healthy and effective healing process.
Stress, anxiety, and depression are often significant problems for people with PCS, and massage therapy may offer important benefits for these complications as well, as long as our clients can be comfortable while they receive our work.
One of the big challenges in caring for clients with PCS is positioning. Problems with balance, dizziness, and vertigo can be exacerbated by lying flat or turning over on a massage table. Practitioners must sometimes be imaginative in how they manage these logistics. Further, some massage therapists find that deep, specific work, especially on the neck, can exacerbate symptoms: it seems to overwhelm the sensory system and can be hard for clients with PCS to process.
Bodywork modalities that seem to be well received include most techniques that are designed to focus on inducing and strengthening a parasympathetic response. Many craniosacral therapists find that this modality produces good results for dizziness, headaches, and stress. Lymphatic drainage techniques for the face and head are also perceived as deeply relaxing. One therapist recommends massaging the whole head, including the facial muscles and the scalp, yet many patients find that caregivers are reluctant to touch them in these areas that need special attention.
It is not only the patients in the PCS community who could benefit from massage and bodywork: their partners and caregivers are likewise under an enormous amount of stress as their loved ones go through major changes.
I hope it’s clear that massage has much to offer people who live with PCS—those who are affected directly, and those who love and care for PCS patients. Research shows that massage can make substantial changes in anxiety, depression, headaches, stress perception, and several other major PCS symptoms. While we don’t have an evidence base specifically for PCS at this time, perhaps some readers of this article will now feel compelled to tell their stories in the form of case reports. It’s not just massage therapists who need to know if massage can help—it’s also the PCS patients and their loved ones who are eager for our work.
Author note: Special thanks to Jay and Jessica Fraga of The Knockout Project, and to the several massage therapists who shared their experiences and their PCS “dos and don’ts” with me for this article.

Ruth Werner is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

Resources
Beth Israel Deaconess Medical Center. “Post-Concussive Syndrome.” Accessed July 2014. Available at www.bit.ly/1oM4sl9.
Chernik, Y. “Concussion and Post-Concussion Syndrome.”
Accessed July 2014. Available at www.massagetherapycanada.com/content/view/1982/62.
Guskiewicz, K. et al. “National Athletic Trainers Association Position Statement: Management of Sport Related Concussion.” Journal of Athletic Training 39, no. 3 (2004): 280–297.
Legome, E. “Postconcussive Syndrome.” Accessed July 2014. Available at
http://emedicine.medscape.com/article/828904-overview.
Military Advantage. “Traumatic Brain Injury Overview.”  Accessed July 2014. Available at www.military.com/benefits/veterans-health-care/traumatic-brain-injury-overview.html.
Mohney, G. “First Soccer Player Diagnosed with CTE Brings Up Sport’s Risks.” Accessed July 2014. Available at http://abcnews.go.com/Health/soccer-player-diagnosed-cte-brings-sports-risks/story?id=22697477.
Nordqvist, J. “Concussions Cause Long-Term Effects Lasting Decades.” Accessed July 2014. Available at
www.medicalnewstoday.com/articles/256518.php.
Scherer, M. and M. Schubert. “Traumatic Brain Injury and Vestibular Pathology as a Comorbidity After Blast Exposure.” American Physical Therapy Association. Accessed July 2014. Available at www.ncbi.nlm.nih.gov/pubmed/19628578.
Science Daily. “Football: Concussions, Years of Play Related to Brain Differences, Especially in Areas Linked To Memory.”
Accessed July 2014. Available at www.sciencedaily.com/releases/2014/05/140513161722.htm.
Singh, R. et al. “Relationship of Collegiate Football Experience and Concussion With Hippocampal Volume and Cognitive Outcomes.” The Journal of the American Medical Association 311, no. 18 (2014): 1,883–8. Accessed July 2014. Available at http://jama.jamanetwork.com/article.aspx?articleid=1869211#Abstract.
The Knockout Project. Accessed July 2014. Available at www.theknockoutproject.org.
US Centers For Disease Control and Prevention. “Concussion.” Accessed July 2014. Available at
www.cdc.gov/concussion/signs_symptoms.html.

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