Clinical Pearl: Functional Dry Needling® and Post-Concussion Pathology

Written by Adam Weaver, PT, DPT

With the public spotlight and evolving research on brain trauma in athletics, it is extremely likely we all have seen or heard athletes missing competitive action due to suffering concussions.  Specifically, mainstream media has jumped on this story with increased attention paid to concussion related injuries in the National Football League and other professional sports, as well as the correlation to chronic traumatic encephalopathy (CTE) in retired athletes.

The increased awareness of this topic in science, research, and popular culture has had a profound impact on youth, high school, and college sports as well.  In our outpatient facility, primarily comprised of pediatric and young adult sports medicine, the number of patients being evaluated for concussion related symptoms by our physicians and physical therapists is rising.  A large portion of these patients will experience symptoms for greater than four weeks, which is considered beyond normal clinical recovery.  These patients often present with a collection of non-specific symptoms that fall under the umbrella of post-concussion syndrome[1].  This trend will likely continue as the depth of our knowledge continues to expand on this topic.

Consider first the nomenclature related to concussion.  The term ‘concussion’ is used interchangeably with mild traumatic brain injury, yet debate remains whether concussive symptoms should fall under the spectrum of symptoms seen in severe brain injury.  Further, newer technology devices measuring head impact location, movement and forces provide limited information regarding the impact to the brain itself.  At the current time, consistent terminology remains unclear.  The term ‘concussion’ will be used for the remainder of this publication in the manner described in the next section.

 

Who Defines the Term Concussion?

In 2017, the Concussion in Sport group modified the definition of concussion for the first time since 2000 in its consensus statement1.  With the evolution of diagnostic technology and advancement in general understanding, the group felt the need to update the definition to give more breadth to the current topic area.  In short, the group moved to identify concussion as “a traumatic brain injury induced by biomechanical forces.”  The meeting also added common events and defining traits to the definition:

  1. A direct blow to the head and results in the acute onset of impairment of neurologic function that resolves spontaneously.
  2. Signs and symptoms cannot be explained by drug, alcohol or medication use or comorbidities.
  3. A range of signs and symptoms that may or may not involve a loss of consciousness.
  4. The clinical signs often present without structural injury or without abnormality on imaging.

 

Normal clinical recovery for the majority of adults is 10-14 days, and a recovery time of 4 weeks for individuals under 18.[2]  Guidelines for these patients can vary, but general recommendations include rest for 24-48 hours and progressive activity that stays below cognitive and physical symptoms thresholds.  Education to patient regarding selective rest, progression of activities to the onset of activities, and gradually increasing cardiovascular activity can help optimize recovery during this time frame.  Unfortunately, a subsect of this population will not resolve in this time frame, or in some cases without further intervention. This is described as the “post-concussion” phenomenon, and it can have dramatic impacts on daily tasks and return to activity.

 

What is Post-Concussion?

The proportion of adult athletes who experience symptoms beyond ‘normal time frames’ has been reported from 10-30%, while in the pediatric population this ranges from 43-73%.[3][4]  Variability in progression and recovery of symptoms beyond normal time frames can make management of this population quite challenging.  For those with persistent post-concussive symptoms, the role of the physical therapist is becoming increasingly popular.  As an aside, and note from the author, any head or neck injury should be examined for red flags and potential outward referrals.  The following acknowledges those such facts and assumes prior screening.

Post-Concussion related pathology traditionally has signs and symptoms which fall under three main categories:  cervicogenic, vestibular-ocular, and cognitive-physiological.  These are often represented by headaches, neck pain, dizziness, auditory and visual sensitivity, difficulty concentrating, sleep disturbance, and fatigue.[5]  It is common for patients to report various degrees and intensities, or varieties of overlap, throughout these categories.

The chart below provides a simple overview of symptoms and exam findings specific to each category inside post-concussive dysfunction.

 

 

Cervicogenic and Cognitive Categories

A detailed assessment of the cervical spine, vestibular system, as well as oculomotor screening can help focus the course of treatment.  While the vestibular and oculomotor aspects of post-concussion are major components of this condition, the focus of this article moving forward will revolve around the cervicogenic and cognitive type categories.  It should be noted that each category requires specific attention and intervention, and it is not the intention of this article to describe each in detail, but rather to highlight the use of needling in cervicogenic based post-concussive patients based on the effects of this modality on musculoskeletal dysfunction.

The most consistent and common findings within this patient cohort are headache type symptoms.  This is typically accompanied by paraspinal and suboccipital tenderness and spasm, decreased cervical spine range of motion, and headaches that are often occipital in location with referrals into the ocular and temporal region.  Symptoms are often exacerbated by poor posture and neck related activities, such as pain with prolonged sitting and active range of motion to end range.  Determining causative factors of the post-concussive headache is essential in determining the path of clinical treatment.

Headaches and pain worsened by reading, computer use, and other cognitive activities indicates a probable physiologic or vestibular headache.  Clinically, these are often met with a neutral response to cervical and manual therapy treatment programs, but rather succeed with activity and cognitive limitations with a focus on intensity graduation[6].  However, headaches and pain that begin at rest and improve throughout the day or with activity will often lead us down a cervical treatment path, a type that typically demonstrate better responses to cervical manual therapy and dry needling.  The use of graded aerobic treadmill testing can help objectively classify these subjective cognitive, vestibular and headache symptoms depending on patient response[7].

 

Management Options for the Cervicogenic Headache

Fig. 1: Soft tissue mobilization of suboccipital region

Fig. 1: Soft tissue mobilization of suboccipital region

With the cervicogenic patient, it has been my experience that a multi-faceted approach is most effective. This commonly includes, but is not limited to, soft tissue mobilization to the paraspinals and suboccipitals (Fig 1), manual therapy techniques to address cranio-cervical dysfunction (Fig. 2), and dry needling to address myofascial dysfunction.

Fig 2: Craniocervical distraction and mobilization

Fig 2: Craniocervical distraction and mobilization

Soft tissue mobilization of suboccipital regionThe pain patterns of the occipital muscles and cervical joints have been well documented as contributing factors in cervicogenic headache.[8][9]  The suboccipital muscles have the highest cervical receptor density and the cervical muscles have multiple connections to the vestibular, visual and postural control systems.[10][11]  Dysfunction in this musculature can contribute to altered joint position sense and cervical proprioception.[12]

 

Where and How Does Dry Needling Fit into This Population?
As noted above, I find dry needling particularly useful in management of myofascial dysfunction.  Dry needling can assist in reducing muscle spasm and pain along the occipitals, paraspinals, sternocleidomastoid (Fig 3,4), and upper trapezius (Fig 5) areas.[13][14]

Fig 3: Dry Needling of Sternocleidomastoid

Fig 4: Dry Needling of Suboccipitals

Fig 5: Dry Needling of Upper Trapezius

 

 

 

 

 

 

 

Trigger point referral patterns of these muscles have been well established and have been shown to contribute to headache symptoms. [15][16]  My initial treatment is focused on dry needling of the phasic muscles of the neck — upper trapezius and sternocleidomastoid, with subsequent visits focusing on the smaller and tonic muscles — cervical multifidi and suboccipitals.    As headache intensity and frequency reduce, the focus of treatment will transition to other aspects of therapy—cervical stabilization, postural training and vestibular training.

Fig. 6: Cervical multifidus dry needling with electrical stimulation

Fig. 6: Cervical multifidus dry needling with electrical stimulation

Personally, I have found the use of electrical stimulation in conjunction with the use of dry needling of the suboccipital and cervical musculature to be helpful in further reducing spasm, improving patient comfort, and reducing patient soreness (Fig 6).[17] Furthermore, the use of dry needling in cervical multifidus in conjunction with electrical stimulation has shown increased peripheral blood flow circulation in associated musculature[18].  I feel that the electrical stimulation provides a very nice supplement to the treatment, both tapping into the neurologic sides of things while also aiding in patient comfort compared to ‘pistoning’ of the needle.

 

Take-Home and Wrap-Up

While many patients recover quickly from a sports related concussion, a cohort of this population can and will have long standing functional limitations.  It can be quite debilitating to the patient, and also demanding on the therapist. While the patient with post-concussion symptoms is likely to present with overlapping exam findings, it is important to exam the three systems outlined above to help develop your treatment direction.

This article focused on the treatment of the cervicogenic aspect of the condition, specifically the treatment of the commonly involved soft tissues related to headaches.  In conjunction with manual therapy strategies, oculomotor, and vestibular system interventions, dry needling seems to fit in effectively as part of a comprehensive treatment program.

As clinicians we must be diligent to respect the multifactorial aspects of this population. Post-concussion is one of many diagnoses that requires overlapping and synergistic therapeutic modalities to get the job done.   The use of dry needling and manual therapy can provide a window of opportunity to allow for better carryover of ocular, vestibular and postural re-training/stabilization.  Ultimately, it’s a tool, but it can be incredibly impactful when implemented the right way!

 

About the Author

Adam Weaver, PT, DPT, is a physical therapist in Farmington, CT, at Connecticut Children’s Medical Center- Elite Sports Medicine with over 12 years of experience.  He has also been an assistant instructor for KinetaCore FDN 1 and FDN 2 courses since 2011.

 

 


[1] McCrory P, et al. “Concussion Statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016”  Br. J Sports Med 2017

[2]Bleiberg J, Cernich AN, Cameron K, et al. Duration of Cognitive Impairment after sports concussion.  Neurosurgery 2005; 56;E1166

[3] Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH.  The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? BR J Sports Med (2013) 47:308-13

[4] Corwin DJ, Zonfrillo MR, Master CL, Arbogast KB, Grady MF, Robinson RL et al.  Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population.  J. Pediatr (2014) 165: 1207-15

[5] Ellis MJ, Leddy J and Willer B, Multi-disciplinary management of athletes with post-concussion syndrome: An Evolving Pathophysiological Approach.  Front. Neurol. 7:135

[6] Baker JG, Freitas MS, Leddy JJ, Koslowski KF, Willer BS.  Return to full functioning after graded exercises assessment and progressive exercise treatment of postconcussion syndrome.  Rehabil Res Pract (2012) 2012: 705309

[7][7] Leddy JJ, Willer B.  Use of graded exercise testing in concussion and return to activity management.    Curr Sports Med Rep (2013) 12: 370-6

[8] Fernandez de la Penas, C, Courtney, C.  Clinical reasoning for manual therapy management of tension type and cervicogenic headache.  Journal of Manual and Manipulative Therapy, 2014

[9] Dwyer, A, Bogduk, N.  Cervical Zygophyseal Joint Pain Patterns I: A study in normal volunteers.  Spine, 1990

[10] Boyd Clark L, Briggs C, Galea M. 2002.  Muscle spindle distribution, morphology, and density in the longus colli and multifidus muscles of the cervical spine.  Spine 27:694-701

[11] Liu J, Thronell L, Pedrosa-Domellof F. 2003.  Muscle spindles in the deep muscles of the human neck: a morphological and immunocytochemical study.  J Histochem Cytochem 51:175-186.

[12] Jull, G, Falla D Retraining cervical joint position sense: The effect of two exercise regimes.  Journal of Orthopaedic Research, 2007

[13] Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med 2010;23:640–6.

[14] Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82:986–92.

[15] Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med 2010;23:640–6.

[16] Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82:986–92.

[17]  León-Hernández JVMartín-Pintado-Zugasti AFrutos LGAlguacil-Diego IMde la Llave-Rincón AI, Fernandez-Carnero JImmediate and short-term effects of the combination of dry needling and percutaneous TENS on post-needling soreness in patients with chronic myofascial neck pain. Braz J Phys Ther. 2016 Jul 11;20(5):422-431.

[18] Lee SH, Chen CC, Lee CS, Lin TC, Chan RC. Effects of needle electrical intramuscular stimulation on shoulder and cervical myofascial pain syndrome and microcirculation. J Chin Med Assoc. 2008;71(4):200-206. 28.