Exercises Worth Repeating with Concussions & Vestibular Migraines

Wondering what treatment or exercises to prescribe to your patient with ongoing symptoms after a concussion or associated with vestibular migraines?

With seeing patients with these two conditions over the years you have likely found that they both have something in common. They can both have a component of symptoms that originate from the neck, whether it be headaches and/or dizziness. It is therefore vital to be able to address the neck in order to stop the cycle of ongoing symptoms or at least help them manage their symptoms better. At North 49, a tool that has been useful in determining if the neck is a factor in one’s symptoms and can also guide our treatment is the use of repeated neck motions that can be learned at McKenzie and Mulligan courses (further info below). 

Using repeated neck motions may be:

• new to some,
• a frequently used tool for others,
• or something that you have dabbled in with mixed results.

Before we get too far let’s review how the neck can cause headaches and dizziness.

How can headaches and dizziness come from the neck?

Abnormal afferent activity in the neck due to an injury, degenerative changes, and/or prolonged poor postures can cause headaches as well as dizziness. This is due to the neck being interconnected with the trigeminal nerve and vestibular system. Given such, abnormal afferent activity in the neck can manifest as headaches by stimulating the trigeminal nerve or dizziness by stimulating the vestibular system.

Therefore, with patients complaining of headaches and/or dizziness, which are both common with vestibular migraines and concussions, it is important to be able to determine if any of the symptoms, or at least a component of the symptoms, are coming from the neck. Is the neck a large driver of the symptoms or a small component?

Using repeated motion to help rule in if the neck is involved

What are repeated end range repeated movements? They are simply neck motions (i.e. flexion, retraction, extension, side bend and rotation) that take the tissue to end range and are performed repetitively (at least 10 times). Similar to how we assess range of motion, but now we perform that same motion several times to see what effect it has on both the symptoms and neck mobility.

Prior to doing the repetitive motions we get a baseline of neck mobility and symptoms (location, intensity). We then perform repeated neck movements in sitting typically into flexion, retraction and extension to see what effect it has on the symptoms and neck mobility. If there is an improvement with a particular motion we will prescribe that motion as their initial home exercise. They will then perform that exercise at least on an hourly basis.

Really, what we are looking for is a directional preference.

What is a directional preference?

A directional preference is where a particular repeated motion or in some situations a sustained posture improves either the symptoms and/or neck mobility. If a directional preference is found, then movement and/or sustained postures in that direction is performed regularly throughout the day.

A directional preference is not only a neck thing, but can be seen in joints throughout the back and extremities.

Of note, often with a directional preference repetitive movements or postures in the opposite direction worsen the symptoms and/or mobility. These motions should then be temporarily avoided.

What happens if a directional preference cannot be found?

If you cannot find a directional preference with neck flexion, retraction or extension when the patient is sitting you can:

• Add more force to the motion by having the patient or you add over pressure.
• Sustain or hold the end range position as some patients tend to respond better to sustained postures than repeated motions.
• Move away from the sagittal plan in sitting and see what effect repeated motion has with rotation and side bending.
• Try repeated movements in an unloaded position by having the patient in supine lying.

Initially it is a trial and error thing that can be tedious, but well worth the time. 

Then, if no directional preference has been found we can address any mobility issues by moving (i.e. stretching, mobilizing) into the direction of the impairment. We should also not forget to provide education regarding proper posture and attempt to desensitize any areas of tenderness whether it be through soft tissue mobilization, needling, etc.

Tips

• Do not forget to get your baselines (symptoms and neck mobility) and reassess those baselines after each test.
• With addressing headaches and dizziness take a step back and see what  effect improving our patients posture has. Just having them sit upright for a couple of minutes can provide some useful information.
• Sometimes using props like towels and balls can guide and localize the neck motion resulting in better outcomes.
• Be patient.

Case studies

To reinforce the benefits of repeated motion here are two case studies.

Concussion Case Study:

History: 11 year old box lacrosse player from a city 2.5 hours away from North 49 reported having near constant headaches, dizziness, and neck pain. This was the result of getting checked, falling, and hitting the back of his head on the concrete floor one month prior to being seen. He was wearing a helmet and there was no LOC, amnesia, or need for hospitalization. There was an immediate onset of symptoms. Given his ongoing symptoms he was not attending school or playing sports. Six months prior he took a puck to the helmet while playing hockey. This resulted in similar symptoms that resolved within a couple of weeks. His medical history was otherwise unremarkable.

Initial Exam: Gait, cranial nerve (2-12) and neck active range of motion appeared unremarkable. There was no spontaneous or gaze evoked nystagmus in room light. Positional testing for BPPV was negative. Repeated movements of his neck into extension abolished his headache. The subocciput region was tender to palpation.

Treatment: During the initial assessment he was provided education regarding the nature of his symptoms and of his favourable prognosis. He was advised on strategies (i.e. proper posture and neck extension exercises) that he could perform to improve his symptoms. He was followed up online and no manual therapy was utilized. Within 3 weeks he was symptom free while being back to full school and lacrosse.

Vestibular Migraine Case Study:

History:  24 year old female with intermittent retro-orbital left sided headaches with tension at the base other skull. The headaches had been on and off over the previous nine months. The headaches were typically worse as the day progressed, especially with bending forward, playing soccer, and with bright lights. She started taking Amitriptyline as well as Magnesium, vitamin B12 and B6 one month prior. Taking an oral contraceptive, attending physical therapy and massage had been of no benefit. She had also seen a naturopath. Her current headaches were in the same area as her migraines. Her current headaches were, however, less intense, longer lasting, and had no associated nausea. In the past month she had left work early 3-4 times due to her headaches.

Initial Exam: Head forward posture. Neck active range of motion appeared full, but passive left rotation seemed limited. Repeated movements of the neck into retraction reduced her headache and there were reports of less “pulling” with passive left rotation. The subocciput region was tender to palpation.

Treatment: During the initial assessment she was provided education regarding the nature of his symptoms and of her favourable prognosis. She was advised on strategies (i.e. proper posture and neck retraction exercises) that she could perform to improve her symptoms. Within 2 sessions her most recent form of headaches had resolved.

Conclusions

With vestibular migraines and concussions it is vital to perform a thorough neck assessment. This will help us determine if any ongoing headaches or dizziness is due to the neck. Once we have a good understanding we can develop a treatment plan and know how we want to proceed with any education, exercises, and manual therapy. Not knowing what the root of the problem is will only lead to prolonged symptoms and frustration for you and your patient.

Further resources

Information about using repeated movements with the McKenzie approach can be found HERE.

Information about using repeated movements with the Mulligan approach can be found at:

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