If a Head Ct Comes Back Normal but Having Double Vision After a Concussion

Ross Hauser, MD

At our center, we generally see one type of patient with a diagnosis of post-concussion syndrome. It is the patient who has long-term, unexplained conditions and symptoms and their post-concussion syndrome has now turned into a persistent post-concussion syndrome. From this one group of patients, we can then describe the three main patient types. This is in no particular order.

The younger athlete with persistent post-concussion syndrome.

• The first group is young school-age athletes who need, along with their parents, to get some answers that will help them maybe play again, play at a lesser risk for future concussions, or at least do well in school again. The concussion has occurred a year, two years, or maybe three years ago and symptoms persist.

The whiplash accident injury people with persistent post-concussion syndrome

• The second group is the people who were in some type of accident, who are trying to get themselves back to work on a full or even part-time basis. In this latter group are older patients, their symptoms have been going on for years. They have reached that point in their "recovery," that their neurologist says there's nothing that can be done for them because MRI, CAT Scan, and EEG say nothing is wrong with them.

The "I have had many concussions" people

• These are the people who are feeling the effects that multiple concussions have brought them. These are the people who have a greater likelihood of problems considered neurologic mysteries.

All three of these groups have very challenging cases.

Here is an example story however of someone who had many concussions:

Twenty years of concussions

The main problems I am having are Vestibular VOR dysfunction which is causing spontaneous vertigo, dizziness, loss of balance, oscillopsia (shaky vision),  neck pain at the base of the skull, tachycardia, tinnitus, headaches, and migraines. I have had many concussions over the last twenty years.

A few years ago I started having migraines which began with blurry vision in both eyes followed by aura then dull pain at the back of my skull. (See our article Occipital neuralgia and suboccipital headache).

I was on a lot of medications that I did not want to be on. So I tried lifestyle modification changes, mainly dietary changes, vitamins, mediation, and stress reduction techniques. I also started chiropractic adjustments. My chiropractor specialized in upper cervical problems. He identified that my C1 had rotated and moved far out of place. After a few adjustments, my migraines were gone but the other issues did not resolve.

I was seeing a neurologist who, after hearing this story sent me to an orthopedic surgeon. The orthopedist did an MRI, said I don't need surgery, and sent me back to my neurologist. My neurologist, who had come to a dead-end with me now sent me to a neuro-ophthalmologist who is not interested in my so-called neck instability issues and focused solely on my vision dysfunction. Unfortunately looking only at my eyes, he cannot find any cause. My neuro-ophthalmologist thinks it may be Multiple Sclerosis but a brain MRI  has ruled that out.

Above is a sample story of a person who contacted us where the number of their conditions and symptoms have become so overwhelming that post-concussion syndrome became one of many problems.  Unfortunately, this is not a unique situation or the most complicated situation we have seen.

Sometimes it only takes one bad bang to the back of the head

Many people contact us with a story about hitting the back of their heads. Some tell us about walking into things backward or mostly from standing up and not realizing something was right behind them. Many times the person didn't even think anything of it. A few days later they had a panic or anxiety attack. Many of these people never knew what a panic or anxiety attack was having never suffered from one before. They describe the panic attack as building from a weird or indescribably type of sensation from the back of the skull. They also develop visual hallucinations that last for a brief moment. This includes a quick burst of light or seeing an object that is not there.  Then they develop a long-lasting hearing loss.

Another story:

We will hear the story of a person who has a cerebrospinal fluid (CSF) leak. This is causing them positional or orthostatic headache headaches. Despite various treatments to address the cerebrospinal fluid (CSF) leak and a seemingly successful patch of the fluid leak, that person describes the chronic and worsening symptoms of tinnitus, neck pain, light and vision sensitivities, tachycardia, and digestive disorders amongst the many problems. Initially, this began with a diagnosis of post-concussion syndrome. A high school and college sports career, unfortunately, brought with it an extensive history of trauma and numerous concussions. Please see my article: Spontaneous intracranial hypotension for more information on understanding cerebrospinal fluid leak and the similar common conditions it shares with post-concussion syndrome.

Everyone tells me I am okay. I am not okay

A person will describe a story that goes like this: I have post-concussion syndrome. I was in an accident a few years back and diagnosed with a concussion. I had all the tests, CAT Scan, MRI, X-Ray, Electroencephalography (EEG). My doctors told me I was cleared. Nothing is wrong with me. While the doctors cleared me, I was still having symptoms. Chronic headache, blurred vision, difficulty reading because of sight challenges and memory retention, memory loss, concentration problem, head pressure, light sensitivity make computer work difficult. I continue to go from doctor to doctor.

My doctors think it is all psychological now, that I have Post-traumatic stress disorder

A person will describe a journey of years from the time of their injury to trying to get back to where they once were. They will tell us, like those above that they have had a barrage of tests and that show nothing yet they have symptoms. Doctors have told them they have PTSD from the injury and that nothing is wrong with them. But many of these people report "noisy" cracking, popping sounds in their necks. They recognize a physical manifestation of their neck pain.

Post-Concussion Syndrome and hypermobile Ehlers-Danlos syndrome

A person will contact us with their history of treatment for hypermobile Ehlers-Danlos Syndrome (hEDS). They will then tell us about an accident and a concussion. Treatment of Ehlers-Danlos Syndrome-related craniocervical instability is challenging enough. Not having an initial, accurate diagnosis can make it more challenging. A lack of a diagnosis can send patients on a many-year journey searching for help that they cannot get because they and their doctors are chasing the wrong problem.

When people contact us they tell us about their symptoms, especially those which are new-onset after the accident. They will also tell us about what was going on in their spine prior to the concussion incident. A complete loss of cervical lordosis, kyphosis lumbar and thoracic spine, S scoliosis, and significant pelvic tilt and rotation.

We have a more extensive discussion on this problem in our articleEhlers-Danlos Syndrome, Atlanto-axial instability, and Craniocervical Instability.

The travels a patient suffering from post-concussion syndrome may take

Above I described a few stories and situations. We see many patients with difficult post-concussion challenges. When they were initially diagnosed with a concussion they were likely given a guarded but the more optimistic outlook of what they could expect from their treatment.

A June 2018 paper published in The Journal of the American Academy of Orthopaedic Surgeons (1) basically describes the travels a patient suffering from post-concussion syndrome may take. I present this here to give you a different perspective. Here the focus is on the athlete where the post-concussion syndrome is not resolving.

• In many patients, typical symptoms of concussion are usually self-limited and resolve within 2 to 3 weeks.
• Initial treatment consists of a reduction in cognitive activity and physical rest.
• A stepwise return-to-play protocol, taking into consideration state laws, with a gradual increase in activity until the athlete is able to perform the full activity without symptoms should be followed.
• Neuropsychologic testing (brain function) may be used as a tool in management.
• For prolonged concussion, physical rehabilitation or medications for headaches, mood, or sleep disturbance may be required.

My brain scan shows nothing: Sometimes it is just a neck injury. Sometimes it is a neurologic mystery. Mild traumatic brain injury and whiplash-associated disorder post-collision symptoms

In our practice, we see many people with a long list of symptoms that are described throughout this article. In many cases, it is initially thought that neurologic conditions mean mild traumatic brain injury as a result of the concussion. When there are neurologic-like conditions, it is clear that something is going on in the brain. But is it the concussion itself that caused injury to the brain or is it a continued injury because of cervical spine instability? Both? This is one of the challenges of diagnosis and treatment of the persistent post-concussion syndrome.

Overlapping symptoms point to cervical spine instability in many people. We are going to focus on the neck to show that neck injury may be A or THE main component of persistent post-concussion syndrome.

Symptoms common to Altlantoaxial instability (Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). Whiplash associated disorder, post-concussion disorder, cervicocranial syndrome, vertebrobasilar insufficiency.

• Headaches
• Dizziness / Vertigo
• Insomnia
• Tinnitus / Ringing in the ears
• Anxiety
• Light-headedness

Symptoms of Mild traumatic brain injury

Here are symptoms of Mild traumatic brain injury common to those of cervical spine instability or whiplash injury to the neck.

• Headaches
• Dizziness/Vertigo
• Insomnia
• Tinnitus/Ringing in the ears
• Anxiety

What we see is that it may be difficult for doctors to discover the source of the patient's symptoms. Is it a whiplash neck injury, is it a traumatic brain injury? Cognitive problems are not the dividing line.

Typically when a patient exhibits cognitive dysfunction, memory problems, mood problems, emotional swings, and depression, it can be thought that this is evidence of brain injury. In fact, it can be. But it can also be evidence that the problem is not in the brain but in the neck as these neurologic-like symptoms are also common in neck injury.

Let's look at a March 2021 study in the medical journal Injury (2). The challenges of diagnosis are explained:

"Although post-motor vehicle collision pain and symptoms are largely convergent among those with mild traumatic brain injury and whiplash associated disorder, and patients oftentimes report initial neck and head complaints, the clinical picture of mild traumatic brain injury and whiplash-associated disorder has been primarily studied as separate conditions which may result in an incomplete clinical picture."

"It seems that while mechanisms of the neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability."

 "Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration."

A December 2021 study in the Journal of psychosomatic research (3) looked at people reporting unexpected symptoms after concussion. In some of these people the researchers noted it may reflect a Functional Neurological Disorder (balance, functional motor skills, seizures, vision problems, etc.), Somatic Symptom Disorder (problems of excessive unexplainable pain or loss of function), or exaggeration (feigning or faking). In this study the researchers aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for Functional Neurological Disorder / Somatic Symptom Disorder, exaggeration, or both.

How was the study done?

• Seventy-seven adults with persistent symptoms following concussion rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing Functional Neurological Disorder and/or Somatic Symptom Disorder (e.g., fear avoidance behavior).

Results:

• Fear avoidance behavior was most strongly related to unexpected neurological symptoms
• Current anxiety scores were most strongly related to unexpected somatic symptoms.

Conclusion: Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate Functional Neurological Disorder and Somatic Symptom Disorder (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion.

For the newest or more recent concussion event, the many people recommended to the 4 – 6 week total rest no activity period suggestion does provide the healing time necessary for symptoms to clear

For the newest or more recent concussion event, the many people recommended the 4 – 6 week total rest no activity period suggestion does provide the healing time necessary for symptoms to clear and the person to regain a sense of "being normal." For others, the reintroduction of sports or work activity at the end of the 4-6 week rest period may reboot the symptoms. These new symptoms may also clear after a short period of time. These are not the people who are coming to our office. We see the people who this has not helped.

The people we see with a post-concussion syndrome that come into our clinics begin their stories with the event. . . , " I was concussed during a game . . ; " I was skiing and crashed . . . "; " I was in a serious car accident . . . "; "I think I have had more than a few concussions, I am really not sure." They describe their past or the current severity of symptoms and recommendations to this injury as:

• I get these annoying headings, they are not intense headaches, mostly annoying. I have had them for years.
• I don't have energy some days, I feel deep and lingering fatigue. The more I push myself, the more tired I get. I am trying to keep my physical activity up but I have to watch my walking. Running is impossible because of the impact.
• Some days I am very nauseous, other days I actually vomit. I have dizziness some days.
• I have been told to do absolutely nothing.

"A greater percentage of athletes in the concussion group was not participating at their perceived pre-injury level of sport competition one-year"

In January 2021 paper published in the Journal of Science and Medicine in Sport (4) tried to provide estimates in the times taken to receive clearance to return to sporting activity and to return to pre-injury level of sport competition following a sport-related concussion, and to estimate the proportion of athletes who were participating at their pre-injury level of sport competition six months and one-year following sport-related concussion.

These are the learning points of this research:

• Study participants: Amateur, adult athletes (16-38 years old) diagnosed with sport-related concussion.
• Participants were assessed at:
  • within one week, upon medical clearance to return to sporting activity,
  • two weeks following return to sporting activity,
  • six months following sport-related concussion
  • and 12 months following sport-related concussion.
• Participants were asked during each study assessment whether they were:
  • participating in any sport,
  • in a different sport than before their sport-related concussion,
  • in the same sport but at a lower level of competition than before their sport-related concussion,
  • or in the same sport at the same level of competition as before their sport-related concussion.
• Fifty concussed participants and 50 non-injured, control participants completed the study.

Results:

• The average time taken to receive clearance to return to sporting activity was 13 days
• The average times taken to get to pre-injury level of sport competition following sport-related concussion were 31 days

One-year following sport-related concussion:

• 52% of participants reported that they were no longer participating in the same sport and at the same level of competition as they were before their sport-related concussion.
• Factors that explain the lower proportion of amateur athletes participating at their pre-injury level of sport competition one year after a sport-related concussion are likely multifaceted and should be considered in future investigations.

My neurologist says there's nothing that can be done. MRI, CAT Scan, and EEG say nothing is wrong with me.

There are many things that can cause Post-Concussion Syndrome. There are many treatments that can help Post-Concussion Syndrome. But what if you continue to have symptoms, nothing is helping, you have had a barrage of tests and your neurologist then walks into the exam room and says: "Your MRI, CAT Scan, and EEG says nothing is wrong with you. I can't help you beyond antidepressants or anti-anxiety medications." Now what?

If you are reading this article it is very likely that you have done a lot of research. You may have found your way through articles that discuss "hidden," or "controversial," causes this has led you to try different types of remedies.

• For some, experimentation with nutritional supplements may begin. Some people report great benefits with B complex and vitamin B12 supplementation. Others add high doses of Vitamin C, E, and D3 along with Omega 3. There are numerous studies supporting and non-supportive of the use of nutritional supplementation.
• For some, fatigue will send them to an endocrinologist for thyroid and hormone testing with the hope that supplementing levels of testosterone and other hormones will improve their condition.
• For some, various manipulation techniques will be tried.

At this point in our article, we will examine the controversies in published research and hopefully provide some information that may help you find your own path of treatment.

Controversy: Do I have Post-concussion syndrome? Or do I NOT have Post-concussion syndrome?

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Can you go to one doctor and be told you have Post-concussion syndrome and go to another one and be told you don't have Post-concussion syndrome? Symptoms, symptoms, and more symptoms.

Can you go to one doctor and be told you have Post-concussion syndrome and go to another one and be told you don't have Post-concussion syndrome? The answer is yes. One doctor may be using one set of criteria to diagnosis post-concussion syndrome and another doctor may be using another set of criteria to diagnosis post-concussion syndrome.

This article is filled with possible symptoms because criteria and diagnosis are matched to symptoms. Above we showed that mild traumatic brain injury and whiplash-related disorders can share post-concussion syndrome symptoms but can be considered separated non-related entities, or as demonstrated below, they can be considered related, concurrent entities.

There is research that can be somewhat alarming to patients and their families where the post-concussion syndrome is present. Published in the medical journal Brain Injury – doctors of the American College of Sports Medicine (ACSM) say a standard definition of Post-Concussion Syndrome (PCS) does not exist. (5)

• Symptoms vary from patient to patient but can include
  • headaches,
  • chronic neck pain,
  • difficulty with concentration,
  • sleep disturbance,
  • irritability,
  • slower reaction times,
  • memory deficits,
  • sensitivity to noise,
  • problems with judgment,
  • dizziness,
  • vertigo,
  • blurred vision,
  • anxiety and depression.

  These symptoms can range in severity from being slightly annoying to becoming an overwhelming disability.

When the doctors in the study asked what would be the minimum number of symptoms required to diagnose PCS, responses varied:

• one symptom (55.9%),
• two symptoms (17.6%),
• three symptoms (14.6%)
• and four or more symptoms (3.2%).

When asked how long these symptoms should persist before a diagnosis of Post Concussion Syndrome is made, the doctors of the studies responded:

• Less than 2 weeks (26.6%),
• 2 weeks to 1 month (20.4%),
• 1-3 months (33%) and
• More than 3 months (11.1%).

Physicians who see more than 10% concussion patients in their practice, as well as physicians whose concussion population consists of more than 50% pediatric patients, were more likely to require more than 1 month of symptoms.

So, presenting to one doctor one symptom would get a diagnosis of post-concussion syndrome while going to a second doctor for a second opinion who believes that there are three symptoms needed will not.

Confusion can lead to prolonged or delayed recovery

A May 2020 study in the Archives of Physiotherapy from Duke University (6) offered a list of risk factors for prolonged or delayed recovery. Here is what they wrote:

"Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis."

• In this study, 163 individuals were seen and treated at a concussion clinic until cleared for sports activity.
• Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation.
• Delayed recovery was calculated by taking the average time to clearance for activity.

Cognitive impairments, visual exam findings, and vestibular exam

Results:

• 80 of 163 individuals were considered delayed in their clearance to activity.
• Cognitive impairments, visual exam findings, and vestibular exam findings all increased the odds of delayed recovery. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for delayed recovery.

Conclusions: The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a delayed recovery to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.

What are vestibular impairments?

We are going to move away from this research for some brief understanding notes and then we will return:

• The vestibular system is the body's sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment).
  • It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism.
    • As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to "keep things steady," to prevent motion from creating dizziness or sway.

What are we seeing in this image?

The vestibular system is the body's sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to "keep things steady," to prevent motion from creating dizziness or sway.

Vestibular impairments can be:

• Vestibular migraine and spontaneous vertigo
• Chronic Post-Traumatic Instability of the Cervical Spine: Persistent neck pain that develops into problems with hearing, vision, swallowing, dizziness, and chronic headache
• Oscillopsia vision disorders
• Blurred or Double Vision Problems

The vestibular system is complicated and includes cognitive disorders including amygdalar,prefrontal connectivity and cingulate connectivity.

In December 2021, researchers writing in the journal Human brain mapping (7) sought to expand the understanding of what is happening in the brain of post-concussion syndrome patients in specific regard to the vestibular system.

Convergent clinical and neuroimaging evidence suggests that higher vestibular function is compromised by a distributed network including visuospatial (in simplest terms depth-perception and space between objects), cognitive-affective, proprioceptive (sense of space), and integrative brain regions (simply the processing of information to help you identify your place in space) as may disturb this network, resulting in deficits across a variety of functional domains

Clinical vestibular syndromes: These are identified as: (8)

• Benign paroxysmal positional vertigo,
• Menière's disease,
• acute unilateral vestibulopathy/vestibular neuritis,
• bilateral vestibulopathy,
• vestibular paroyxsmia, and the third mobile window syndromes (Superior canal dehiscence being one – an anatomical structure defect).

In this study in the journal Human brain mapping, the researchers examined structural and functional neuroimaging to characterize this extended network in healthy control participants and patients with post-concussive vestibular dysfunction (PCVD).  . . PCVD participants exhibited diminished integration and centrality among vestibular and affective nodes and increased centrality of visual, supplementary motor, and frontal and cingulate eye field nodes. Clinical outcomes, derived from dynamic posturography, were associated with approximately 62% of all connections but best predicted by cognitive disorders including amygdalar (the area of fear and apprehensive), prefrontal connectivity (the ability to process information including predicting what will happen and the consequence of what will happen. For example if you take a step you predict that you are moving closer to that which you are walking towards,) and cingulate connectivity (the control of emotions). . . These findings indicate that cognitive, affective, and proprioceptive substrates contribute to vestibular processing and performance and highlight the need to consider these domains during clinical diagnosis and treatment planning.

Should a patient suffering from an apparent post-concussion syndrome ask the doctors first, how many symptoms do I need to be diagnosed, in your opinion?

Canadian and Australian university researchers combined in recent 2017 research published in the British Journal of Sports Medicine (9) that indirectly support the findings above. In this study, confusion over what are 'persistent symptoms' of sports-related concussion are discussed.

" 'Persistent symptoms' following sports-related concussion can be defined as the clinical recovery that falls outside expected time frames (for example more than 10-14 days in adults and more than 4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies."

In other words, it is usually not ONE thing that is causing persistent symptoms but a constellation or many problems that are the symptoms of post-concussion or the result of compounding problems of existing symptoms. In other words, a doctor needs to thoroughly investigate the problem of post-concussion.

Anxiety caused by these mixed messages of confusing diagnosis can lead to an exacerbation of post-concussion syndrome in the patient

In the journal Brain Injury, (10)  August 2019, Nigel King of the Oxford Institute of Clinical Psychology Training, University of Oxford wrote this concerning the confusion of understanding post-concussion syndrome in patients:

"The last 20 years have seen the emergence of a sub-category of the mild traumatic brain injury literature termed 'sport-related concussion'. Some important differences now exist between this sub-category and the wider findings in the field and these could be detrimental to patients with persisting post-concussion symptoms (PCS). Sport-related studies often emphasize the cerebral risks associated with concussive injuries whilst the broader literature typically focuses on the relatively benign organic implications and the role of psychological factors in persisting symptoms. Clinically, anxiety caused by these mixed messages could lead to an exacerbation of post-concussion syndrome."

What makes this 2019 research so impactful is that the same researcher, Nigel King, wrote in the October 2003 edition of The British Journal of Psychiatry (11) an article titled: "Post-concussion syndrome: clarity amid the controversy?" In established research, doctors have long questioned the traditional diagnostic tools of determining post-concussion syndrome. In 2006 in research in BMC Neurology, (12) doctors noted that: "One well-accepted hypothesis claims that chronic PCS has a neural origin, and is related to neurobehavioral deficits. But the evidence is not conclusive."

Persistent post-concussion symptoms – it may not be all in your head, it may be all in your neck

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"These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mild traumatic brain injury."

In September 2019, the Archives of Physical Medicine and Rehabilitation (13) researchers at the Medical College of Wisconsin Department of Neurosurgery examined the frequency of neck pain in mild traumatic brain injury/concussion patients. The purpose? How many of these patients will develop primary neck pain.

• 95 patients came into the emergency room with mild traumatic brain injury – suspected concussion
• These patients were asked within three days, then at 8 days, then at 15 days, and then at 45 days post-injury how their neck pain was.
  • At three days 68.4% reported neck pain
  • At eight days 50.6% reported neck pain
  • At 15 days 49% reported neck pain
  • At 45 days 41.9% reported neck pain.
• These patients were then asked was the neck pain equal to or greater than any other symptom.
  • At three days 35.8% reported neck pain was equal to other symptoms, 17.9% said it was the worse symptom.
  • At eight days 34.9% reported neck pain was equal to other symptoms, 14.5% said it was the worse symptom.
  • At 15 days 37% reported neck pain was equal to other symptoms, 14.8% said it was the worse symptom.
  • At 15 days 39.2% reported neck pain was equal to other symptoms, 10.8% said it was the worse symptom.

The researchers concluded: These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mild traumatic brain injury.

At our center, we see many patients with the many symptoms of post-concussion syndrome that we discussed above. In some patients, we explain that while they have a general diagnosis of post-concussion syndrome, their problem may lie in the domain of damaged, weakened cervical neck ligaments. For some patients, this makes a lot of sense. For others, this is a "curious," theory that they do want to explore further as they have not been provided relief from traditional treatment. We have published research and gathered research that helps show that cervical neck instability can be the missing diagnosis of post-concussion syndrome.

In our 2014 research led by Danielle R. Steilen-Matias, MMS, PA-C and published inThe Open Orthopaedics Journal (14) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine, this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. Vertebrobasilar insufficiency describes a narrowing of the arteries that is usually treated with blood thinners and cholesterol medication. In this context, vertebrobasilar insufficiency is describing a situation where hypermobility of the neck vertebrae is causing a "squeezing," of the arteries by pinching movement. This could lead to drop attacks, fainting spells, and blackouts.

In Ross Hauser's, MD open letter of August 2017 Could Neck Injury Be the Culprit in Post-Concussion Symptoms and the Development of Chronic Traumatic Encephalopathy? Dr. Hauser wrote: "Understanding cervical instability as a possible cause of Chronic Traumatic Encephalopathy is understanding the difference between cellular damage in the brain caused by repeated blows to the head and cellular damage's cause by cervical instability pinching and compromising oxygen flow and interrupting message signaling between the brain and the body."

In the research below we present arguments and evidence that understanding damage caused by cervical instability pinching and compromising oxygen flow and interrupting message signaling between the brain and the body, may be the missing diagnosis in many post-concussion syndrome patients.

• Symptoms of headaches:
  • In our article: Cervicogenic headaches – Migraines, tension headaches, and cervical neck instability, we demonstrate research and clinical observation that people suffering from these headaches have a high incidence of neck pain and neck instability.
  • In our article Occipital neuralgia and Suboccipital headache – C2 neuralgia treatments we also demonstrate research and clinical observation that people suffering from these headaches have a high incidence of neck pain and neck instability.
• Difficulty with ringing in the ears, postural sway, head tremors
  • In our article Treatment of Whiplash associated disorders, we demonstrate that problems that can be related to post-concussion syndrome Swaying, posture control, balance, jaw pain TMD, head tremors, ringing in the ears (tinnitus) are problems of cervical neck instability.
• Symptoms of  dizziness and vertigo:
  • In our article Can neck problems cause vertigo? Cervical Vertigo and Cervicogenic Dizziness we discuss:
    • The diagnosis and treatment of cervical vertigo and chronic dizziness are associated with neck movement.
    • We present research on when neck pain causes dizziness and possible conservative treatment options.
    • We will also include research and evaluation on regenerative medicine injections including Prolotherapy.
• Symptoms of  blurred vision:
  • In our article: Chronic Neck Pain and Blurred Double Vision Problems – Is the answer in the neck ligaments? we discuss seeing patients following an acute head or neck trauma, such as concussion, whiplash, and sports injury who suffer from these various problems including double vision and other vision problems. In these patients, we see cervical vertebrae that are hypermobile and are moving in and out of their natural position because of weakened, damaged cervical neck ligaments.

Cervical afferent dysfunction: A distortion of time and space in post-concussion syndrome patients

In some patients with post-concussion syndrome, they report symptoms of "out of body," or a sensation of "exaggerated movement," like they are moving at a high rate of speed. Things around them have become "accelerated."

Cervical afferent dysfunction in simple terms means something is not working correctly within the nerves of the neck. This dysfunction can be caused by a traumatic injury to the neck such as in sports or whiplash.

In her study in the Journal of Orthopaedic & Sports Physical Therapy, (15) Dr. Julia Treleaven of the University of Queensland wrote:

• There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms.
• However, there are other possible causes for these symptoms beyond cervical afferent dysfunction
• Understanding the nature of these symptoms and differential diagnosis of their potential origin is important for rehabilitation.
• In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits.

Altered cervical joint position

Let's look at the altered cervical joint position

• The cervical joint position error test is a test that measures cervicocephalic proprioception and neck reposition sense. In simplest terms, tests to measure if the neck is in the correct position and if it is not, what type of problems it causes by restricting blood vessels and nerve networks.
• Cervicocephalic syndrome, symptoms caused by cervical joint position error results in pain and restriction of motion of the upper cervical spine which may result in the many symptoms attributed to post-concussion listed above.

Altered cervical joint position – cervical neck ligament damage

Let's now explore cervical joint position error. A recent piece in the medical journal Child's Nervous System – Official Journal of the International Society for Pediatric Neurosurgery, (16) from Vanderbilt University School of Medicine researchers can make for a fascinating revelation and a great understanding of how to treat the post-concussion syndrome persistent symptoms. Notice that in this study discussed below, the obvious treatment recommendation, in our opinion, is not mentioned but certainly alluded to… that is the treatment of the cervical neck ligaments for cervical stability and alleviation of symptoms.

The goal of the Vanderbilt study was to assess the usefulness and cost-effectiveness of neurologic imaging two or more weeks post-injury in youth athletes with post-concussion syndrome (PCS).

Here are the numbers:

Of 52 patients with PCS, 23 of 52 (44 %) had neuroimaging at least 2 weeks after the initial injury, for a total of 32 diagnostic studies.

• 1 of 19 MRIs (5.3 %), 1 of 8 CT Scans (13 %), and 0 of 5 x-rays (0 %) yielded significant positive findings, none of which altered clinical management.
• Chronic phase neuroimaging estimated costs from these 52 pediatric patients totaled $129,025. We estimate the cost to identify a single positive finding was $21,000 for head CT and $104,500 for brain MRI.
• Read the conclusion
  "brain imaging in the chronic phase (defined as more than 2 weeks after concussion) was pursued in almost half the study sample, had:
  • low diagnostic yield,
  • and had poor cost-effectiveness.
  • Based on these results, outpatient management of pediatric patients with long-term post-concussive symptoms should rarely include repeat neuroimaging beyond the acute phase.

So what should be said here? The problems of long-term PCS should not be confined or even be supported by brain imaging because images will not help and may hinder the treatment of PCS symptoms.

In other words – you need to look somewhere else to help these people. That place is the cervical neck ligaments as symptoms of PCS, including headaches, dizziness, or vertigo can be caused by a cervical injury. In such cases, recovery from PCS can be addressed and resolved with Prolotherapy.

Altered cervical joint position – cervical neck ligament damage – How we explain treatment to the Neck for post-concussion syndrome

Many people we see have a demonstrated ligament problem. The problem is that the ligament problem offer gets lost in a sea of neurological problems. People will contact us saying that they have an MRI and the MRI clearly demonstrates that their alar ligament is damaged. That they, the person, not their doctors suspect, from their own research, that the alar ligament is a problem because their post-concussion syndrome has worsened and that they have taken to wearing neck collars to minimize pain, discomfort, and headaches.

As discussed in the video below by Ross Hauser, MD., we explain to patients that a concussion can be caused by many things including blunt force trauma to the head. When the head receives that blunt trauma impact, the force of that blow radiates like an aftershock into the neck area and causing injury and disruption. The area where most of this aftershock occurs is in the C1 – C2 vertebrae and at the Atlas, the small boney platform that the head sits on. It is not the vertebrae themselves that are impacted, but the strong bands, the cervical ligaments that hold the vertebrae in place that are also impacted and damaged.

We have seen when the cervical joint capsule (capsular) ligaments are damaged, the patient has many of the symptoms, already outlined in this article, that are typically applied to a diagnosis of post-concussion syndrome.

It can be difficult for people to believe that their problems, including memory problems, are coming from neck instability, or their dizziness, or their ringing in the ears. These are symptoms commonly and well known to be those of getting "your bell rung," in football, soccer, or any contact sport or falling off a bike, skis, or being in an accident.

Orthostatic intolerance in younger concussion athletes is different than in general orthostatic intolerance patients.

In this next section, we will discuss the body and head positions as a cause of worsening or sudden onset of symptoms

My high school-age daughter was recently discovered to have had multiple concussions in the last two years. She has headaches, neck pain, TMJ pain, memory problems, difficulty in school. When she gets up, many times she has to get right back down again and lay down to relieve her symptoms.

A July 2021 study in the journal The Physician and Sports Medicine (17) discusses the problem of understanding symptoms and outcomes in patients with orthostatic intolerance following pediatric concussion. Orthostatic intolerance is the development or worsening of many of the above-described symptoms when the person stands upright that are, many times, quickly relieved when reclining.

To help doctors understand orthostatic intolerance the doctors of this study "set out to describe concussion-related orthostatic intolerance in adolescence, with particular emphasis on time to recovery and differences from non-concussion-related orthostatic intolerance  (including male vs. female prevalence)."

They did this by retrospective chart reviews of patients with post-concussion and symptoms of orthostatic intolerance. The patients' gender, sports history, previous concussions, time since injury, and recovery time were analyzed and compared between males and females as well as against general orthostatic intolerance statistics.

• Thirty-nine pediatric patients, representing 8.7% of all new patients referred to a specialized concussion clinic over a 13-month interval, were included in the chart review.
• The average age of onset was 15 years old, 18 patients (46%) were males.
• The average times from evaluation to symptom resolution were 120 days.
• Of 18 patients who completed head-up tilt table testing, 17 (94%) had an orthostatic tachycardic response (more than a 40 bpm heart rate increment).

These observations helped the researchers suggest that post-concussive orthostatic intolerance differs from other orthostatic intolerance etiologies, lacking a strong female predominance (a typically post-concussion syndrome in adolescents is seen more in the girls) and exhibiting a shorter time course to recovery compared to other etiologies of orthostatic intolerance (but longer recovery time compared to concussion patients in general).

Here is the conclusion: "Clinical orthostatic vital signs may not be sensitive for diagnosing orthostatic intolerance in athletes, likely due to the higher vagal tone and more efficient skeletal muscle pump."

So what does this mean?

• The guidelines for recognizing orthostatic intolerance as a problem in post-concussion athletes cannot be used to accurately assess the adolescent athlete with suspected orthostatic intolerance. This makes treatment understanding more complex. The doctor has to thoroughly invest the symptoms that the patient is displaying.

Vagal tone. What does this mean?

• The younger athlete has a better course of recovery from post-concussion syndrome due to higher vagal tone and more efficient skeletal muscle pump.

Many people reading this article will have a great understanding of the role of the vagus nerve and its function. The vagus nerves work optimally when their signals, messages, and relayed brain instructions flow through the body unimpeded.

The most important nerve in the body is the vagus nerve and we have two of them – one on each side of the neck. The health of the body is determined by the ability of these two vagus nerves to accurately, quickly, and effectively assess everything going on from moment to moment. The vagus nerves assess everything we eat, say, hear, think, and do and help the body make the proper adjustments for vigorous optimal health. With healthy vagus nerves, the overall nervous system is stronger, faster, calmer, and better equipped to handle stress. Strong vagus nerves are correlated with energy, mental alertness, intelligence, and vibrant functioning of the human body. Poor vagus functioning, called vagopathy or vagal tone, precedes illness and chronic condition It also perpetuates illness and makes recovery from diseases difficult. Low vagus nerve function has four main manifestations in the human body that increase the risk for almost all human diseases: chronic inflammation, elevated oxidative stress, sympathetic dominance, and coagulopathy. For more information on the Vagus nerve please see our article: Testing the vagus nerve.

What we suggest here is that if the athlete has better recovery time and better response to recovery in situations of orthostatic intolerance because of a stronger vagal tone, should we not look for vagus nerve dysfunction in athletes who are not responding well?

When I turn my head my symptoms get worse – when I get an MRI no one asks me to turn my head

The title of a December 2020 paper, "Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers" published in the journal Brain Sciences (18) explored the idea that a novel test to determine if someone is suffering from post-concussion syndrome, is to have the patient turn their head to one side and then the next. Let's get to the research and then the explanation of what this would mean to someone suffering from these symptoms:

"Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB)."

Some of you reading this article may be familiar with Computerized Dynamic Posturography testing. The idea is that there are three systems in our bodies that help maintain proper balance. They are:

• Vestibular (inner ear system),
• Somatosensory (simply how your feet sense a change in the surface that you are standing or walking on and how the feet transmits messages back to the brain)
• Vision

As comprehensive as this sounds, there is a problem with this system. According to these researchers, that problem is: " . . . tests relying largely on eyes-open and eyes-closed standing positions with the head in a neutral position, associated with the probability of missing postural instabilities associated with head positions of the neutral plane."

In other words, testing when someone is standing even on the ground may miss problems associated with someone walking on an uneven surface. Uneven surfaces would also impact the position of the head with the rest of the body.

Let's hear more from the researchers: "Postural stability scores are compromised with changes in head positions after a concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores. . . "

In other words, when the patients turn their heads, they have less stability.

Here is the summary conclusion of this research:

"Balance loss or compromise may be caused by neurological disorders that increase the time delay in the neuromuscular system. (The study authors) have demonstrated that the position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores . . . Sport-related concussion is associated with inconsistency in clinical assessment integrity, largely focusing on the function of neurocognition, symptom scores, and postural stability.  . . Concussion represents a functional rather than a structural injury that results in shear stress to the brain and neck. The standardized (test) head-neutral postural examinations are not adequate to identify individuals that have suffered a concussion. However, this study has identified significant differences in the postural stability scores with head turns in post-concussion syndrome subjects that differentiate them from normal healthy controls."

The suggestion was then made that head turns be included in post-concussion patient analysis.

Turning their head to one side or another will make the patient dizzy or blur their vision or cause ringing in the ears or make them pass out

Many patients we see with post-concussion syndrome, whiplash, cervical spine instability, will often tell us that their symptoms are worse when they turn their head from side to side. What can cause this? In some instances, it can be some type of brain injury that is causing a blockage to the brain. But what about MRIs and Scans that don't show anything out of the norm?

Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and arterial compression

Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). This junction is a unique junction in the cervical spine as the C1 and C2 are not shaped like cervical vertebrae. They are more flattened so as to serve as a platform to hold the head up. The bundle of ligaments that support this joint is strong bands that provide strength and stability while allowing the flexibility of head movement and allow unimpeded access (prevention of herniation or "pinch") of blood vessels that travel through them to the brain.

In impact injuries, significant enough to cause a concussion, there is a strong likelihood that in head-snapping or head impact collision, some type of damage occurred to the cervical spine ligaments.

Understanding blood flow to the brain in patients

Most patients know the exact head position that gives them the symptoms of dizziness, "lack of oxygen to the brain," and related problems. I can tell you that head position is almost always when they are standing or sitting upright, not when they are lying down or standing upright with a stiff postural position. Their head does not move.

The cervical spine is intertwined with nerves and blood vessels. Cervical spine instability can compress or pinch the nerves and arteries causing a myriad of symptoms depending on how the patient moves his/her head.

Post-Concussion Syndrome, Intracranial Hypotension and cerebrospinal fluid (CSF) leak

We will often be contacted by people who have a wide array of symptoms such as those mentioned above, fatigue, neck pain, pain that travels down to the lumbar spine, insomnia,  disassociation, anxiety, and depression. After many visits to many doctors and many tests with no or little alleviation of their problems, Intracranial Hypotension and cerebrospinal fluid (CSF) leak may be suspected.

We have seen many patients who were eventually diagnosed with intracranial hypertension. In many of these people, intracranial hypertension was not initially thought of as a problem as their doctors instead tackled the symptoms that these people were facing. Once a problem of intracranial hypertension or a  build-up of pressure around the brain was discovered, a myriad of tests and treatments were tried.

Two case histories presented in the medical journal Cureus (19) in September 2020 helps give an independent insight into the problems we see at our center. The two case histories are of two US football players. Here are the learning points of this research.

Doctors are not sure if a concussion can cause a CSF leaf

"Intracranial hypotension can be a common sequela of a cerebrospinal fluid (CSF) leak. However, evidence of such a condition related to an injury in American football is currently lacking in the literature. While a positional or orthostatic headache is the most classic symptom of headaches due to intracranial hypotension, a variety of nonspecific symptoms such as neck pain, nausea, vomiting, photophobia, phonophobia (an anxiety level fear of loud sounds) and visual changes can also be present."

The two college football players

The doctors of this study then presented two cases where collegiate American football players developed protracted headaches after a concussive injury and were subsequently diagnosed with intracranial hypotension thought secondary to spinal CSF leaks.

Both players underwent multiple procedures of fluoroscopic-guided autologous blood patching (the use of blood to patch leaks), with improvement in their headaches. Recovery varied between the athletes.

The researchers concluded: "Both these cases emphasize the importance of including CSF leak as a cause of post-traumatic headache in an American football player."

In some cases, people will tell us of many years of symptoms and many years of treatment when finally an upright MRI revealed displaced C1-C2 causing blocked CSF flow. Adjustments help improve their symptoms but would not hold.

Post-Concussion and carotid artery compression

Sometimes people will describe a long history of neck pain treatments that took them all the way to surgery to decompress the carotid artery. What got them to this point was a sensation that they were not getting enough blood to the brain or that they seemed to be oxygen-starved. They had brain fog, mood problems, memory problems. They also repeat repeated concussions, neck impact injuries, and multiple herniated discs.

What are we seeing in this image? Kinking or compression of the carotid sheath at the craniocervical junction.

The carotid sheath contents include the internal carotid artery, internal jugular vein as well as the vagus, glossopharyngeal and spinal accessory nerves. These vital structures can be compressed as they make their way from the neck to the brain. Specifically challenging in the 90 degrees right-angle turn this carotid sheath makes at the C1 atlas transverse process which the white arrow in the center of the image demonstrates.

Transcranial Doppler & Extracranial Doppler Ultrasound

For this and other reasons, we offer testing with Transcranial Doppler & Extracranial Doppler Ultrasound. For the full article on this testing please visit our page:Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center.

Here is a summary of that article and how this type of testing can show disruptions in blood flow to the brain and may help explain to patients why they feel that they are "not getting enough oxygen."

• Transcranial doppler (TCD) can track real-time, moment-to-moment changes in blood flow to the brain. This allows for an assessment of blood flow changes to the brain and their impact on patient symptoms when the patient moves their head and creates changes in neck positioning. This includes monitoring the blood flow even while the patient walks into the office.

Understanding that blood flow may only be suppressed in certain positions of the neck

• If the blood flow is intermittently compromised, such as only when the neck is in certain positions, it will be difficult to catch and diagnose. To assess proper blood flow to the body's most important nerves and nervous tissue (the brain), especially with head and neck motions, we perform transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound examinations.
• It is through dynamic transcranial doppler (TCD) and extracranial Doppler (ECD) ultrasound analysis that this decrease in blood supply can be documented with its root cause being compression of the arteries as they run through the cervical spine.

Digital motion X-Ray C1 – C2

At our center, we use a Digital motion X-ray so we can watch your head in motion. The digital motion x-ray is explained and demonstrated below

• Digital Motion X-ray can show instability at the C1-C2 Facet Joints
• The amount of misalignment or "overhang" between the C1-C2 demonstrates the degree of instability in the upper cervical spine which may lead to an understanding of why the patient is not responding to conventional treatments for post-concussion syndrome.

You can also visit this page on our site for more information on Digital Motion X-ray (DMX)

Treatment of interest: Prolotherapy for cervical ligaments damage and cervical neck instability may help post-concussion syndrome

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.

The above research shows us where medicine is in regard to the difficult to treat patients with persistent chronic whiplash disorder.In our opinion, prolonged symptoms of concussion or whiplash – and difficulties with concentration and memory or other neurologic type issues are usually not problems solely correlated with the cervical discs damaged in whiplash concussion but a problem of damage to the cervical ligaments.

When ligaments are subjected to quick forces, as occurs in whiplash concussion traumas, it does not take much to tear or overstretch them. All whiplash traumas have the potential to significantly injure cervical ligaments and cause neck instability.

The treatment of cervical spine instability at the Hauser Neck Center – Research on cervical instability and Prolotherapy

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Our research documents our experience with our patients.

In 2015, our research team at Caring Medical published findings in the European Journal of Preventive Medicine (20) investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots. Irritation of nerve roots causes many of the symptoms and challenges our patients face.

Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

• Ninety-five percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
• Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
• Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability ofProlotherapy for cervical spine instability.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments inThe Open Orthopaedics Journal. (21) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

This is what we wrote in this paper: "To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems is not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs (such as excessive sweating or inability to sweat and temperature dysregulation or other skin sensations mentioned in this article) or symptoms."

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of many of the symptoms we mentioned above.

Summary and contact us. Can we help you? How do I know if I'm a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding persistent post-concussion syndrome. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References:

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This article was updated December 13,2021

If a Head Ct Comes Back Normal but Having Double Vision After a Concussion

Source: https://www.caringmedical.com/prolotherapy-news/post-concussion-syndrome/

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