Concussions and Post Concussion Syndrome

Concussions and Post Concussion Syndrome
By Lillian Byington PT, DPT, OCS, CMPT

Up to 3 million people each year seek medical treatment for concussions and concussion related symptoms; and further research indicates that up to half of people experiencing concussion do not report their symptoms. This suggests that up to 6 million people each year experience symptoms of concussion. While most people recover within a few weeks, 14-33% of patients complain of persistent symptoms 3+ months after injury. Current testing for concussion is limited. In the first 3 days after injury, there are some standardized assessments such as bloodwork, CT, and/or MRI which can be performed to diagnose concussion. These are often impractical and are not yet commonly used in the diagnosis or treatment of concussion.[/caption]

Once 4-5 days after injury have passed, there are no specific tests for concussion. Becoming more common is the use of physical therapy to treat the symptoms associated with concussions to maximize return to sport. Below we have summarized the most common symptoms and reviewed what physical therapy treatment addresses in order to treat patients.
60% of people suffering from concussion complain of dizziness. Physical therapy exam consists of testing your vision, how well you can track moving objects, balance, and inner ear function. Once we know which aspects are contributing to symptoms of dizziness, we can design a treatment program to help address any deficits you may have
Memory loss and/or exercise intolerance
Memory loss and exercise intolerance seem to be correlated in patients after concussion. Research suggests that this is due to cerebral blood flow changes in the first 3 days after injury. While these symptoms can persist for weeks to months, blood flow changes seem to resolve within the first 3 days. We use a combination of endurance/cardiovascular tests and patient reported symptoms to design a gradual exercise program to minimize these symptoms
Visual disturbances
42-55% of patients note visual disturbances after concussion. A full exam to test your vision and how well you track moving objects can help differentiate these symptoms from dizziness. Once we know which aspects are contributing to your symptoms, we can design a treatment program to help address any deficits you may have
Mood changes/anxiety
25% of patients with concussion report new symptoms of anxiety and mood changes. These are usually assessed with patient history and subjective reports
Migraine headache
70% of patients with concussion report new onset of migraine headaches. There is an international classification criteria to diagnose migraine vs headache. A full exam of your neck will also help us determine what is causing your headaches. Once we know what your deficits are, we can coordinate with your doctor and/or treat any physical impairments we have found in order to reduce your headache.
Neck pain
Neck pain can also contribute to headaches and dizziness. A full neck exam, visual exam, and balance screen can help us determine what specifically is causing your symptoms and allow us to design a treatment plan to address your specific issues to help you feel better
Cognitive deficits
Changes in mental function are some of the first diagnosis tools we had for concussion. Studies suggest these deficits can last days to months. While pre-injury baseline testing is useful, it is not necessary. We use a combination of patient history and dynamic balance/memory tests to help determine what your deficits are and incorporate them into your treatment plan

Recovery from concussions

Clinical recovery from a concussion (what the patient reports as their symptoms) is often very different from physiological recovery from concussion. We know changes in electrical response, metabolic balance, and oxygen consumption persist for several months after a patient’s clinical testing comes back normal and patients report being symptom free. We base most of our return to activity on the clinical tests listed above, and patient reports of symptoms.
Allowing clinical signs to completely resolve before returning to sport not only reduces the risk for future concussion, but also reduces the risk of other injury.

What does this mean for me?

If you have been diagnosed with a concussion OR if you feel that you may have suffered a concussion, and are still dealing with side effects, physical therapy can help. Here at PT First we focus on what your symptoms are and how they affect you, and use that to guide our examination and treatment plan so we can get you back to your activities.

Original Article – Diagnosis and Management of Concussion

Mucha, Anne, and Alicia Trbovich. “Considerations for Diagnosis and Management of Concussion.” Journal of Orhopaedic and Sports Physical Therapy, vol. 49, ser. 11, Nov. 2019, pp. 787–798. 11.

Dry Needling Treatment – How it Works

Dry Needling Treatment Explained
by Logan Swisher SPT

How is Dry Needling treatment applied?

Dry needling treatment has become an increasingly popular treatment technique performed by certified health care providers. It refers to the insertion of a very thin needle into muscles, ligaments, tendons, subcutaneous fascia, and/or scar tissue for the management of numerous musculoskeletal pain syndromes.

Trigger points

There are several advantages to the technique documented in the literature which include an immediate reduction in local and /or widespread pain, restoration of range of motion and normalization of chemical imbalances with active myofascial trigger points. A trigger point is a hyperirritable spot often referred to “a knot” in the muscle or fascia which can cause pinpoint pain in the or refer to another area in the body. Trigger points can further be divided into active and latent trigger points. Active trigger points commonly have spontaneous local and referred pain while latent trigger points do not cause spontaneous pain unless they are stimulated by pressure.

How are trigger points formed?

The exact mechanism of trigger point formation is not well understood but it is thought that it starts as the development of tight muscle fibers or taut bands which may or may not be painful. This is possibly due to chemical reaction dysfunction at the cellular level of muscle fibers. Trigger points are thought to develop following low-load repetitive tasks, sustained postures or rapid loading and unloading of muscles. Initially taut band formation is a normal physiologic, protective and stabilizing mechanism associated with damage or potential muscle damage. Active trigger points produce constant pain signals to the brain which can alter movement patterns and lead to disuse. Trigger points have also been seen to cause decreased blood flow and oxygen to the affect muscle which further decreases the muscles ability to function properly.

Differences between dry needling treatment and manual trigger point release

The main difference between dry needling and manual trigger point release is the specificity dry needling provides. Dry needling latent trigger points can lead to their inactivation and prevent the formation of active trigger points as well as reduce the pain signals they produce. It is rarely a stand-alone treatment and is generally considered another instrument assisted manual therapy technique. Dry needling can be very useful in facilitating a rapid reduction of pain and return to function.

How it is applied at Physical Therapy First

Here at PTFirst we will perform a comprehensive exam and work with you to decide if dry needling is a good option for you. We pride ourselves on taking a multimodal approach to reducing pain and improving function so you can return to the activities that are important to you.

Can Physical Therapy help my Headache?

By Maureen Ambrose PT, DPT, OCS


Headaches are a common complaint for many people, and most assume that it is just normal part of life. Some may experience headaches multiple times per week or even daily. Patients often report that headache medication may help reduce the severity of the symptoms, but does not eliminate them entirely or stop them from coming back.  If this is true for you, it may be a sign that your headaches are related to dysfunction in your neck. Both tension headache and the various forms of migraine headaches will likely have a musculoskeletal component.


The term “cervicogenic headache” indicates that although pain is felt in the head, the root cause of the symptoms related to the neck (cervical spine). Common root causes of head and facial pain include:

– Altered cervical spine alignment

– Forward head posture

– Muscle tightness or trigger points in the following muscles (see figure above)

– Upper Trapezius

– Suboccipitals

– Sternocleidomastoid

– Splenius capitus and Splenius cervicis

– Shallow breathing pattern using the neck muscles

– Jaw clenching or grinding


 Now, what about those who just attribute their headaches to work-life stress? While it may be true that the headache feels worse during times of stress, it could be related to some of the root causes listed above. During a stressful meeting, do you resort to a shallow breathing pattern and overwork the neck muscles? Or, while concentrating on work, are you holding tension in your jaw or facial muscles and clenching? Each of these, over time and with repetition, has the potential to create trigger points in the neck muscles that can lead to referred pain in the head and face.

Physical Therapy for headaches begins with an exam of your neck alignment, posture, muscle strength, and breathing pattern. Treatment involves postural correction and neck strengthening, releasing trigger points, correcting breathing patterns, and improving postural and muscle awareness. If you feel that these factors could be a cause of your headaches, Physical Therapy First can help identify and treat these issues.


There are times when the headache is more than “cervicogenic,” and the following red flags from The Amercian Migraine Foundation indicate the need for medical attention:

  1. Thunderclap Headache: very severe headache that reaches its maximum severity immediately (within a couple of minutes). Thunderclap headaches require emergent medical evaluation.
  2. Positional Headache: headache that substantially changes in intensity in association with changes in position – e.g. standing from lying or vice-versa.
  3. Headaches Initiated by Exertion: headache starting while coughing, sneezing, and/or straining.
  4. New Headaches: especially if older than 50 years of age, or if there are medical conditions that make worrisome headaches more likely (e.g. cancer, blood clotting disorder).
  5. Substantial Change in Headache Pattern
  6. Constant Headache Always in the Same Location of the Head
  7. Worrisome Neurologic Symptoms: about 1/3 of people with migraine have neurologic symptoms (“migraine aura”) that typically precede onset of a migraine headache. Commonly, aura symptoms consist of slowly spreading visual symptoms sometimes accompanied by tingling of the face and upper extremity. These symptoms resolve within 60 minutes. If these symptoms have immediate onset (as opposed to a slow progression of symptoms), last longer than 60 minutes, or do not completely resolve, medical attention is required. Medical attention is also required if other symptoms are present, such as weakness of one side of the body, change in level of consciousness, significant difficulty walking, or other symptoms that worry you.
  8. Headache that never goes away
  9. Systemic symptoms: including fever, chills, weight loss, night sweats


(1)Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1. Baltimore. Williams and Wilkins. 1993

(2) American Migraine Foundation

Does Dry Needling really work?

A Dry Needling Study
by Logan Swisher SPT


Myofascial pain syndrome is caused by myofascial trigger points or highly localized and irritable spots in muscle. Recently dry needling has been used as an instrument assisted technique to address myofascial trigger points. Research in the effectiveness of dry needling has been limited by the difficulty of providing a true control or sham treatment. This study took advantage of a planned total knee replacement to allow for needling vs no needling while a patient was under anesthesia to allow for a true randomized clinical trial. Trigger points are common in lower extremity muscles in patients with hip and/or knee osteoarthritis. Most patients experience the greatest amount of pain in the first month following a total knee replacement.


40 total participants

-20 participants in the true dry needling group

-20 participants in the sham dry needling group


This study was a double-blind, placebo-controlled, randomized clinical trial. Several hours prior to their total knee replacement surgery, patients were examined by experienced physical therapist for the presence of trigger points. The participants placed into the dry needling group received dry needling for 20 insertions of the intended site while under anesthesia. The participants in the sham dry needling* group did not receive any treatment for their trigger points. Patients gave a baseline and follow up measurements at 1, 3- and 6-months following surgery using the visual analog scale (VAS), need for postoperative analgesics, and the western Ontario and McMaster Universities Osteoarthritis Index Questionnaire (WOMAC).


There was a significant improvement in VAS values with the dry needling* group in the first month as compared to the sham dry needling* group. It was also found that the use of analgesic medications was significantly lower in the dry needling* group.

Dry Needling – Clinical Application:

This study demonstrated dry needling* of trigger points in the lower limbs allowed patients to reach the same degree of pain reduction in 1-month as the subjects with the placebo intervention achieved in 6-months.  The use of dry needling* also significantly reduced the need for post surgical analgesic medications which is always a postoperative goal. While this study was limited to surgical patients, ti was a well-designed study which suggests dry needling* would be beneficial for many patients with muscle pain. Here at PTFirst we can incorporate the use of dry needling, other manual techniques and modalities to reduce muscle pain associated with surgery, injury, and/or overuse.

Dry Needling Article:

Mayoral, O., Salvat, I., Martín, M. T., Martín, S., Santiago, J., Cotarelo, J., & Rodríguez, C. (2013). Efficacy of myofascial trigger point dry needling* in the prevention of pain after total knee arthroplasty: A randomized, double-blinded, placebo-controlled trial. Evidence-Based Complementary and Alternative Medicine : ECAM, 2013, 694941-8. doi:10.1155/2013/694941

A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series

Frozen Shoulder : A Case Series
By Brianna Hurt, SPT

Lirios Dueñas, PT, PhD, Mercè Balasch-Bernat, PT, PhD, Marta Aguilar-Rodríguez, PT, PhD, Filip Struyf, PT, PhD, Mira Meeus, PT, PhD, Enrique Lluch, PT, PhD


Frozen shoulder is a common musculoskeletal disorder that is characterized by a progressive loss of both active and passive mobility of the glenohumeral (shoulder) joint. Muscle strength deficits in external and internal rotation are also common with this condition. Typically, frozen shoulder is thought to follow 3 phases (painful, stiff, and recovery) into a full recovery without any type of treatment. However, recent systematic reviews have found that improvements in mobility and function decrease with time, with the possibility of limitations being present for multiple years.

When managing persons with frozen shoulder, it is important to consider the level of tissue irritability (high, moderate, and low) and adapt treatment strategies based on this. Manual therapy techniques can be used to help restore normal tissue extensibility of the shoulder and help improve range of motion. To restore mobility, improving shoulder rotation should be emphasized over forcing full flexion.

The purpose of this case series was to describe outcomes after the application of manual therapy and a home stretching exercise program for persons with frozen shoulder.

Frozen Shoulder Case Description

Eleven patients diagnosed with frozen shoulder were included in the study. One physical therapist performed all of the baseline measurements and follow up assessments. Measurements were taken before the intervention period, after the 3 month intervention period and at 3 and 6 months after the intervention period. A second physical therapist conducted all of the manual therapy techniques.

Baseline measurements included shoulder pain and disability, range of motion and muscular strength. For the treatment sessions, patients received a 12-session treatment program with treatments lasting 60 minutes, scheduled once a week over 12 weeks. The intervention program consisted of manual therapy techniques based on tissue irritability and shoulder mobility and home stretching exercises.


For the shoulder pain and disability outcome measures, 8 out of the 11 patients showed improvements in pain by 9 months posttreatment and all but one patient improved in their shoulder disability at posttreatment. For range of motion, there were improvements in shoulder flexion, abduction and external rotation at posttreatment in up to 9 patients. For strength measurements, 8 of 11 patients had improvements in shoulder flexion and internal rotation strength at posttreatment, however, none of the patients had improvements in external rotation strength.


When treating patients with frozen shoulder, a multimodal manual therapy approach along with a home stretching program based on tissue irritability and specific shoulder mobility impairments should be used. This approach results in reduced shoulder pain, improved range of motion and increased strength.

Physical Therapy First Approach to Frozen Shoulder Treatment

Here at Physical Therapy First, a complete evaluation is conducted and based on those findings a specific treatment plan is designed that best addresses our patient’s needs. Treatment plans typically include advanced manual therapy joint mobilization techniques, soft tissue mobilization, stretching, therapeutic exercises and providing our patients with a unique home exercise program to maximize outcomes. We offer individualized home exercise routines that can be updated and followed by patients on a user friendly app.  Patients at Physical Therapy First can also benefit from a variety of modalities as well as myofascial trigger point dry needling treatment to muscles as indicated.  Our goal is to provide quality patient care and as this study suggests, a manual therapy approach with home stretching can be used to improve pain, mobility, strength and function in those with frozen shoulder.

Original Article

Dueñas L, Balasch-Bernat M, Aguilar-Rodríguez M, Struyf F, Meeus M, Lluch E. A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series. Journal of Orthopaedic & Sports Physical Therapy. 2019;49(3):192-201. doi:10.2519/jospt.2019.8194