Concussion Phenotypes Part 2
The 7 Phenotypes of Concussions: Finishing the Conversation
Today, we’re diving into the second half of our discussion on the seven phenotypes of concussions. If you’re just tuning in now, I highly recommend going back to our previous post where we introduced the first three phenotypes: autonomics, vestibular, and visual. Why? Because understanding these foundational pieces will enhance how you engage with what’s coming next.
Full disclosure, those three are my favorites—there's just something beautiful about how they integrate. But today, we're moving into four more phenotypes, some of which stretch outside my personal scope as a physical therapist. That’s why having a solid multidisciplinary team is critical. This is the approach we take at my clinic, Symphony Brain Performance, in Nanaimo, where we have PTs, OTs, SLPs, clinical counselors, and athletic therapists working together to address the full spectrum of a client's needs. After all, a holistic and collaborative approach is non-negotiable in effective concussion care...
While most clients start with physical or athletic therapy, it's essential that we screen for all phenotypes early on, making the appropriate referral when needed. This is especially important given the significant symptom overlap between the phenotypes—a recurring theme throughout our conversation. We use tools like subjective clinical outcome scores and objective assessments to ensure we identify the right phenotype and build the most specific, individualized treatment plan, or make the right referral.
Last time, we touched on tools like the Clinical Profile Screen and Compass 31 to assess autonomic dysfunction. Today, we're focusing on cervical, affective, cognitive, and headache/migraine phenotypes. Let’s dive in...
The Cervical Phenotype
When you think about the mechanism of a concussion—essentially the acceleration and deceleration of the brain within the skull—this isn’t just from a blow to the head. A force to the neck or body can also cause it. Interestingly, while it takes about 70g of force to cause a concussion, it only takes 6g for whiplash. So, if you or a client has experienced a concussion, please ensure that the neck is thoroughly assessed.
The cervical phenotype can involve dizziness, pain in the neck, suboccipitals, and even referral patterns into the skull or shoulders. And yes, dizziness, that notorious word, is back again! Whenever someone says, "I feel dizzy," I always ask, “Can you describe it using any other word?” This simple question can offer so much insight into what’s really going on...
When assessing the cervical phenotype, we also consider balance. Through tests like a cervical challenge (not my term, but what my posturography system calls it), we look at how balance and posture shift when we alter head positioning. It’s fascinating how cognitive dysfunction, autonomic dysfunction, and even emotional symptoms can be mimicked by cervical spine issues. Cervical proprioceptors—especially those in the suboccipitals—are among the most concentrated in the body, meaning cervical dysfunction is almost always part of the concussion picture.
However, one of the most common things I hear from clients is, "I've already had my neck treated." When I dig deeper, it’s often passive treatments like massage or osteopathy. Those approaches are valuable, but they often leave the journey unfinished. It’s just the beginning... We need to address pain, muscle tone, motor control, and whether the head knows where it is in space.
The Affective Phenotype
The affective phenotype revolves around emotional health—specifically anxiety, depression, and mood regulation. It breaks my heart when I hear clients say they were told, "It's just your anxiety" or "It's just your depression." Whether these symptoms were present pre-concussion or not, they are real and rooted in neurophysiological changes. One study compared depression in those with a history of mild traumatic brain injury (mTBI) to those without and found that post-TBI depression may not respond as well to standard treatments like SSRIs. Why? Because it may stem from connectivity issues in the brain...
Symptoms of the affective phenotype often overlap with others—there's that dizziness again, headaches, and behavior changes, like irritability, inattention, or even dissociation. When anxiety is present, we must always ask: "Is this being driven by an underlying nervous system imbalance?" Anxiety is a symptom, often linked to a more sympathetic nervous system state, whereas depression can reflect a dorsal vagal state. And imagine leaving your house only to feel like the world is tilted... that would create anxiety for anyone! This is why our assessments need to dive deep into what's truly going on...
Here’s where collaboration shines—connecting clients with somatic therapists, clinical counselors, and psychologists who understand the nervous system is key. Addressing anxiety and depression in concussion clients requires a nuanced and supportive approach.
The Cognitive Phenotype
Cognitive challenges are typically the most noticeable issues for clients. Whether it’s memory loss, slowed thinking, or feeling overwhelmed by even simple tasks, cognitive dysfunction hits hard. Clients often report "cognitive intolerance"—like exercise intolerance, but for mental tasks. Sustained cognitive activity leads to increased symptoms...
Common triggers include work, academic settings, and social situations. Tasks that involve planning or sequencing, like cooking or organizing, become frustrating and overwhelming. Reaction times can be delayed, making everyday interactions challenging.
Personally, I screen for cognitive issues in every client, but deeper assessments often mean referrals to occupational therapists or speech-language pathologists (SLPs). If an in-depth assessment is needed, neuropsychologists come into the mix. This is another layer of our holistic team approach...
The Headache/Migraine Phenotype
Some classify headaches and migraines as their own phenotype, but I struggle with this categorization. A headache is a symptom, not a root cause. It can be driven by autonomic, vestibular, visual, or cervical dysfunction, among others. Treating it with medication alone? That’s just a band-aid. Unless we dig deeper to understand why the headache is happening, we’re missing the opportunity for true healing.
Migraines are another story. We can absolutely dive into migraines in a future post, and I’d love to bring in a guest expert for that. For now, just know that migraines can be influenced by a combination of hormonal, musculoskeletal, neurological, and even nutritional factors.
Final Thoughts
What I hope these two posts have shown is that you can’t simply treat symptoms without looking at their root cause. I want to share a quick story. Recently, a mother reached out to me on Instagram. Her daughter had sustained a concussion, and they were doing all the right things. They even had an appointment at a concussion clinic. However, when they left, the mother messaged me to say the therapist had told them, “There are no different types of concussion; we just treat symptoms.”
I had to pause.
What you’ve likely gathered from this series is that there are different types of concussion, and each symptom needs to be approached based on its root cause. A headache driven by autonomic dysfunction is not the same as one caused by cervical issues or visual dysfunction.
Communication is key. Clients are well-informed today. They know when someone is just pulling things from thin air. In my early days as a therapist, I had no idea how complex concussion treatment was. But I learned, and I communicated openly with my clients.
So clinicians, I encourage you to take a moment and dive deeper with your clients. A little extra time spent explaining the connection between symptoms and root causes will go a long way. And clients, I hope this series has helped you feel seen, heard, and validated.
Now it's your turn: Have you experienced symptoms that didn’t quite fit into a single category? What has your journey with concussion recovery looked like so far? Let’s talk…
