Overview
Concussion of the cervical spinal cord, often referred to as cervical spine concussion (CSC), is a complex condition that extends beyond the typical brain-focused concussion paradigm. It encompasses injuries where the cervical spine is involved, potentially exacerbating symptoms and recovery times. Epidemiological studies highlight significant sex differences, with female athletes experiencing higher rates of concussion and more severe symptoms compared to their male counterparts, particularly in comparable sports [PMID:30645949]. These disparities are hypothesized to stem from differences in cervical spine biomechanics, suggesting that anatomical and physiological factors play crucial roles in injury susceptibility and outcomes [PMID:30645949]. Despite these insights, the exact mechanisms underlying these differences remain areas of ongoing research, emphasizing the need for tailored prevention and management strategies.
Epidemiology
Epidemiological studies reveal notable disparities in concussion incidence among athletes based on sex and prior injury history. Female university athletes competing in similar sports exhibit higher rates of sport-related concussions (SRC) compared to males, often accompanied by more severe symptoms and prolonged recovery periods [PMID:30645949]. This gender disparity may be attributed to differences in cervical spine biomechanics, where females might experience greater vulnerability to injury due to variations in neck strength, girth, and muscle activation patterns [PMID:30645949]. However, a study involving 451 elite athletes found no significant differences in neck flexor, extensor, and lateral flexor strengths between athletes with and without a history of SRC, indicating that baseline strength alone may not fully explain injury risk [PMID:40902328].
The protective role of neck strength against SRC remains an area of interest but with mixed evidence. A systematic review and meta-analysis encompassing 7625 participants across various team sports suggested a small, nonsignificant trend towards a protective effect of neck strength, though the evidence was characterized by substantial heterogeneity and very low certainty [PMID:37428807]. This variability underscores the complexity of concussion risk factors and highlights the need for more robust, consistent methodologies in future research. Additionally, a prospective cohort study of 136 male professional rugby players indicated that a history of concussion significantly increased the odds of sustaining another concussion (OR = 2.25; 95% CI: 0.73, 6.22), emphasizing the cumulative risk associated with prior injuries [PMID:37017931].
Incidence rates of concussions vary across sports and populations. For instance, during a full season, 45 concussions were reported among 44 players, translating to an incidence rate of 19.7 concussions per 1000 player-match hours [PMID:35526515]. Similarly, another study documented 30 concussions in 29 players over the 2018/2019 season, yielding a rate of 13.7 concussions per 1000 hours played [PMID:35197247]. These data highlight the variability in concussion incidence and underscore the importance of sport-specific risk assessments and tailored prevention strategies.
Clinical Presentation
The clinical presentation of cervical spine concussion (CSC) often includes both neurological and musculoskeletal symptoms, reflecting the multifaceted nature of these injuries. Neck strength and girth are emerging as potential modifiable risk factors, with lower neck strength and girth associated with increased head acceleration during impact, thereby elevating concussion risk [PMID:30645949]. Interestingly, athletes with a recent SRC (within the last 12 months) exhibited a slight increase in neck extensor strength, though this finding was small and may not have substantial clinical implications [PMID:40902328]. Despite this, peak isometric flexion strength and endurance were not found to be associated with concussion risk, while marginally increased peak isometric extension strength showed a weak correlation that lacks clinical significance [PMID:37017931].
Cervicogenic symptoms, originating from the cervical spine, are particularly noteworthy as they can significantly contribute to persistent postconcussion symptoms [PMID:33771946]. This highlights the necessity for a comprehensive evaluation that includes cervical spine assessment to identify and manage these symptoms effectively. Kinematic studies further emphasize the critical role of impact dynamics over cervical muscle activation states in influencing head kinematics [PMID:30745221]. Clinicians should therefore consider not only muscle strength but also the mechanics of impact when evaluating concussion risk and managing patients post-injury.
Diagnosis
Diagnosing cervical spine concussion (CSC) requires a multifaceted approach that integrates clinical assessment with biomechanical considerations. Athletic trainers (ATs) play a pivotal role in this process, with their likelihood of utilizing cervical clinical testing post-concussion influenced significantly by their perceived importance of such tests [PMID:33771946]. Diagnostic assessments often rely on models like the Hybrid III and free-head models to evaluate head kinematics. However, studies indicate notable differences in linear and angular acceleration metrics between these models and relaxed neck conditions, suggesting caution in interpreting diagnostic outcomes solely based on these models [PMID:30745221]. This variability underscores the need for comprehensive clinical evaluation that includes subjective symptoms, neurological assessments, and cervical spine-specific tests to ensure accurate diagnosis.
Management
Effective management of cervical spine concussion (CSC) involves a holistic approach that addresses both neurological and musculoskeletal aspects of the injury. Sternocleidomastoid (SCM) muscle strength has been identified as a critical factor, predicting both linear and rotational head acceleration, thus playing a key role in SRC risk reduction [PMID:30645949]. Importantly, while a history of concussion does not impair maximal isometric neck strength, management strategies focusing on neck strengthening can be broadly applied without significant adjustments based on prior injury history [PMID:40902328]. Given the suggestive evidence linking higher neck strength to reduced SRC incidence, incorporating neck strength training into athlete preparation programs could be beneficial, although the current evidence is characterized by low certainty [PMID:37428807].
Interventions aimed at concussion prevention and management should prioritize addressing athletes with a history of concussions, as these individuals face a heightened risk of recurrence [PMID:37017931]. Enhancing proprioceptive function, particularly in right rotation, shows promise in mitigating concussion risk [PMID:35526515]. Additionally, focusing on neck extension strength as a modifiable intrinsic risk factor may contribute to prevention efforts [PMID:35197247]. Clinicians should also consider the comfort level and utilization patterns of cervical treatments, as low comfort and low utilization of cervical clinical testing correlate with higher post-concussion testing [PMID:33771946]. Predictive models suggest that recommendations for cervical-specific therapy in managing persistent post-concussion symptoms can be guided by ATs' clinical experience and utilization of cervical tests, with notable predictive accuracy [PMID:33771946].
However, it is crucial to recognize that interventions targeting solely neck strength might not substantially reduce concussion risk due to the minimal impact of cervical muscle activation compared to impact dynamics [PMID:30745221]. Therefore, a comprehensive approach that includes biomechanical education, protective equipment, and multifaceted training programs is essential for effective concussion prevention and management.
Key Recommendations
References
1 Streifer M, Brown AM, Porfido T, Anderson EZ, Buckman JF, Esopenko C. The Potential Role of the Cervical Spine in Sports-Related Concussion: Clinical Perspectives and Considerations for Risk Reduction. The Journal of orthopaedic and sports physical therapy 2019. link 2 Kavyani A, Bourne M, Williams M, Timmins R, Peek K, Bennett H et al.. The impact of sport-related concussion history on neck strength in elite Australian rules football and rugby league athletes. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine 2025. link 3 Garrett JM, Mastrorocco M, Peek K, van den Hoek DJ, McGuckian TB. The Relationship Between Neck Strength and Sports-Related Concussion in Team Sports: A Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy 2023. link 4 Liston M, Leckey C, Whale A, van Dyk N. Neck Strength Assessment Offers No Clinical Value in Predicting Concussion in Male Professional Rugby Players: A Prospective Cohort Study. The Journal of orthopaedic and sports physical therapy 2023. link 5 Farley T, Barry E, Bester K, Barbero A, Thoroughgood J, De Medici A et al.. Poor cervical proprioception as a risk factor for concussion in professional male rugby union players. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine 2022. link 6 Farley T, Barry E, Sylvester R, Medici A, Wilson MG. Poor isometric neck extension strength as a risk factor for concussion in male professional Rugby Union players. British journal of sports medicine 2022. link 7 Cheever K, Kay M. Certified Athletic Trainers' Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion. Journal of sport rehabilitation 2021. link 8 Eckersley CP, Nightingale RW, Luck JF, Bass CR. The role of cervical muscles in mitigating concussion. Journal of science and medicine in sport 2019. link