In recent years, our understanding of concussion has grown significantly, with the American Centers of Disease Control and Prevention now labelling the mild traumatic brain injury as a public health issue [1]. Research has linked recurrent concussions with potential neurodegenerative problems in older adulthood [2]. For athletes who may be at risk of concussion, it is no longer simply a matter of resting for a few days and getting back out on the field.
In 2010, a cohort study looked at elite and community-based players of Australian Rules Football. With pre-season cognitive testing on 1,015 original participants in the study, they found 88 concussions in 78 players over the course of the season.
This study (and no doubt other research on this issue) seemed to provide impetus for a change in concussion management protocols. In fact, one of the study’s authors (Michael Makdissi) later co-authored the “Updated Guidelines for the Management of Sports Related Concussion in General Practice” (carried in the Australian Family Physican’s journal Neurology in March 2014 [4]). The paper recommended a focus on improved recognition and reporting of concussion, as well as an emphasis on return to school and learning rather than a return to sport, and suggested a comprehensive clinical approach that included [4]:
- a period of cognitive and physical rest to facilitate recovery
- monitoring post-concussion symptoms and signs to asses recovery
- the use of neuropsychological tests to estimate recovery of cognitive function
- a graduated return to activity with monitoring for recurrence of symptoms
Both papers were indicative of other research and of changing international approaches to concussion management. Still, they came from the world of traditional medicine. In terms of chiropractic research on this important topic, the pickings remain slim. Given that so many chiropractors care for athletes and young people who engage in various levels of sport, any addition to the evidence bank would be noteworthy indeed.
The Chiropractic Case Report
To that end, the most recent edition of the Journal of Contemporary Chiropractic carried a case report of an adolescent football player who reported with concussion. In it, the authors noted that “Generally, concussions self-resolve within 7-14 days. High school and collegiate athletes may have an extended recovery time of 21-28 days [1].” They also noted that while the most common treatment is still rest and medication, research suggests a more active approach. They also noted:
“An active and targeted treatment is dependent on the individuals clinical profile. There are few case reports describing the treatment and management of concussion involve chiropractic care. Concussion is so widely variable and individualized that a 1-treatment-fits-all approach may be less effective.”
Immediate assessment of the patient following his injury on the field was undertaken by the team chiropractor. It revealed some significant indicators. Despite the fact that his pupils were responsive and reactive to light, he showed decreased strength in the upper left extremities, light touch sensation, orientation, immediate memory and delayed recall. Following the prescribed amount of cognitive and physical rest, he reported to the chiropractor days later reporting dizziness, headaches and nausea (the latter when trying to complete homework). In fact, concentration, reaction times, nausea and neck pain remained an issue.
The papers authors explained that:
“Five days following the initial concussion, the patient came for his second office visit. Symptoms included episodes of dizziness and feeling in a “fog”. He had a headache that he verbally rates at a 3/10. Objective examination demonstrated difficulty with balance, especially with his eyes closed. The SCAT-5 assessment was again given for ongoing assessment as well to help monitor deficiencies in cognition and balance. The SCAT-5 revealed the following deficits: orientation 4/5, immediate memory 13/15, concentration 2/5 7 out of 30 possible balance errors, delayed recall 0/5. At this visit, both cervical and thoracic spinal segmental dysfunctions were identified along with continued myofascial restrictions noted at the initial evaluation.”
The patients care was multimodal, including myofascial release, ultrasound-electrical stimulation, spinal manipulation and a targeted home exercise program. The patient was asymptomatic by the 19th day but still tested as (only) slightly below baseline on visual memory and reaction time. On his 6th and final visit on the 27th day post-concussion, he was completely back to normal. While it may seem as if the patients recovery was lengthy, one could also argue that it was the thorough assessment that revealed even slight impairment once the patient was feeling better.
The researchers noted that:
“There is
emerging literature that indicates both active treatment strategies and manual
therapy in the early stages for those suffering from SRC, including cervical spine
and vestibular rehabilitation for that dysfunction [1].”
“It has become evident that cervical spine manipulation provides functional improvement to a target and adjacent motion segment by improving motion in all planes. Improving the motion of the involves spinal segments helps to decrease cervical dysfunction. The patient demonstrated restoration of cervical range of motion during the course of his care, along with resolution of symptomatology [1].“
Chiropractic care has already been shown to benefit cervical spine range of motion, and there are strong indicators that we may also have a role in vestibular rehabilitation. Therefore these findings are enlightening. Among the conclusions of the study was the assertion that “chiropractic care may offer an active approach to concussion management and treatment to expedite recovery and patient outcomes [1].”
In this case, the attending chiropractor was ideally placed to perform functional and neurocognitive tests and facilitate any imaging that was required for this individuals management and recovery. Indeed, this offers a little insight into the positive results a partnership between chiropractor and concussion patient may yield on a road to full recovery.
So much more research is needed. But while we wait for the randomized controlled trials, its certainly nice to have this case report in the bank. For the full case report, including more detailed progress breakdowns and details of the chiropractors approach, check out the full report referenced below.
REFERENCES:
- McArthur T and Olson H (2019), “Concussion management in an adolescent football player using individualized rehabilitation along with spinal manipulation: a case report,” Journal of Contemporary Chiropractic, Vol 2 (2019), https://journal.parker.edu/index.php/jcc/article/view/49 retrieved 15 April 2019
- Giza C and Hovda D (2014), “The New Neurometabolic Cascade of Concussion,” Neurosurgery: Oxford Academic/ Congress of Neurological Surgeons, https://academic.oup.com/neurosurgery/article-abstract/75/suppl_4/S24/2453619 retrieved 16 April 2019
- Makdissi M, Darby D and Maruff P (2010), “Natural History of Concussion in Sport: Markers of Severity and Implications for Management,” The American Journal of Sports Medicine, https://doi.org/10.1177/0363546509349491 retrieved 16 April 2019
- Makdissi M, Davis G and McCrory P (2014), “Updated Guidelines for the management of Sports-Related Concussion in General Practice,” Neurology (Australian Family Physician), Volume 43, No 3 March 2014, https://www.racgp.org.au/afp/2014/march/sports-related-concussion/ retrieved 16 April 2019
