Concussion: A clinical primer for chiropractors

Concussion in sporting environments is common, but this injury can also occur in occupational settings, motor vehicle collisions, falls and so on. Practising chiropractors should have a working knowledge of contemporary evaluation and management issues surrounding concussion, as this form of mild traumatic brain injury can result in long-term disability or even death. On-field and clinical assessment, as well as treatment and management of concussion are becoming more evidence-based as new literature emerges to address best practices and support clinical decision-making. Because athletes are often eager to return to play and potential serious injury may result if they return too early, it is important that concussion be managed using current practice guidelines to ensure best practices are followed.

The Consensus Statement on Concussion in Sport defines concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” Several common features that incorporate clinical, pathological and biomechanical injury constructs may be utilized in defining the nature of a concussive head injury:

• Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.
• Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.
• Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
• Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.

The timing of concussion assessment can range from acute on-field situations to the clinic setting. As always, chiropractors should immediately manage emergent concerns on-field and subsequently conduct a complete history and physical examination when possible and appropriate.  

The cornerstone of concussion management is immediate physical and cognitive rest until acute symptoms resolve. Cognitive rest involves no reading, homework, watching TV, smartphone/tablets, social contact. Then, a graded program of progressive exertion should be supervised prior to medical clearance and return to play (for athletes) or integration into normal activities (for other patients).

 Below is a general outline for progressively increasing activity for a patient who has suffered a concussion. Patients should proceed to subsequent levels if they maintain asymptomatic status at the current/prior level. If symptoms arise, back up one level after 24-hours rest and proceed again to subsequent levels, as stated above. Each step should take from 24 hours to a week, if all goes well.

• Step 1: No activity
• Step 2: Light aerobic exercise to increase heart rate (HR): less than 70 per cent HR maximum activities only (ex. walking, swimming, cycling), no weight-training at this stage
• Step 3: Sport-specific exercise (adding movement): skating, running, no head impact drills (as in soccer)
• Step 4: Non-contact training drills: more complex drills, can begin progressive resistance training
• Step 5: Full-contact practice: following medical clearance
• Step 6: Return to normal game play

The literature pertaining to chiropractic management of concussion, overall, is sparse at this point. DCs manage patients with head trauma from sports, motor vehicle accidents and falls, with assessment stages ranging from on-field assessment to late-stage rehab. Despite the current lack of high quality research evidence, concussions can result in many symptoms and conditions that DCs commonly assess and treat, including: headache, vertigo, neck pain and back pain.

Therefore, DCs have a variety of important roles to play for concussion patients: provide rational and efficient on-field or clinical assessment; identify high risk patients and manage accordingly; facilitate/participate in multidisciplinary care; provide nutritional support/advice; manage recovery expectations and monitor symptom improvement; educate and support patients during recovery and graded activity protocols; and deliver individualized manual treatment in accordance with emerging evidence.

(Above is a recap of my presentation at the 2014 OCA Conference on Oct. 25. Watch for more concussion-related topics at upcoming seminars offered through Research Review Service.)

Dr. SHAWN THISTLE owns and operates Research Review Service Inc., helping clinicians integrate scientific evidence into practice through subscription-based service (researchreviewservice.com), online courses (onlinecourses.researchreviewservice.com) and seminars (epicureanscholar.com).