Concussions

Fort Collins Whiplash

ABSTRACT
Concussion or mild traumatic brain injury (mTBI) remains a significant social and public health problem. This paper provides a literature review on concussion primarily related to sports injury and chiropractic. A proposed protocol flowchart for triage and assessment of concussion is included.

KEY WORDS
Mild traumatic brain injury, concussion, head injury, post-concussive syndrome, chronic traumatic encephalopathy, fine-motor control, assessment, treatment

INTRODUCTION
This overview of the current status of sport-incurred concussion describes major signs and symptoms of concussion, provides an example algorithm to assess concussion, and discusses treatment and prevention. In the literature, concussion is used interchangeably with mild traumatic brain injury (mTBI) and should not be interpreted as clinically insignificant in terms of risk, attributable factors, detection, diagnosis, management, treatment, or follow-up care. Concussion is a clinical subset of traumatic brain injury (TBI).

Athletic trainers, coaches, medical staff, parents, and injured players often perceive that a concussion is unimportant because no blood or other obvious clinical signs are visible. Other health problems, such as uncontrolled diabetes, severe dehydration, and adverse drug reactions, can cause signs and symptoms similar to concussion.

Concussion is difficult to diagnose. Actual damage may not manifest immediately because the neurological, physical, physiological, behavioral, and cognitive functions are differentially affected. Behavioral, cognitive, and personality deficits are often more disabling than residual physical deficits in persons suffering concussion, as well as repeated concussions.l Current debate on optimum recovery time before resumption of normal activities is tempered by consideration of many factors, such as age, physiology, physical and mental condition, presence of post-concussive symptoms (PCS), and the severity and frequency of concussive events.

TBI currently affects at least 5.3 million Americans who require lifelong assistance and services to perform basic activities of daily living.2 In 2000, direct medical costs and indirect costs, such as lost productivity, were estimated to be $60 billion in the U.S., excluding more than 20 percent of concussions that were under-reported and/or misdiagnosed.3 The number of concussions caused by sports injuries, military combat, falls, motor vehicle crashes, assaults, and work-related accidents is steadily increasing with a disproportionate rate of injury to young males. Experts predict that mTBIs and other forms of traumatic brain injuries will be the top global public health problem by 2020 when loss of productive life and health and social burdens are factored into the equation.2

As many as 3.8 million recreational- and sports-related concussions occur annually in the U.S. and represent 8.9 percent of all high school athletic injuries.4 The highest incidence for males and females occurs between the ages of 15 and 35.3,5

Recovery may occur spontaneously. Unfortunately, under-reporting is widespread. This paper addresses the 20 percent of head injuries that may cause prolonged disorientation, loss of short-term memory, slower thinking, headaches, dizziness, sleep disturbances, fatigue, and impulsive and disruptive behavior.

Approximately two-thirds of all chiropractors practicing in the U.S. are licensed to diagnose and treat patients as “portal of entry” health providers. Chiropractors can assume a major role in evaluating, diagnosing, and treating concussions, particularly head injuries that affect the spine and related extremities.6,7

Patients with prolonged disorientation, headaches, dizziness, loss of short-term memory, slower thinking, sleep disturbances, fatigue, and impulsive, disruptive behavior may visit chiropractors. To avoid the possibility of lifelong injury and dysfunction for these patients, DCs should screen the patients for concussion. Such screening includes mental status assessment, examination of the site of trauma and the opposite side of the skull, neurological integrity testing, and vision, hearing, smell, peripheral motor power (rating scale 0-5), and coordination. Individuals with declining mental status, nausea/vomiting, mood changes, memory problems, clumsiness, or slurred speech should be referred immediately.

Any sudden impact to the head can cause TBI and change the way the brain works. Concussions also occur from a force that causes the head to move rapidly and violently back and forth. Infants and toddlers who suffer from shaken baby syndrome or shaken baby impact syndrome are particularly susceptible to cerebral hemorrhage, subdural hematoma, traumatic optic neuropathy, retinal tear, and papillary hemorrhage.

Appropriate use of existing and new detection and diagnostic tools and methods will enhance the management of concussion to minimize or prevent subsequent long-term health problems and reduce the economic burden of head injury.

OPERATIONAL DEFINITIONS OF CONCUSSION AND SUBCONCUSSION
Slang, such as “bump” or “ding,” is often used by informed people to downgrade the perception of a head injury. Without obvious signs, like a laceration or any open wound, mTBI becomes an invisible injury.

The classification of concussion based on severity remains a challenge because of problems with instruments and testers, as well as the likelihood that the injured will deny the injury. Denial may result from cognitive impairment that is the result of the injury. It also stems from group conditioning that places a premium on endurance.

Pelletier defines concussion as “a complex neuro-pathophysiological process affecting the brain, induced by traumatic biomechanical forces, which include a traumatic alteration in brain function that is manifested by an alteration in awareness of consciousness.”7 These forces cause injuries to the subcortical white matter that include shearing or diffuse axonal injury that may occur with or without a focal injury. Resulting lesions are likely to produce PCS and may explain chronic difficulties experienced by some patients.8 A unified approach to the prevention, diagnosis, and treatment of concussion is essential when white-matter tracts are abruptly sheared as a result of an external force to the head.

In 2011, the Brain Injury Association of America adopted a broad definition of TBI as “an alteration in brain function, or other evidence of brain pathology, caused by an external force.” 9

The Defense and Veterans Brain Injury Center (DVBIC) included observable signs and symptoms of concussion, specifically “an injury to the brain caused by an external force and/or acceleration/deceleration mechanism from an event such as a blast, fall, direct impact, or motor vehicle accident, which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache, nausea, vomiting, dizziness/balance problems, fatigue, insomnia/sleep disturbances, drowsiness, sensitivity to light/noise, blurred vision, difficulty remembering and/or other difficulty concentrating.”10

One promising attempt to operationalize concussion objectively and reliably is a measurement of muscular control and functionality. If concussion is to be detected, a physiological change must occur. To illustrate, timing deficits associated with processing speed, balance, and coordination can be measured precisely and noninvasively as primary post-concussion symptoms.8,11 A quantitative measurement of fine motor control (FMC) of the hands can detect concussion and categorize severity at the earliest phase of injury.12

A proposed working definition of subconcussion is “any alteration in brain function or FMC, or other evidence of brain pathology caused by an external force that concurrently decreases functionality by 20 percent and increases temporal delays by 20 percent within 48 hours of head impact, followed by full recovery.”13 Although the clinical significance of differences between concussion and subconcussion is still unknown, the most prudent approach is to detect and define them as early as possible to provide appropriate interventions and care.

Table 1 lists the four categories of the signs and symptoms of concussion used by the American Academy of Pediatrics4 for sport-related concussion. Headache is the most common physical symptom reported immediately after head impact. Concussion signs and symptoms overlap with those of depression, anxiety, and attention-deficit disorders. Individuals with such pre-existing disorders are at risk of exacerbating concussion’s effects.

The Quality Standards Subcommittee of the American Academy of Neurology provides a basic taxonomy and scale of concussion for sports injuries using signs of mental abnormalities plus loss of consciousness (LOC). Table 2 shows the grades of concussion and associated clinical descriptions used to define and categorize sport-related concussion.14

The World Health Organization’s intracranial International Classification of Diseases (ICD) provides a comprehensive and uniform taxonomy of concussion injury, excluding skull fracture. These codes define primary or secondary diagnosis of physical injury. Table 3 shows the ICD-9 codes for concussion.15

Transient or permanent dysfunction may occur in any concussion. Increased intracranial pressure can disrupt neuronal membranes. Symptoms and effects of “simple” concussion are resolved within seven to ten days. Both LOC of more than 30 seconds and under 30 seconds can be serious. A concussion is considered “complex” when LOC exceeds a minute, cognitive impairment is persistent or prolonged, and there is a history of multiple concussions.16 However, LOC occurs in fewer than 10 percent of concussions.17 In cases with LOC, duration is often unknown or unobserved. It is important to remember that no LOC does not equate to no injury.

An estimated 70 percent to 85 percent of concussions are “mild” and rarely receive rehabilitation.1 With such concussions, there is an 80 percent chance of returning to normal within one to two weeks. The symptomatic 10 percent to 15 percent have persistent post-concussive symptoms, including headaches, memory and attention problems, sleeping difficulties, changes in taste and hearing, and impaired social relationships among other health, educational, emotional, and social disruptions or difficulties.18 Other signs and symptoms are listed in Table 1.4 Recovery from behavioral and cognitive changes can occur within three to six months. Chronic untreated symptoms associated with concussion may cause serious health and mental conditions, such as depression, anxiety, and personality and behavior changes. Residual lifelong cognitive and behavioral problems can reduce the quality of life and result in self-harm or injury to others. They may also cause premature death.

Undetected or improperly treated concussions can cause more serious problems when an athlete is again hit on the head during the healing and recovery process. Second-impact syndrome can cause brain swelling and other widespread damage that can be fatal7 or lead to chronic disability.8  

Repeated concussions over time cause cumulative neurological and functional impairments, particularly in young children. Such impairments affect children’s developing neurological systems and increase susceptibility to the shearing strain and tissue deformation caused by repeated head impacts. Chronic traumatic encephalopathy (CTE) describes the pathophysiological effects of repeated concussions and resulting degenerative brain disease.19 Since 1928, boxers have been described as “punch drunk.” “Dementia pugilistica” is this sport’s term for CTE, which results in slowed movement, confusion, dementia, speech problems, and muscular tremors.20 Symptoms of CTE and Alzheimer’s disease are similar. Post-mortem tissues show similar histological damages.

U.S. STATISICS ON CONCUSSION
General Population

The Centers for Disease Prevention and Control (CDC) provide some of the most reliable population estimates on concussion through data analysis from the National Electronic Injury Surveillance System—All Injury Program (NEISS-AIP). NEISS-AIP is operated by the U.S. Consumer Product Safety Commission (see http://www.cdc.gov/concussion).

  • 7 million people sustain TBIs (mild, severe, or fatal) annually; 1.4 million will be treated and released from emergency departments.
  • 52,000 people die each year from TBI.
  • 275,000 people will be hospitalized for TBI.
  • TBI is a contributing factor to a third of all injury-related deaths.
  • About 75 percent of TBIs are concussions or mTBIs.
  • Annually, an estimated 5,000 U.S. children and youth are hospitalized or die from sports-related concussion. Children and teens are more likely to get concussion and take longer to recover than adults.
  • Males aged 0 to 4 years have the highest rates of concussion-related emergency department visits, hospitalizations, and deaths, followed by males 15 to 19 and 65 to 75.

Sports Population
More than 4 million American youth play some form of football. In 2009, CDC and the Brain Trauma Foundation reported there were an estimated 3.8 million sports-related concussions (see http://www.cdc.gov/concussion). In amateur sports, there were 300,000 diagnosed concussion cases, 50,000 of which were reportedly untreated.13

Concussion rates per 100,000 athlete-exposures during practice and competition are significantly different by gender and sport.13 For males, concussion rates are 19.91 during practice and 59.64 during actual games. Females have lower rates at 10.91 and 18.61, respectively.

Intentional “spearing,” “head-down tackling,” or helmet-to-helmet collisions can cause mild, moderate, or severe concussions. Football players are particularly at risk for repeated blows to the head with cumulative adverse effects, such as SIS and CTE.

The National Football League (NFL) provides the following statistics and updates:21

  • NFL players were 19 times more likely to develop Alzheimer’s or other memory-related diseases than other men between the ages of 30 and 50.
  • The NFL recently reported 127 concussions during the first eight weeks of the 2010 preseason, an increase of 21 percent over the same period in 2009.
  • In recognition of the dangers of TBI, the NFL has announced that all 32 teams will have the same guidelines to evaluate a player’s condition and return-to-play status. The guidelines recommend physical, neurological, and cognitive assessment examinations.
  • Approximately 32 percent of U.S. college football recruits sustained moderate cervical injuries in high school.22,23
  • In one season, a 21-year-old defensive end took 537 hits to the head.24

Military Population
The military looks to sports medicine for research in multiple and cumulative concussion.10 Athletes, as a proxy for the military: 1) are the same age range, 2) are highly trained and competitive, 3) strongly deny any or all injuries, 4) exhibit a strong team/squad dynamic, 5) and function at peak performance or become a liability. The mechanism and injury related to concussion are vastly different, however, between athletes and military personnel.

Military personnel deployed in combat areas are at high risk for concussion. Often, intense psychological experiences compound TBI and cause delayed responses collectively grouped as post-traumatic stress disorder (PTSD). PTSD manifests vividly from one month to many years after the actual experience in the form of sleep disorders, emotional and behavioral problems, and difficulty with social and professional relationships. The military has acknowledged the high rates of domestic violence, substance abuse, violent and aggressive behavior among veterans, and suicide among active personnel. It is imperative for health providers to accurately differentiate TBI from PTSD and treat each appropriately. PTSD is a common co-morbidity and can pose a significant challenge to the effective treatment and rehabilitation in most military cases of concussion. New screening methods for field medics and first responders are now available to reliably detect concussion immediately after injury. Early detection, timely intervention, and proper treatment are essential.

Shock waves from an explosive device blast can result in a whole-body, multi-organ response. Blast-induced TBI or blast-induced neurotrauma (BINT) causes numerous complications leading to functional deficits, such as metabolic abnormalities in the deeper brain structures. Chronic neurological deficits may persist years after exposure.

Concussion has become the signature injury of wars in Iraq and Afghanistan. Post-acute care is available, but limited.

The military reports the following statistics:

  • Between 2001 and 2007, 320,000 deployed service members screened positive for probable concussion ranging from mild to severe.25
  • Approximately 88 percent of concussion is caused by blast-related trauma resulting in BINT.26
  • An unpublished study revealed that one of the Pentagon’s primary screening methods misses as many as 40 percent of possible mTBIs. Military personnel discharged with “personality disorders” lose medical care benefits or coverage for those disorders.27
  • As of Feb. 17, 2011, DVBIC estimated that 202,281 service personnel were diagnosed with TBI between 2000 and 2010 and 155,623 (77 percent) were determined to have mTBI or concussion.28

The military acknowledges that concussion may be missed when other more obvious or more life-threatening injuries are present.

NEUROLOGICAL, PHYSIOLOGICAL, COGNITIVE, AND BEHAVIORAL ASPECTS OF CONCUSSION AND ASSESSMENT METHODS
Major groupings of signs and symptoms of concussion are: 1) neurological, 2) physiological, 3) cognitive, and 4) behavioral. See Table 4. Not all signs and symptoms listed below are specific or unique to concussion.

More than 25 different published quantitative and qualitative grading systems for concussion4 and hundreds of objective neurological and subjective assessments exist, including pencil-and-paper tests and self-reports. Some screening tests are easily accessible and used online. Many proven, standardized, reliable, and valid assessment methods are included in Buros Institute of Mental Measurements (www.nebraskapress.unl.edu). The number of measurement methods useful in diagnosing and managing sports concussion is increasing.20,29,30 There are no “best” measures of concussion due to the complex neuropathology of concussion and to differing medical and lay interpretations of assessments.

Neurological Assessment (Motor, Sensory, and Autonomic)
A neurological exam should include a detailed history and basic test(s) of cognition to include: movements and reaction of the eye; hearing; sense of smell; ability to whistle, smile, clench teeth, and move head; classic hand and arm movements; unilateral or bilateral motor weakness; and coordination and position sense. For instance, lack of the sense of smell in each nostril may signal frontal-lobe damage. Also, FMC can be substantially altered by trauma to the central nervous system and present peripheral dysfunction in the hands.12

Coordination of gait can be heavily affected by concussion. Gait disorders are heterogeneous and result in disabilities that vary substantially from person to person. Technology for acquisition and analysis of gait biophysiology and biomechanics remains inefficient and insufficient for the development of intelligent countermeasures to mitigate gait-related disability. Current clinical methods of gait analysis are time- and labor- intensive and involve extensive post-hoc data analysis. These limitations reduce access to gait analysis and exclude direct application of the patient’s gait data to rehabilitative and interventions in real time.

Neurological Assessment Methods
Various neurological signs and symptoms of deteriorating neurological function developed in 2004,31,32 adapted by the CDC, are now widely used. (See www.cdc.gov/injury.)

  • Functional MRI has promise, but CT and other MRI images, although commonly used for TBI, may not show the injury of most concussion.33,34,35
  • Acute Concussion Evaluation (ACE) Physician/Clinician Office Version.36 ACE is an evidence-based clinical protocol for initial evaluation and diagnosis of children and adults.
  • Military Acute Concussion Evaluation (MACE) is the only standardized mental status exam to assess neurocognitive impairment in military operational settings.
  • Brief Traumatic Brain Injury Survey (BTBIS), Warrior Administered Retrospective Casualty Assessment Tool (WARCAT), and Post-Deployment Health Assessment (PDHA).
  • Glasgow Coma Scale (GCS) is a standardized neurological scale that reliably, objectively assesses post-injury consciousness. The GCS is widely used in advanced first aid by field medics, first responders, and trauma doctors.
  • Rhomberg Test or Rhomberg Manuever, used widely for testing drunk drivers, is a simple test of neurological function.
  • Quantitative electroencephalography (qEEG) employs computer-assisted imaging and statistical analysis of EEG to create topographical brain maps that identify neurological abnormalities37,38,39 with specificity of 96 percent in identifying PCS.40

Physiological Assessment
Physiological assessments are primarily quantitative and objective in method. When voluntary muscle control is affected by concussion, the injured person may have difficulty with balance, orientation, strength, and fatigue.

Primary physical symptoms typically related to motor control include timing deficit of muscular control, compromised neural signals, sensory degradation, muscle fatigue and weakness, and decreased performance that result in gross problems with balance and coordination41 and subtle and measurable changes in peripheral FMC of the hands.12 Other physical signs or symptoms are blurred vision, dizziness, tinnitus, and hypersensitivity to light or noise.

Physiological Assessment Methods: 

  • Balance Error Scoring System (BESS) is a portable, cost-effective, and objective method to assess static postural stability.
  • Sensory Organization Test (SOT) is a postural stability assessment that measures vertical ground reaction forces and posture produced by movement of a person’s center of gravity around a fixed base of support. The sensory selection process is disrupted by altering available somatosensory or visual information or both.42
  • Head Impact Trauma Screen (HITS) measures FMC noninvasively to determine alterations in peripheral functionality as an indicator of concussion or subconcussion. This medical device has been cleared by the FDA as a class B device. It exists in beta version pending validation study.12

Cognitive Assessments
Cognitive measures of concussion, also referred to as neuropsychological tests, are used widely in sports-related concussion as an objective way to measure brain function. Cognitive tests alone do not independently determine the presence of concussion but often supplement other concussion assessment tests. Most cognitive tests emphasize mental tasks, such as attention and memory or recall ability, pre- and post-injury. Major cognitive deficits usually relate to attention, concentration, perception, memory, and speech/language. Resulting cognitive sequelae from concussion are difficult to measure and are based on traumatic events or premorbid factors.43,44

Cognitive Assessment Methods

  • Automated Neuropsychological Assessment Metric (ANAM) measures reaction time, code substitution, mathematical processing, and matching to sample.
  • Standardized Assessment of Concussion (SAC) and Sport/Standard Concussion Assessment Tool (SCAT and SCAT2) are standardized methods to evaluate concussion in sport by measuring mental status.
  • Hit your head, Emergency room, Lose consciousness, Problems, and Sickness (HELPS) Brain Injury Screening Tool, a subjective questionnaire, has five yes or no interview questions.
  • 3-Question Defense and Veterans’ Brain Injury Center TBI Screening Tool is similar to HELPS. Each of the three subjective questions of the self-test has six to 80 check boxes. DVBIC cautions that this test cannot be used reliably to diagnose TBI without a clinical interview. (See http://www.dvbic.org/images/pdfs/3-Question-Screening-Tool.aspx.)
  • Post-Concussion Assessment and Cognitive Testing (ImPACT) has six neuropsychological tests designed to target different aspects of cognitive functions.
  • Wechsler Adult Intelligence Scale Digit Span tests immediate auditory recall and freedom from distraction by repeating given sets of digits forward then backward.42

Behavioral Assessments
If concussion is suspected, a comprehensive battery of personality tests may be unnecessary. However, widely used pencil-and-paper behavioral tests include Beck’s Depression Inventory, Taylor-Johnson Temperament Analysis, the Johnson Psychoeducational Battery, and others. Major behavioral factors pertain to detection of psychosis, depression, mania, PTSD, agitation, and aggression, which are suggestive of long-term effects of concussion.

Typical observable personality disorders include antisocial and self-destructive behavior, emotional instability, irritability, depression, anxiety, temper outbursts, and decreased self-control. Difficulty in maintaining interpersonal relationships, achieving academic goals, and fulfilling personal goals decrease the person’s independence and adversely affect social status, employment opportunities, and lifetime income.

On-Field Assessments
Most tests require access to the Internet, testing equipment, or a laboratory. Immediate assessment of concussion after an injury ideally should be conducted on the sidelines or on the battlefield to determine presence and extent of concussion. Most questionnaires and assessments are conducted by athletic trainers, coaches, or emergency medical technicians but are inconsistently interpreted and recorded. Individuals who want to return to play can easily manipulate subjective tests that rely on verbal responses. Objective assessments, such as CT and MRI, are prohibitively expensive and may not show concussion.33,34,35

Disagreement exists in reporting the signs of concussion by medical staff and injured athletes,32 and the signs overlap with other injuries and illnesses unrelated to concussion.  Table 4 shows commonly observed signs of concussion reported by medical staff and athletes.

Regardless of methodology limitations, carefully selected on-field assessments are adequate to detect concussion and triage severe cases for immediate medical intervention. Athletic trainers and medical personnel on the sidelines or in locker rooms can use the following list of mental assessment tests for high school-age and older athletes. Inability to appropriately respond to any of the questions related to orientation, amnesia, concentration, word-memory tests, and neurological function should be considered abnormal and indicative of concussion, as shown in Table 5.32

RECOVERY, RETURN TO PLAY, TREATMENT 
Little agreement exists on the optimal time to return to play or resume normal activities of daily living. Coaches, team members, and parents may encourage a quick return to action following a blow to the head.

Cumulative effects of concussion on football players in particular and the potential long-term effects of resulting injuries provide compelling case studies of the risk and dangers of an American sport.45,46 Based on the mean reported cognitive scores for players with concussions, the recovery time to preseason level of the players was six to seven days.

A three-year study determined that recovery time for cognitive dysfunction and physical balance was seven days.47 Overall guidelines for return to play following concussion suggest that athletes may have a reduced threshold for subsequent concussions that lasts several days after injury.48 A three-fold greater risk for concussion was noted after three prior injuries, with recovery being prolonged. After an initial concussion, an athlete is four to six times more likely to experience another concussion, sometimes before recovering from a previous injury.49

TREATMENT FOR CONCUSSION
Management of concussion ranges from simple to highly integrated care, depending on the severity of concussion.1 Specialized care or ancillary treatment is offered by neuropsychologists, neurosurgeons, neurologists, general practitioners, sports medicine physicians, chiropractors, clinical psychologists, allied health professionals, nurses, rehabilitation specialists, acupuncturists,50 and nutritionists.51

Although most concussions are considered passive, intervention may be necessary. Rest and minimizing physical activities allow the body to heal. Mental activities should be restricted or limited to decrease stimulation of the brain.

Therapy and rehabilitation may include post-traumatic amnesia monitoring, pain management, cognitive and behavioral therapies, pharmacological management with prescription medicines, assistive technology, environmental modifications, family education, and counseling. Long-term outcome studies are needed.

General Treatment
At present, standardized manipulation techniques are recommended for treatment. Direct techniques include spinal adjustments, high-velocity thrusts, myofascial release, ART®, Graston Technique®, or muscle energy techniques. Two indirect chiropractic techniques that do not directly release restriction of the joints or soft tissues but can be effective in managing concussion are strain-counterstrain and positional release therapy: cranial adjustments and sacro-occipital technique.7

Cranial Manipulation
Cranial manipulation and adjustment of cervical and thoracic vertebrae have been documented for concussion with measurable success.52 Appropriate adjustments of the upper spine and cranial bones may improve circulation and lymphatic flow to promote neurogenesis and healing. Careful identification of neurological dysfunctions and resultant monitoring allow the chiropractor to observe and record improvement or to modify the treatment if recovery is not progressive. Chronic headache and neck and shoulder pain are common complaints among concussed patients in car crashes, falls, and assaults. Assessment of concussion through quantitative physiological screening should be standard practice to detect and address a true head trauma from a pathological condition.

The diffuse axonal injuries present in TBIs require high levels of metabolic energy to heal. Compounding this fact is that a blow to the head can often cause shifting of the cranial plates, the occiput on C1, and misalignment of the upper cervical vertebra. These changes can increase resistance of the flow of nutrients to affected areas in the brain.  Reduced cranial compliance can directly cause reduction of brain metabolism.53 The focus of an adjustment is to reduce any resistance of blood flow to CNS structures. Careful analysis and discretion are advised as the area may be in an acute or subacute healing phase.

Research supporting the mechanisms of cranial manipulation was carried out by NASA and the Russian cosmonaut programs. It demonstrated that cranial bones move enough to relieve entrapment of cranial nerves and traumatically induced calvarial pressures on brain centers that cause neurological dysfunction (see http://cranialfoundation.org/pdf/NeurocognitiveStudy.pdf).

Several clinical studies reported benefits from osteopathic manipulative treatment (OMT) as a therapeutic and rehabilitative intervention for patients suffering from TBI. Neuro-anatomical understanding and application of OMT is well developed in the practice of cranial manipulation. Cranial nerve entrapment from the osteopathic perspective is well researched.54 OMT benefit has been reported for individuals with neurological development disorders, learning difficulties, cerebral palsy, pediatric seizure disorders, and Parkinson’s disease. In neurological disorders and TBI, cranial manipulation addressed the calvarial bone and intracranial dural membrane structures deranged through trauma. Distances of structural change can range from 100 µm to 200 µm, but are sufficient to decompress impingement on cranial nerve and micro-vascular structures.

Nutrition
The DoD recommends that in the first 24 hours post-head trauma, patients receive at least 50 percent of their typical calorie intake to include a higher-than-normal amount of protein to reduce inflammation and swelling of the brain and help the brain repair itself. Both high and low blood-sugar levels are dangerous for patients with severe concussion.51

Quantitative EEG
Use of qEEG to customize individual treatment that incorporates guided neurotherapy and biofeedback has shown some promise among young concussed athletes.38,39,40 Noninvasive brain stimulation (NBS) promotes neurogenesis after a disease or traumatic injury, given appropriate stimuli and reinforcement. NBS helps improve cortical reorganization and restores neurological function.30 NBS also includes transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), low-level laser therapy (LLLT), and transcranial Doppler (TCD).

Brain and Auditory Stimulation
New therapies for concussion are deep-brain stimulation (DBS) and repetitive auditory stimulation (RAS). In the most severe concussion, bilateral deep brain electrical stimulation of the central thalamus modulates behavioral responses in patients,55  but external stimulation of the auditory system by tones, chords, and musical rhythm is less invasive. Melodic intonation therapy (MIT) pairs speaking with rhythms, and physical movement of the hand opposite the injured side of the brain promotes neurological repair.56 Music therapy designed for concussed patients shows some positive results.57,58  However, more data in well-designed studies with controls and higher statistical power are required.

Anti-Inflammation and Electrolyte Therapy
Medical treatments involving anti-inflammation and fluid/electrolyte therapy have been introduced to arrest or slow nerve damage during the first hours after TBI. The critical factor required for this therapy to be effective is getting the injured person into an acute care or trauma center as soon as possible.

Treatment of mTBI should include avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), acetyl salicylic acid (ASA), narcotics, and pain relievers, such as tramadol hydrochloride, until CT-confirmed TBI negative.10 Acetaminophen may be used as needed to manage pain and headache. Medical treatment and electrolyte therapy must be carefully supervised and monitored by trained clinicians specializing in head injury.

Patient-Centered Medical Home
Health practitioners work primarily in disparate clinical settings. A more cooperative health enterprise or a community of health providers, such as the patient-centered medical home (PCMH), could be established specifically to deal with concussion cases to ensure that care is appropriate, continuous, and effective. In a PCMH setting, chiropractors, as active and/or virtual clinical partners with other health professionals, could closely follow concussed patients and devise efficient and effective care management plans to achieve positive health outcomes and maintain follow-up to determine best practices.

The American Academy of Pediatrics introduced the medical home concept in 1967 to advance the effectiveness and quality of communication and access to health records of children.59 In 2002, the concept was expanded to include accessible, continuous, comprehensive, family-centered, coordinated, and culturally effective health care in the PCMH model.60 To reduce service gaps in the system, the continuum of care must originate with primary prevention and education, followed by secondary and tertiary prevention based on accurate and reliable early detection or screening, appropriate triage and treatment, rehabilitative therapy, and recovery and restoration of health and function. For severe concussions, adjustment and adaptation in functionality based on physical disability and cognitive deficits, lifestyle, quality of life, and long-term social and health-related support should be made available to patients, families, and caregivers.

The early idea of the community of child and family advocates61 was expanded to include the quality and safety of care, as well as social responsibility and just treatment of the physical and intellectually disabled to design and create a patient-centered health care community.62

TRIAGE AND ASSESSMENT FLOWCHART FOR CONCUSSION
After extensive review of the literature in chiropractic and sports-related injury specific to concussion, the author devised and expanded a protocol flowchart for triage and assessment of concussion, based on patients’ history and severity of head impact. The section above the dashed line in Figure 1 is from a basic chiropractic text.63 The section below the dashed line was developed by the author. This flowchart incorporates new technology to accurately detect and screen concussion. Moreover, the flowchart emphasizes the value of monitoring the recovery period to ensure that the patient is responding favorably to treatment and to determine more precisely when to return to play or work. The flowchart has two phases: determination of an emergency situation, followed by assessment of functional deficit and treatment.

In general,

  1. If a concussion is suspected, remove athlete from play for at least a week.
  2. Ensure athlete is evaluated by a physician.
  3. If no symptoms are currently present, physical exertion can be gradually increased. Rest >  Light Exercise > Light Training (no contact) > Moderate Training (no contact)
  4. Allow return to play if physician finds athlete symptom free for at least one week.

CHIROPRACTIC ROLES
DCs, as portals of entry, are appropriate providers to address physical disorders associated with body contact and misalignment of the neck and spine that may result from concussion. Patients may visit the chiropractor well after injury. Also, a patient with a severe headache may not associate the headache with a previous whiplash or head impact in a car crash. If the patient was not evaluated in an emergency department for concussion, chiropractors can play a role in diagnosing and treating the injury and providing patient education, as well as rehabilitation.

Evaluation of a concussion by a chiropractor is aided by additional training, such as CCSP, DACBSP, orthopedic classes, neurology classes, or other related specialized classes. Integrated and more comprehensive health care for concussed patients, such as that offered in the PCMH, may promote healing and recovery.

DISCUSSION
This literature review paper worked to capture the breadth of contemporary medical discussion and research in concussion and its impact. Research and understanding of concussion are still in their infancy.

The author has drawn several early conclusions that warrant further consideration and peer discussion from a community of disciplines because of the magnitude, health significance, and socioeconomic implications of this prevalent traumatic injury.

Early detection and diagnosis remain a challenge. Some proposed treatments for concussion are experimental. Others lack validation and long-term outcome health measures to determine their efficacy across a diverse risk population.

Concussion, as a common form of traumatic injury, is highly preventable, given the appropriate safety measures and education. Safety measures and education are vital in preventing the occurrence of concussion in sports or to reduce the health and social impact of this trauma.

For a Concussion Consultation with a Chiropractor in Fort Collins  Dr Mathew BSc, DC accepts WALK INS! Located at 220 W.Prospect Rd STE D Fort Collins CO 80526 or Call for an appointment at 970-491-9191 or 970-224-4852.

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