Chiropractic and concussion in sport: a narrative review of the literature

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Unstable Cervical Spine Fracture in a Surfer Presenting as Concussion With Associated Low Grade Neck Pain: A Case Report

Objective

The purpose of this study is to describe the evaluation and management of a surfer who presented with concussion-like symptoms and was eventually diagnosed with an unstable cervical spine fracture.

Clinical Features

A young man presented to a chiropractic clinic 5 weeks after a surfing injury. He had mild lower cervical spine pain and complaints of cognitive disturbance. He was previously evaluated by his primary care provider who diagnosed cervical sprain and strain injuries. There was no prior imaging or follow-up concussion management.

Intervention and Outcome

After a history, exams were performed of the cervical spine, thoracic spine, shoulder, and head, including a modified Sport Concussion Assessment Tool, Third Edition, concussion evaluation. Cervical spine radiographs were taken, which demonstrated a right C6 pillar fracture grade 2 anterior spondylolisthesis. These findings were confirmed with a CT scan. The patient was referred to an orthopedic spine specialist for further consultation, which resulted in cervical fusion of the C6/7 motor unit.

Conclusion

The use of clinical guidelines for head and neck injury assisted in the appropriate management of this patient with cervical spine injury presenting with concussion symptoms.

Concussion knowledge among Sport Chiropractic Fellows from the Royal College of Chiropractic Sports Sciences (Canada)

OBJECTIVES

The objective of this study was to investigate the degree of knowledge that sports chiropractors have in regard to concussion diagnosis and management.

METHODS

A concussion knowledge survey was administered to Sport Chiropractic Fellows of the Royal College of Chiropractic Sports Sciences - Canada (RCCSS(C)) (n=44) via SurveyMonkey.com.

RESULTS

Sports chiropractors scored statistically higher on the survey when compared to chiropractic residents (mean =5.57 vs. 5.25; t=2.12; p=0.04) and to fourth year chiropractic interns (mean = 5.57 vs 5.2; t=2.45; p=0.02). Additionally, with our modified scoring, the sports chiropractors scored 85.3%. A few knowledge gaps were identified in the sample population.

CONCLUSION

Sports chiropractors demonstrated the skills and knowledge to diagnose concussion and excel at identifying the definition and mechanism of concussion, but knowledge gaps regarding diagnosis and management of concussion were found in the sample population.

Survey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study

OBJECTIVE

The purpose of this study was to assess the self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners by means of a pilot study of the need, construct validity, and feasibility for further investigation of mild traumatic brain injury (MTBI) knowledge base.

METHODS

Two hundred forty-eight practicing chiropractic and 120 medical physicians in the south and northeastern sections of the United States were contacted by e-mail, telephone, and postal mail to answer an 18-item survey on knowledge, diagnosis, and common practice with respect to traumatic brain injury patients. Descriptive analysis was used to assess common trends.

RESULTS

Twenty-three chiropractic and 11 medical primary care practitioners returned completed surveys, making this a low-power pilot study. The majority claimed confidence in diagnosis of MTBI, but a lack of knowledge of many of the assessment tools and the international guidelines. Chiropractic and medical clinicians revealed similar competencies and differing deficiencies. Both groups admitted infrequent diagnosis of MTBI in practice. There was recognition of major TBI signs, but lack of recognition or inquiry for subtle MTBI signs.

CONCLUSIONS

There is a need and feasibility for further study of the knowledge transfer to the chiropractic physician with a larger population. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBI. The survey instrument appears to provide valid data on knowledge of MTBIs, with some modifications.

Concussion assessment and management knowledge among chiropractic fourth year interns and residents

OBJECTIVES

To investigate the degree of knowledge chiropractic fourth year interns and post-graduate chiropractic residents have in regard to concussion diagnosis and management.

METHODS

A survey modified from a study conducted by Boggild and Tator (2012), was administered to fourth year chiropractic interns and post-graduate residents via SurveyMonkey.com.

RESULTS

Chiropractic fourth year interns and postgraduate chiropractic specialty college residents scored 5.2 and 5.25 out of 9 respectively, which compares well with Bogglid and Tator's reports on medical students and residents. Several knowledge gaps were identified in the sample population.

CONCLUSION

The results from this survey show that the concussion knowledge among Canadian fourth year chiropractic interns and specialty college residents compares favorably with the knowledge of fourth year medical students and residents in diagnosing and managing concussions. Chiropractors appear to possess the skills and knowledge to diagnose and manage concussion equal to their medical counterparts. However, knowledge gaps regarding concussion diagnosis and management were found among chiropractic students and residents.

Chiropractic Management of Musculoskeletal Symptoms in a 14-Year-Old Hockey Player With Postconcussion Symptoms: A Case Report

OBJECTIVE

The purpose of this study is to describe the chiropractic management of a student athlete with postconcussion syndrome.

CLINICAL FEATURES

A 14-year-old male hockey player presented to a chiropractic clinic with postconcussion symptoms 13 days after his initial injury. He experienced an occipital headache with a pain rating of 8/10, upset stomach, blurry vision, nausea, dizziness, balance problems, a "foggy feeling," difficulty with concentration, difficulty with memory, fatigue, confusion, drowsiness, and irritability. Prior to seeing the doctor of chiropractic, the patient was monitored by a medical doctor, and the care he had been receiving was in accordance with current concussion guidelines. At the time of presentation to the chiropractic clinic, he had failed to progress toward return to play, and his computerized neurocognitive testing scores had not improved.

INTERVENTION AND OUTCOME

Chiropractic manipulative therapy, myofascial release, instrument-assisted soft tissue technique, and therapeutic exercises were provided over 5 treatments spanning a 20-day period. The patient followed up each treatment with ImPACT testing. At the conclusion of the treatments, the patient's computerized neurocognitive testing scores had improved, and the patient was returned to play.

CONCLUSION

This case demonstrates the improvement of postconcussion syndrome in a 14-year-old male hockey player under chiropractic management.

Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report

OBJECTIVE

The objective was to describe chiropractic and acupuncture care of a patient with acute mild traumatic brain injury (mTBI) symptoms.

CLINICAL FEATURES

A 31-year-old woman had acute neck pain, headache, dizziness, nausea, tinnitus, difficulty concentrating, and fatigue following a fall. She was diagnosed at an urgent care facility with mTBI immediately following the fall. Pharmaceutical intervention had been ineffective for her symptoms.

INTERVENTION AND OUTCOME

The patient was treated with chiropractic adjustments characterized as high velocity, low amplitude thrusts directed to the cervical spine and local acupuncture points in the cervical and cranial regions. The patient received care for a total of 8 visits over 2.5 weeks with resolution of concussive symptoms.

CONCLUSION

This patient with mTBI responded favorably to a conservative treatment protocol with the combination of chiropractic and acupuncture care.

The American Chiropractic Board of Sports Physicians Position Statement on Pre-Participation Examinations: An Expert Consensus

OBJECTIVE

The purpose of this paper is to present a position statement of best practices for the provision of a safe and high-quality pre-participation examination (PPE) and to provide recommendations on education requirements for doctors of chiropractic providing the PPE.

METHODS

In 2014, the American Chiropractic Board of Sports Physicians (ACBSP) Board of Directors identified a need to review and update the ACBSP position statements and practice guidelines in order to be current with evolving best practices. Twelve ACBSP certificants, 10 Diplomates of the ACBSP, and 2 Certified Chiropractic Sports Physicians, met in April 2015 to author a pre-participation position statement using an expert consensus process. Panel members excluded anyone with commercial conflicts of interest and included individuals with expertise in clinical sports medicine and the performance of PPEs. A literature review was performed and circulated in advance for use by the panel in addressing the topic. The position statement was written through a consensus process and accepted by the ACBSP Board of Directors in May of 2015.

RESULTS

The ACBSP Position Statement on Pre-participation Examinations identifies the qualifications and best practices for doctors of chiropractic to perform a PPE.

CONCLUSION

This position statement states that doctors of chiropractic with post graduate education and current Diplomates of the ACBSP or Certified Chiropractic Sports Physicians certification have the prerequisite education and qualifying skills to perform PPEs.