After a long scamper this past season in a Denver Broncos vs. Kansas City Chiefs matchup, Denver QB Russell Wilson struck the turf hard, taking a shot to the right temple – a lateral impact – as his helmet hit the turf. Concussed, he momentarily lay motionless. “Scary,” observed multiple national headlines reporting the event. In 30 years covering football from the sidelines, I’ve observed lateral impacts to produce concussion with loss of consciousness (LOC) more often than blows to the head from other directions. The literature seems to substantiate this. Thankfully, and despite the “scare-factor,” LOC is not the primary determinant of the severity of a sport concussion.
What does the chiropractor have to offer athletes who sustain a sport concussion? Valuable skills and meaningful outcomes. Intuitively we know that the same blow to the head that causes a concussion can also injure the neck. In fact, the paper we’ll unpack in this blog reports that neck pain is one of the top four symptoms reported by concussed athletes. Whether you are a chiropractic colleague with sports specialty training or not, you are a chiropractor – a spine specialist – and perceived by the American public as an expert in back and neck pain treatment.
Our paper is “Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial” (Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Br. J Sports Med 2014;48:1294-1298.) From the Sport Injury Prevention Research Centre (SIPRC) at the University of Calgary in Alberta, Canada (an IOC Research Centre of Excellence), this study examined whether a combination of cervical manual therapy/joint mobilization technique with vestibular rehabilitation, range-of-motion and posture exercises (treatment group) differed from the use of only range of motion and posture exercises (control group) in returning athletes to practice and competition after sport concussion.
The primary outcome was the number of days from treatment initiation until medical clearance to return to sport. Medical clearance was determined by the absence of any concussion symptoms at rest and through a series of graded exertion activities. The study sport physician who determined medical clearance was blinded to group allocation of the participants.
Fifty-eight individuals between ages 12 and 30 years with greater than 10 days of persistent sport concussion symptoms of dizziness, neck pain and/or headache were recruited from November 2010 through October 2011. Thirty-one participants were randomized to either the treatment group (15 finishers) or the control group (13 finishers). Two control group participants withdrew from the study, and another did not complete follow-up measures, leaving 28 participants for analysis.
The Kaplan-Meier plot (figure 1 in the paper) summarizes the proportion of patients medically cleared to return to sport over time in each group. Of those who completed the study, participants in the treatment group were over 10 times more likely (10.27; 95% CI 1.51. to 69.56) to be medically cleared to return to sport within eight weeks than the participants in the control group. (X2 = 13.08, p<0.001). All 15 finishers in the treatment group were cleared within eight weeks compared to only one finisher in the control group. If we assume that the three non-finishing participants from the control group had finished the study and that all these were medically cleared to return to sport, there would still be a four times greater likelihood that individuals in the treatment group would be cleared compared with the control group (95% CI 1.24 to 11.34).
In sport concussion the cervical spine and vestibular apparatus may be injured along with the brain. Manual and manipulative therapy of the cervical spine is more effective than passive therapies for cervical spine injury resulting in pain. Likewise, vestibular rehabilitation adapts, habituates, and up-regulates other balance systems to improve balance in cases of vestibular injury. This study suggests that the combination of manual and vestibular treatments may accelerate medical clearance for return to sport in concussed athletes.
The manual therapy used in this study included high velocity, low-amplitude manipulation of the cervical spine. Vestibular rehabilitation in this study was straightforward, including canalith repositioning maneuvers, dynamic balance exercises, gaze stabilization training, and balance habituation and adaptation exercises. Who better to provide this multimodal post-concussion rehabilitation than a member of the health profession that is a widely recognized and highly skilled in the art and science of cervical spinal manipulative therapy and trained in vestibulo-oculomotor evaluation and rehabilitation?
Readers familiar with the interpretation of confidence intervals will note the lack of precision of point estimates calculated in this small study as evidenced by wide 95% CI’s. This is due to the small sample size. Additionally, participants could not be blinded from the treatment arm they received due to the nature of manual therapy. Despite these limitations, the study is worth the close attention of the chiropractor seeking to optimize return-to-sport for athletes after concussion once a careful initial clinical examination has ruled out contraindications to this multimodal treatment program.
Joel Carmichael, DC, PhD practices at The Center for Spine, Sport & Physical Medicine in Colorado. He teaches at Universidad Central del Caribe in Puerto Rico and maintains volunteer clinical faculty status at the University of Colorado School of Medicine. His research seeks to improve the practice habits of sport and spine professionals. Dr. Carmichael loves teaching, latté art, C.S. Lewis, and an occasional morsel of chocolate. He and his wife enjoy morning strolls with their golden retrievers, Stella and Noli.
