Concussion and Athletic Injury for the Sports Chiropractor

Frederick R Carrick, DC, PhD, MS-HPEd

 

Physical activity has been associated with widespread anatomical and functional brain changes that occur following acute exercise or, in the case of athletes, throughout life. High levels of physical activity through the practice of sports also lead to better general health and increased cognitive function. Exercise for exercise sake? Certainly there must be benefits that patients might be able to understand. One thing is for sure, exercise results in changes in brain function as well as with changes in general health that might affect the lifespan of individuals. I am very impressed with the knowledge of members of the ICA Council on Fitness & Sports Health Science as they address the benefits of better general health and increase cognition as a consequence of high levels of physical activity through participation in sports.

However, sometimes things just go wrong. When athletes suffer a concussion they are more than a statistic, they have a brain injury. Unfortunately, we don't know what the overall long-term consequences of sports concussions are when we change levels of fitness after an injury. We also don't know what the long-term effects of a concussion are with someone that is in good physical shape versus someone that is not before the injury. Each year we are learning more about the consequences of playing sports and general physical activity when it comes to the excitability of the brain, its neurochemistry and is anatomical composition.

We expect and understand that exercise is going to have a brain consequence and it is generally considered that the brains of athletes are different from those people who are non-active. Chiropractors might realize that individuals that suffer sports concussions are individuals that have pre-existing structural and functional plastic changes to their nervous systems as a consequence of their lifestyle before an injury. The consequences of structural and biological changes of the brain means that athletes need different therapies and intervention after brain injuries than non-athletes. When an athlete injures his/her brain, there is a consequence when we take them out of play specific to the function of their brain structure that is used to physical activation at a higher rate than non athletes 1.

Approximately 3.8 million sports related TBIs occur per year with variations in genetic makeups affecting both the risk and outcomes for sports concussions 2. The sports chiropractor is ideally positioned to attend individuals who suffer from sports related neurological injuries. However, many patients present to the chiropractor for the first time after an injury. These people may or may not have baseline testing that will allow their provider the guidance necessary to treat them to the best of their abilities. Our clinical team has found great benefit from using the C-3 Logix platform designed by the Cleveland Clinic, not only for baseline testing but to give empirical quantifiable measurements that might be able to direct our treatments 3.

Baseline data is of great significance if it includes a concussion/medical history as well as standardized assessment of concussion and/or the sports concussion assessment tool. Vestibular testing and expert spinal functional examinations can complement these instruments by the chiropractor. Chiropractors also have a civic and professional responsibility to participate in interdisciplinary efforts specific to concussion treatment. Their expertise and experience in spinal injuries complements the evidence-based literature specific to sports concussions. They should be prepared to enter into clinical trials and to share their case studies with individuals in representative governmental positions who have the responsibility of implementation of concussion guidelines that might ultimately reduce the negative outcomes associated with brain injuries in our schools and in our societies 4.

The ICA Council on Fitness & Sports Health Science is positioned well to survey chiropractors trained in sports and those that have a general practice. A general knowledge and consensus of the attitudes, knowledge and experience of a profession specific to brain injuries in sports is very helpful, not only to the profession, but to society at large. Other professions and disciplines have done this. For example, members of the American Academy of pediatrics and the Council on sports medicine and fitness were surveyed specifically in regards to their thoughts of allowing their own children to play contact sports. Most of the respondents would not allow their own child to play tackle football and endorsed limiting or eliminating tackling in practice 5. The ICA Council on Fitness & Sports Health Science should consider official recommendations and or restrictions on tackling in football to support the current concussion concerns of its members, regardless of what they might be.

There has been a great dilemma in the use of baseline computerized neurocognitive assessments. Athletes know about these tests and oftentimes will intentionally underperform in order to score a lower baseline 6. A lower baseline means that after an injury, the player might not be held out of play if their post concussion scores are higher than their baseline. Chiropractors have traditionally relied on their observational and examination skills, particularly in the area of spinal function and central neurological integrity. The addition of clinical examination findings to neurocognitive assessments has the potential to add to the integrity of a valid baseline examination. Certainly, we have found this to be true in our treatment of professional and Olympic athletes from around the globe. 

It is evident that chiropractors that are trained in sports injuries will most probably have a better knowledge of sports than non-sports trained providers. Virtually every sport is associated with head injuries and concussions. However, there are against specific characteristics that might positively/negatively contribute to the occurrence of sports concussions in various sports such as soccer, volleyball, handball, basketball, hockey and football, etc. 7. It is important to understand game specific characteristics of concussions to be able to decrease contributing factors of injury. The chiropractors job does not stop at the office. He/she must embrace a proactive preventative responsibility in sports injuries. The development of preventive strategies by chiropractors will have a consequence in sports and the disabilities that might be associated with injuries.

I have 3° black belt in karate and understand the utilization of the martial arts as a vehicle to improve overall physical fitness. Although many forms of martial arts are associated with injury, there are some evolving noncontact basic patterns and techniques that are associated with low relative risk of injury 8. As in the martial arts, many sports can be associated with safe methodology associated with increased physical conditioning. Knowing a sport well can have advantages to patients that participate in the sport. Chiropractors might consider being involved in the development of different equipment and technology that might be protective in nature. However, it would seem reasonable to suggest that expertise in training might result in changes in routines that might be associated with a decrease of injury.

A chiropractor that desires to work in the field of sports concussions would be well served to spend some time with boxers in training. My experience has demonstrated that many boxers who would do backflips to have a chiropractor ringside. I know that I would have loved to have one (or a few) there during my youth. It is very easy to be involved in the sport from a healthcare professional viewpoint. Professional boxing is associated with a risk of chronic neurological injury, with up to 20-50% of former boxers exhibiting symptoms of chronic brain injury 9. The boxing world has been concerned with brain injury for years and has developed very specific guidelines that are utilized in the sport when injury occurs. Practical experience gained by clinicians that attend boxers contributes to the skill level of the practitioner and I suggest to the overall health of the boxer. I think it is a worthwhile consideration to gain experience for any chiropractor that desires to be involved in the world of brain injury treatment.

There are many public health concerns associated with sports injuries. The chiropractor must make decisions upon his/her recommendations of activities of daily life. Should a patient drive a vehicle or not? There are guidelines that suggest that patients with a concussion should not drive a vehicle for 24 hours but this may not be enough 10. There are many other concerns including the use of mobile phones, computers, social media, music listening, drinking alcohol, etc. that must be addressed in the course of our treatment of brain injured people. The chiropractor should have a plan of action addressing all components of the patient's life. It sometimes is easy to get caught up in the moment of a return to play need and forget other important personal variables that can affect the outcome of our treatment in the outcome of the patient's life.

The sports chiropractor understands the benefits of regular exercise, physical fitness and sports participation on cardiovascular and brain health. Physical activity reduces the risk for cardiovascular disease, type 2 diabetes, hypertension, obesity, and stroke, and produces beneficial effects on cholesterol levels, antioxidant systems, inflammation, and vascular function 11. Exercise is associated with preventing loss of brain volume and increasing cognition that may be associated with decreased development of dementia and increased cognitive abilities throughout the lifespan. But, there are risks of injury in sports that must be taken into account. The public is aware of conditions such as chronic traumatic encephalopathy and results of repetitive injury. Our research team addressed this in our study of the treatment of long-term chronic post concussion syndrome 3. These individual’s lives have been grossly compromised and the fear, family stress soars and societal consequences associated with these injuries are items that healthcare professionals must understand.

Athletes commonly will suffer head injuries resulting in concussion after participating in contact and collision sports. Sports concussions are not simple problems but are among the most complex injuries to manage in a sports medicine setting 12. Confounding the complexity of a sports concussion is the availability of a variety of high tech diagnostic and management systems. The use of a variety of instruments can help the chiropractor embrace a greater empirical evidence-based model that might assist in helping their patients. We have found that the use of the C-3 Logix platform gives us the best evidence-based information in a validated format that is beneficial inpatient applications. Patients also report that they don't mind the testing with this instrument and there is no way of downplaying a neuro- psychological inventory with it.

There are a variety of other tests that we use and that sports chiropractors might find beneficial in the treatment of concussions. The King – Devik (KD) test addresses eye-movement impairment and other brain functions. We have use this testing for many years and find that it is a good basic screen, however our clinical examination goes into greater depth. The benefits of the KD test is that it can be utilized by non-trained laypeople as a good screening tool that will identify individuals that have suffered a sports concussion 13. You can feel comfortable having your staff assistance run this test for you. There is high enter examiner reliability among non-trained personnel. It is cheap and it is effective. At the very least, you should be familiar with the test and have your staff ready to utilize it should you find the necessity to quantify.

The sports chiropractor needs to address the reality that some patients that they return to play will have exacerbations of their symptoms. Therefore the time to return to play is very important and without additional training it is likely that the chiropractor may return the patient prematurely to play. A retrospective review of records in a specialist concussion clinic demonstrated that in 43.5% of concussion cases, the patient returned to sport too soon and in 44.7% of concussion cases, the patient returned to school to soon as well 14. Often time the healthcare professional doesn't know if the return to play or activities has been to early until the patient suffers an exacerbation. The utilization of diagnostic instruments and criterion has a good probability of increasing accuracy in return to play paradigms. Quite simply, the sports chiropractor and others who deal with head injuries in sports often time have to make guesses as to timing that might affect the long-term health of their patients. Our patient population deserves more and in fact our profession should demand more.

There has been a trend of lower physical fitness and increased prevalence of obesity in children and adolescents. As a consequence, society seems to welcome the increased participation of young people in organized sports. However early age participation in sporting activities is not without danger because of their unique vulnerability to injury and potential for adverse long-term health outcomes and escalating health costs 15. There is no doubt that the media and athletes are currently addressing concussion as a primary hot topic of interest. This is of considerable interest to the sports chiropractor that treats children. Almost every child in North America is required to attend school and it is important to have the best functioning brain during these formative years of training 16. This reality brings a greater responsibility to the sports chiropractor whose skills are necessary not only to return the child to play an activity but also to address the reality of long-term learning and brain function. There is therefore an ethical and professional demand to be trained to recognize neurocognitive impairments as well as capacity as part of our treatment of the young.

Our clinic attends professional and Olympic hockey player sent to us from around the globe. We see both male and female players who have suffered head injuries as a consequence of collisions. Many of the collisions are non intentional in nature. Even though females do not involve themselves in active body checking, because of the rules of their sport, they frequently suffer head injuries. Clearly, boys have a two to three time increase in the risk of all injury, severe injury and concussion as a consequence of body checking when compared to girls 17. The ICA Council on Fitness & Sports Health Science should become active in advising strict enforcement of rules such as the American Academy of pediatrics has done. Involvement in helmets, non-checking programs and restriction of contact in younger people is an important professional responsibility that can result in decreased injury and long-term sports participation. It is, in fact, our responsibility. This responsibility is based upon a knowledge base of the literature and clinical experience that the sports chiropractor must have.

All chiropractors that are accepting head injury patients for treatment should be trained and competent in a standardized examination. The American Academy of neurology has called for the development of such a systematic evaluation for the immediate assessment of concussion in athletes 18. In fact, all healthcare practitioners that attend sports concussion patients should maintain that they have performed a standardized examination that reflects the standard of the clinical community. This has the probability of increasing the detection of concussion and determining the appropriate time to return the patient to play and full activities of daily living. The consequences of making an error are two great to neglect the training necessary to serve the sports community at the highest standard. By adopting or creating standards and protocols, the ICA Council on Fitness & Sports Health Science can contribute to the clinical protocols and evidence that best serve our patient populations.

So where do we go from here? Where can the chiropractor learn the skills necessary to participate in a high level of interdisciplinary applications? There are a multitude of quality conferences that are held regularly throughout the world. There are also good quality educational programs that can train the chiropractor to function at a higher level. Most universities that have a medical school also have diversified programs for healthcare professionals in the treatment of a variety of injuries. The Carrick Institute has educational programs that are very specific for chiropractors and are different from traditional allopathic applications. The sports chiropractor should choose their educational programs wisely and ensure that they meet their professional needs. A blended education of synchronous and asynchronous learning appears to be the most contemporary model of clinical learning available. For instance, our Institute, the Carrick Institute, maintains 28 extension facilities throughout the world and trains healthcare professionals from all disciplines in a variety of neurological specialties. Our pedagogy has been studied by randomized controlled trial and published in high tier journals reflecting a similar outcome between on-site and on-demand learning. This has profound implications for learners who might obtain maximum benefit from their studies without embracing the necessity of leaving their home or office.

Each year in Orlando, Florida hosts the International Symposium on Clinical Neuroscience. At this symposium there is always presentations from Olympic athletes who have suffered injuries and recovered. As well as these top-tier athletes there also is presentations from world-renowned scholar clinicians hailing from the best universities in the world. I think that this convention is something that everyone that is involved in sports chiropractic should attend. Truly, it is career changing in nature and the ability to talk and converse with highly published clinician scholars is something that does make a difference. Plus, this symposium is one that also always maintains credentialed and published chiropractors in both its platform and plenary sessions.

Information about the International Symposium On Clinical Neuroscience can be found at iscn 2018.com.

Information about the Carrick Institute courses and certification in TBI and its rehabilitation programs may be found at www.carrickinstitute.org

Dr Carrick has no disclosures or relationships, incentives or financial interest in any of the technology or products referenced in his article.

Dr Carrick’s recent publications in neurology, sports injury and education can be found at Pubmed https://www.ncbi.nlm.nih.gov/pubmed/?term=carrick+fr

You may have specific interest in the following papers that might be downloaded free of charge:

Head-Eye Vestibular Motion Therapy Affects the Mental and Physical Health of Severe Chronic Postconcussion Patients.
Carrick FR, Clark JF, Pagnacco G, Antonucci MM, Hankir A, Zaman R, Oggero E. Front Neurol. 2017 Aug 22;8:414. doi: 10.3389/fneur.2017.00414. eCollection 2017.

Randomized Controlled Study of a Remote Flipped Classroom Neuro-otology Curriculum.
Carrick FR, Abdulrahman M, Hankir A, Zayaruzny M, Najem K, Lungchukiet P, Edwards RA. Front Neurol. 2017 Jul 24;8:349. doi: 10.3389/fneur.2017.00349. eCollection 2017.

Eye-Movement Training Results in Changes in qEEG and NIH Stroke Scale in Subjects Suffering from Acute Middle Cerebral Artery Ischemic Stroke: A Randomized Control Trial.
Carrick FR, Oggero E, Pagnacco G, Wright CH, Machado C, Estrada G, Pando A, Cossio JC, Beltrán C. Front Neurol. 2016 Jan 22;7:3. doi: 10.3389/fneur.2016.00003. eCollection 2016.

Short- and Long-Term Effectiveness of a Subject's Specific Novel Brain and Vestibular Rehabilitation Treatment Modality in Combat Veterans Suffering from PTSD.
Carrick FR, Pagnacco G, McLellan K, Solis R, Shores J, Fredieu A, Brock JB, Randall C, Wright C, Oggero E. Front Public Health. 2015 Jun 1;3:151. doi: 10.3389/fpubh.2015.00151. eCollection 2015.

Evaluation of the Effectiveness of a Novel Brain and Vestibular Rehabilitation Treatment Modality in PTSD Patients Who have Suffered Combat-Related Traumatic Brain Injuries.
Carrick FR, McLellan K, Brock JB, Randall C, Oggero E. Front Public Health. 2015 Feb 4;3:15. doi: 10.3389/fpubh.2015.00015. eCollection 2015.

References:

  1. Tremblay S, Pascual-Leone A, Theoret H. A review of the effects of physical activity and sports concussion on brain function and anatomy. International journal of psychophysiology : official journal of the International Organization of Psychophysiology 2017.
  2. Terrell TR, Bostick R, Barth J, et al. Multicenter cohort study on association of genotypes with prospective sports concussion: methods, lessons learned, and recommendations. The Journal of sports medicine and physical fitness 2017;57:77-89.
  3. Carrick FR, Clark JF, Pagnacco G, et al. Head-Eye Vestibular Motion Therapy Affects the Mental and Physical Health of Severe Chronic Postconcussion Patients. Frontiers in neurology 2017;8:414.
  4. Kajankova M, Oswald JM, Terranova LM, et al. Response of School Districts to the New York State Concussion Awareness and Management Act: Review of Policies and Procedures. The Journal of school health 2017;87:409-15.
  5. Fishman M, Taranto E, Perlman M, Quinlan K, Benjamin HJ, Ross LF. Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks. The Journal of pediatrics 2017;184:19-25.
  6. Siedlik JA, Siscos S, Evans K, et al. Computerized neurocognitive assessments and detection of the malingering athlete. The Journal of sports medicine and physical fitness 2016;56:1086-91.
  7. Helmich I. Game-specific characteristics of sport-related concussions. The Journal of sports medicine and physical fitness 2016.
  8. Demorest RA, Koutures C. Youth Participation and Injury Risk in Martial Arts. Pediatrics 2016;138.
  9. Seifert T, Bernick C, Jordan B, et al. Determining brain fitness to fight: Has the time come? The Physician and sportsmedicine 2015;43:395-402.
  10. Baker A, Unsworth CA, Lannin NA. Fitness-to-drive after mild traumatic brain injury: mapping the time trajectory of recovery in the acute stages post injury. Accident; analysis and prevention 2015;79:50-5.
  11. !!! INVALID CITATION !!! .
  12. McCrea M, Guskiewicz K. Evidence-based management of sport-related concussion. Progress in neurological surgery 2014;28:112-27.
  13. Leong DF, Balcer LJ, Galetta SL, Liu Z, Master CL. The King-Devick test as a concussion screening tool administered by sports parents. The Journal of sports medicine and physical fitness 2014;54:70-7.
  14. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician's chart review. Canadian family physician Medecin de famille canadien 2014;60:e310, e2-5.
  15. Caine D, Purcell L, Maffulli N. The child and adolescent athlete: a review of three potentially serious injuries. BMC sports science, medicine & rehabilitation 2014;6:22.
  16. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics 2013;132:948-57.
  17. Brooks A, Loud KJ, Brenner JS, et al. Reducing injury risk from body checking in boys' youth ice hockey. Pediatrics 2014;133:1151-7.

 

  Dr. Frederick Carrick is a Professor of Neurology and Senior Research Fellow at BCMHR in association with the University of Cambridge, Cambridge UK. He holds a DC degree from CMCC in Toronto, Canada and a PhD from Walden University in Minneapolis, Minnesota (Dissertation: Neurophysiological Implications in Learning).  Professor Carrick was a Global Clinical Scholar at Harvard Medical School and is a Faculty Scholar at Harvard Medical School’s Harvard Macy Institute. He has a Master of Science in Health Professions Education degree from the Harvard Macy and MGH Institutes and holds board certifications in neurology with fellowship credentials in Neuro-otology, Vestibular Rehabilitation and EEG. He has maintained a consultant specialist practice in neurology over 4 decades and has been a Medical Educator for 38 years. He is the subject of the Emmy award-winning PBS documentary "Waking up the Brain" as well as countless prime time television, newspaper, magazine and journal articles.  The Carrick Institute maintains 28 extension facilities throughout the world and is the largest provider of training in the field of Functional Neurology (www.carrickinstitute.org).

To see a list of publications by Prof Carrick please visit https://loop.frontiersin.org/people/96141/overview and https://www.ncbi.nlm.nih.gov/pubmed/?term=carrick+fr

 

 

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