Neck effect: Chiropractic’s emerging role in concussion management
New evidence is making a case for chiropractic in concussion management
By Mari-Len De
It was just supposed to be a regular hockey game and the only thing different with Andrew Parks that day was he was having pain on his neck and some cramping.
It took only what seemed like a harmless bump on the shoulder with another player to realize something was terribly wrong.
That shoulder bump caused him to fall on the ice, and that’s when everything started spinning around him. He remembers being slightly confused on the bench as he sits out the rest of the game. Parks then went to the hospital, where he was diagnosed with a “minor concussion.”
It was only later on that Parks realized his brain injury must have started even before he got on the ice on Sept. 29, 2012. At another game the day before, he sustained a serious hit on the head.
“This hit hurt at that moment, but there was no specific or noticeable changes – no dizziness, no loss of consciousness, no stars,” Parks recalls. He then continued to play and finish the game. Little did he know that one hit would leave him debilitated, mentally and physically, for the next several months.
Unfortunately, it’s a scenario that occurs far too many times in the sporting world: a player suffers a blow to the head and, not exhibiting any symptoms that would indicate an injury, continues to play the game.
This is what makes concussions a very serious matter, says Dr. Michelle Laframboise, a sports chiropractic specialist based in Orillia, Ont., who has seen many concussion cases in her practice – Parks is one of them.
“I think we know what a concussion is. What we don’t know is why everybody is so different and why it affects people in different ways,” says Laframboise.
A concussion is a traumatic brain injury that can be caused by a blow to the head or when the head or upper body is violently shaken. This type of injury can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don’t realize it – and that, Laframboise says, has been one of the biggest challenges with concussion.
Concussion seems to affect people in different ways: some could have headaches and dizziness, others are knocked unconscious, and many will exhibit no immediate symptoms following a hit or a concussion-causing incident. Yet, all of them could have sustained a concussion.
There is a growing number of sports injury prevention advocates, like Canada’s Royal College of Chiropractic Sports Sciences (RCCSS), calling for better collaboration and increased education among athletes, parents, coaches, athletic groups and health-care providers regarding concussions.
“What we need to do really is come together so that we are all in understanding of how we diagnose (concussion), and what we do to manage it,” says Laframboise, who also chairs the RCCSS public health committee.
The RCCSS is doing its part to educate chiropractors about concussion as part of the college’s two-year residency program in sports chiropractic. The efforts in education are not only limited in the learning environment, however, as the trained chiropractors transfer their knowledge in the clinical setting, serving as a resource for patients who are either athletes or parents of athletes. Doctors who work with sports teams are also trying to increase knowledge about this potentially debilitating brain injury.
A concussion is a self-limiting condition and most cases – about 80 to 90 per cent – will resolve in seven to 10 days, if managed properly. This means complete rest and no activity requiring physical and mental exertion.
The importance of rest and full recovery before returning to play cannot be overstated, however.
“It can go into post-concussive syndrome, which is another beast in and of itself,” Laframboise says about the complications that may arise if an initial concussion is not managed appropriately. “Or you can also get what’s called ‘second impact syndrome,’ which you can get if you suffer another concussion back-to-back, which can be devastating – even deadly.
“That is why it’s really important that we keep patients out of sports until they’re fully healed.”
The issue around concussions, particularly in the sporting world, has gained increased public attention in recent years. The hope is that greater awareness will pave the way for improved safety and injury prevention in sports, as well as better, more consistent management of concussion.
There are also more resources today than ever before about the risks, diagnoses and management of concussion and post-concussion syndrome that provide athletes, parents, coaches, sports organizations and health-care providers a better understanding of what to do and what not to do when an athlete sustains a head injury.
This wasn’t necessarily the case when 30-year-old hockey player Jimmy Marinakos was at the prime of his athletic career. He believes he’s had more than 14 sport-related concussions in his lifetime – the first one occurring when he was eight years old and the more recent one just last year.
“Back when I played, it was more like I was letting myself or my teammates down if I was out (of the game) for any time,” Marinakos says. “It’s an injury that you can’t see so you think everything is OK. You kind of lie to your team doctors and your team trainers.”
He says the situation is different today; with various groups drumming up awareness, it’s bound to benefit young athletes today.
“Nowadays, it’s OK to say, ‘You know what, I don’t feel good. I don’t feel myself.’ And you’re not going to be looked upon by your peers or your coaches like you’re letting them down, because it’s such a huge issue.”
Marinakos is now suffering from post-concussion syndrome (PCS), as a result of all those head hits and concussions that were left unattended. He experiences the typical symptoms of someone with PCS: dizziness, depression, anger issues, short-term memory loss. The only thing that seems to help with his symptoms, he says, is chiropractic care.
“I have been seeing Michelle (Laframboise) for about eight months now… it’s part of my weekly routine, so I don’t forget,” says Marinakos. “She does some active release work on my neck and head area. I can’t go more than a week without seeing my chiropractor – my neck just tightens up and I start to get the headaches.”
Marinakos is currently taking part in a concussion research program called the Canadian Sports Concussion Project at Toronto Western Hospital’s Krembil Neuroscience Centre, headed by neurosurgeon Dr. Charles Tator. Marinakos hopes by participating in this program, he will be able to understand more about what he is going through.
The research project is only one of a growing number of initiatives that have taken place in recent years with the objective of increasing clinical knowledge and raising awareness about concussion – among them, the Canadian Concussion Collaborative (CCC), an umbrella organization consisting of various health-care and sports associations, including the Canadian Academy of Sport and Exercise Medicine (CASEM). The goal of the CCC is to create synergy between health organizations to improve education on concussions and implementat best practices for the prevention and management of concussions.
The RCCSS has worked closely with CASEM in the past on several initiatives, according to Dr. Scott Howitt, vice-president of the RCCSS.
He says it’s important that chiropractors who are providing care for sports teams or individual athletes be appropriately educated on concussion.
“We acknowledge that chiropractors, as much as any other health-care practitioner, may be the first person to see a patient that comes in with a concussion,” says Howitt. This is especially true in many rural communities where access to a family physician is a challenge.
“If you’re in a big city, there’s a bunch of specialists that are available to you. But if you’re from somewhere in Northern Ontario, where you don’t even have a family doctor in your community, but you play hockey and you get a concussion. There needs to be various health-care providers, whether it’s a chiropractor or physiotherapist or some other health-care practitioner, that are going to be able to help manage these concussions,” he points out.
RCCSS members are trained in sport injury, including concussions. They are also encouraged to constantly update their knowledge on concussion as new developments and information about this condition come out fairly frequently.
There are a number of resources for chiropractors to get up to speed on concussion developments. The Concussion Consensus Statements, for example, is an international document that RCCSS members and many health practitioners use to find guidance around concussion diagnosis and management. The Concussion Consensus Statement is an evolving document, however, and has already seen its fourth update since the first version was released at the International Conference on Concussion in Sport held in Vienna in 2001. The last version was released in 2012.
Familiarity with the concussion assessment tool SCAT 3 is also necessary, says Howitt.
“These are common knowledge, common pieces if you’re working with sporting teams, where there are going to be concussions,” he says.
While sports chiropractic specialists would likely have the knowledge to appropriately deal with potentially critical sports injuries, like a concussion, one cannot expect an average practitioner with no specialized training to be able to handle these types of conditions. Collaboration with other health-care providers, therefore, is critical.
Not all concussions are created equally, according to Howitt, and while most concussions resolve on their own with proper care, some will spiral into more serious and debilitating PCS.
It is when symptoms persist – even worsen – beyond the typical ten-day time frame that more careful and specialized care is needed.
“That’s where a multidisciplinary approach is likely applicable because that’s where we find that maybe, besides the fact this person has a concussion, they also have some whiplash injury or some sort of cervical spine injury that is contributing to the headaches or to some of the symptoms described,” explains Howitt.
In the spotlight
Perhaps one of the greatest publicities for chiropractic as a treatment for concussion symptoms happened when Canadian hockey hero Sidney Crosby attributed his recovery from a serious concussion – that kept him out of the game for several months – to Toronto-born chiropractor Dr. Ted Carrick.
Carrick, who specializes in chiropractic neurology, had Crosby undergo vestibular stimulation with the help of a rotating chair called the GyroStim.
In a Huffington Post article, published in November of 2011, Carrick explains: “The vestibular system is a powerful activator of brain function and its stimulation may be associated with an improvement of many functions with a decrease of symptoms including head pain, fogginess, concentration, balance, gait and motor co-ordination. Vestibular stimulation in concert with eye exercises and other physical modalities affects central pathways in the brain. The brain is plastic in its function and activation of the brain may result in changes in structure and function.”
Crosby’s infamous chiropractic experience is only one of several recent developments supporting the value of chiropractic for alleviating the debilitating symptoms of concussion and post-concussion syndrome.
Recent studies are showing a connection between the cervical spine and concussion symptoms. One such study comes from the University of Calgary, where Kathryn Schneider, a researcher with the school’s Faculty of Kinesiology’s Sport Injury Prevention Research Centre, found cervical spine and vestibular therapy helped athletes with prolonged concussion symptoms return to play within eight weeks after their therapy.
The study, published in the British Journal of Sports Medicine in the spring of 2014, was a randomised controlled trial involving 31 athletes, male and female, with persistent symptoms of dizziness, neck pain and/or headache following a sport-related concussion. Participants were divided into two: the control group and the intervention group. Both groups received weekly sessions with a physiotherapist for eight weeks or until the time of medical clearance. Both groups received postural education, range of motion exercises and cognitive and physical rest until asymptomatic followed by a protocol of graded exertion. The intervention group additionally received cervical spine and vestibular rehabilitation.
The result revealed 73 per cent of the participants in the intervention group were medically cleared within eight weeks of initial treatment, compared to only seven per cent in the control group.
Another recent study that is making the rounds in the chiropractic community comes from the University of Buffalo, which compares subjects with neck injuries and those with PCS. It found no difference between symptoms of a neck injury and symptoms of PCS.
“There is no change or different pattern of symptoms from concussion to neck injury,” says Dr. John Leddy, a sports medicine physician and professor of clinical orthopaedics at the University of Buffalo, who led the study. “You can get cognitive symptoms with both – like trouble thinking, trouble concentrating, trouble remembering – you can get headaches from both, dizziness from both, emotional symptoms from both, trouble sleeping from both. So that if you try to go by symptoms alone, after any kind of sport injury, it’s hard to separate someone who has a neck injury from someone who has a concussion – and they may have both.”
The study may provide evidence that treating the cervical spine can help patients or athletes experiencing prolonged symptoms after a concussion.
“For example, sometimes more often than not, we see people here who have been symptomatic for weeks and months after a head injury, and with some more evaluation we have determined that the concussion part is over, but what they are really experiencing was a neck injury or a balance or vision problem that occurred at the time of the concussion, but now it’s responsible for the prolonged symptoms,” Leddy explains.
The treatment for these conditions – neck injury, balance or vision problems – is different than just the treatment for concussion, so it is important to also identify these issues by examining the neck, the eyes and the balance systems, he adds.
Toronto chiropractor Dr. Cameron Marshall, who worked with Leddy on the University of Buffalo study, also looked at more evidence that shows a connection between concussions and neck injuries.
Data from football studies in the U.S. indicate the acceleration value that causes a concussion can be anywhere between 60-Gs and 120-Gs (G = force of gravity).
“When we look at data from biomechanical whiplash studies, we find that the acceleration required to cause a mild cervical strain injury is only 4.5-Gs,” says Marshall. “So anyone that is getting a concussion that is between 60 to 120-Gs of acceleration to the head is likely to be experiencing at least 4.5-Gs of acceleration to the neck. So there is a high probability of every single concussion patient having some form of soft tissue, cervical spine injury, which can present very much like a concussion.”
Both Leddy and Marshall emphasize the need for multidisciplinary approach when it comes to managing concussions, particularly in cases with prolonged symptoms.
It was his interest in concussion research and treatment and what he believes as a need for increasing education among health-care practitioners about concussions and how to manage them effectively that led Marshall to develop Complete Concussion Management Inc. (CCMI), a multidisciplinary network of chiropractic, physiotherapy and sports medicine clinics across Canada specializing in concussion management.
“Because I was immersed in this (concussion) research, I decided to start educating health-care practitioners and form a network of clinics equipped with the knowledge and resources to deal both with acute concussion management as well as chronic post-concussion syndrome rehab and treatment that have been shown to be effective,” says Marshall.
CCMI clinics are fully equipped to provide the necessary tests, assessments and care for athletes and concussed patients based on CCMI standards, says Marshall. Practitioners in these clinics are educated on the latest information, assessment, management and treatment protocols.
The education component includes a three-day seminar covering everything about concussion management, including the pathophysiology (what happens inside the brain during an impact), the biomechanics (the force required to cause an injury to the brain), and what potential other injuries can be caused by the same mechanism. Practitioners within this network are also required to keep up with ongoing continuing education in order to retain their certification.
“It’s really cutting edge protocols that are at the forefront of the research,” Marshall says. “We are continually updating everything on a monthly basis, updating the protocols based on new research that has emerged for that particular month.”
There are currently more than 70 CCMI locations across Canada, according to Marshall. These clinics work with amateur and youth sports teams in their community, conducting pre-season baseline testing and post-injury care for all athletes. These tests include all areas of the brain that can be potentially affected in a concussion: balance, visual tracking and processing, and neurocognitive measures, including memory, concentration and executive function. When an injury occurs, the injured athlete – after undergoing appropriate treatment and physical testing – is measured by his or her baseline data to determine full recovery, prior to allowing the athlete to return to competition.
CCMI clinics are connected by a centralized health records system, so if an athlete gets injured outside of his or her home clinic, the athlete can just walk into any CCMI-affiliated clinic and that location is able to access the athlete’s concussion file, including all baseline and previous injury data, explains Marshall.
“So that if an athlete who lives in Ottawa, for example, is playing a hockey tournament in Toronto and they get a suspected concussion, they have the ability to compare their baseline right on the spot, thereby improving diagnostic accuracy and having a trained clinician deliver proper, evidence-based management recommendations,” he adds.
There is growing evidence to demonstrate the important role chiropractic can play in the treatment of concussion-related disorders. However, more research is needed to strengthen the evidence in favour of chiropractic care.
Guelph, Ont.-based chiropractor and researcher Dr. John Crawford is among those pursuing more research in the area of concussion, and foresees some “brilliant stuff” that is going to come out in the very near future. He believes there is a place for chiropractors in the treatment of this type of brain injury.
“But in order to do that successfully, and with some degree of expertise, the most important thing would be to become certified in the area of concussion management,” says Crawford who himself trained through Shift Concussion Management. This training program is based on protocols developed by the University of Pittsburgh Medical Centre.
Specializing in concussion management takes time, focus and experience.
“Some formal training in this area is required, and then you work through case after case after case and eventually, you develop an understanding of what you are looking for – just like any speciality,” Crawford notes.
Because concussions can potentially turn into very complex, chronic cases, having a network of health-care providers – psychologists, neuropsychologists, medical doctors and optometrists – with specialization on concussion-related disorders is vital.
For Crawford, the bottom-line for concussion management is not just return-to-play, but most importantly, he wants to “return people to life” – back to the way they were before they sustained their injury.
Perhaps that is the hope of Jimmy Marinakos, as well, as he learns to live with his PCS symptoms.
Although he will always love hockey, he has learned to accept he may not be able to go back to his heyday as a star goalie. He plays recreational hockey from time to time, and is careful – or hopes – he doesn’t get another concussion.
He also tries to give back to the sport he loves by helping other kids pursue their own dreams of making it in the big leagues someday.
His advice to kids: “If something is wrong, you need to speak up and not play if you’re really not feeling great; because at the end of the day, it is our brain, it’s basically all we have. It’s our identity.”
Mari-Len De Guzman is the editor of Canadian Chiropractor magazine. Email her at email@example.com
A different breed
By Jennifer Marinakos
(Editor’s note: This is the story of Jimmy Marinakos’ struggle with post-concussion syndrome, as told from the point of view of his wife, Jenny.)
I first met Jimmy in high-school. He was going to the States on a hockey scholarship. He was charismatic, fun, lively and always positive. I was not eager to date a hockey player then. But Jimmy always reassured me: “Goalies are a different breed, Jen; you have nothing to worry about.” And so, we began a relationship.
During that time he travelled much of Canada and the U.S. and got a name for himself as being small, yet dynamic in the net. He was electric to watch when he was in his crease – that is, until he would get a skate, puck or another player, for that matter, to the head. Jimmy’s words would always echo in my head whenever I watched him play or heard about his concussions after a game: “Goalies are a different breed, Jen; you have nothing to worry about.”
As I travelled around watching Jimmy play on my breaks from university, I noticed that as he suffered more severe concussions, he also began to change. Gone was the charismatic, fun and lively man. Jimmy had a career-ending concussion when I was in my last year of university. It was so bad he could not recall a single thing about “us” when I arrived in Tulsa, Oklahoma, to see him. It was then that Jimmy was first diagnosed with post-concussion syndrome. Shortly after, he became a liability and his team would not re-sign him. Jimmy came home depressed, struggling with day-to-day functioning. His long- and short-term memories were affected, he suffered headaches, light and sound sensitivity, and mood swings – horrible and uncontrollable mood swings. It was a very difficult time in our relationship. It was hard to watch the person I loved so much be so down.
Jimmy and I married on August 14, 2010. It was our 10-year anniversary of dating. Jokes flew at our reception about getting married on that day so Jimmy didn’t have to memorize yet another day in time. But the truth was, they were right. Jimmy had learned to adapt many good coping strategies over the years. Being an elementary special education teacher, I always considered Jimmy my first student. We worked on memory games and activities to help with organizing information and people, and eventually Jimmy started to do very well. He began playing pickup hockey again. The more time Jimmy spent on the ice, however, so too did I notice an increase in the post-concussion symptoms returning.
He began to withdraw from social interactions, was unable to speak clearly or form a thought, and was not handling stress or his emotions well. He would have prolonged processing delays and stare off with a blank expression, almost like he had zoned out.
Jimmy walked away from his life and our marriage in October of 2013. Being pregnant and alone, I was devastated. He was lost. I truly believe that Jimmy walked away because he knew in his heart something was wrong with him and he just didn’t know how to ask for help. Nevertheless, the stress of what would follow caused me to miscarry just shy of 11 weeks. It was one of the lowest times of my life.
I had no choice but to pick up the pieces. I started therapy, eventually went back to work, and began to re-evaluate my life. Jimmy, for the first time in years, went to the doctor. He was diagnosed with severe depression and post-concussion syndrome.
Playing hockey had given Jimmy many wonderful traits: confidence, maturity, responsibility, dedication, passion; but it had also given him a broken mind. Sure, he made the choice to stand in that net for as long as he did, but who wouldn’t for something they love? Jimmy says only a hockey player would understand that. I understand it. That’s what it’s like to live behind the mask, and that’s what it’s like to love the person behind the mask.
As Jimmy reaches out to doctors, specialists, support networks and therapists, I see continued growth. I wish him love, health and happiness on his journey. I continue to be his advocate and friend because everyone needs someone who loves them in their corner.