THE BACK PAGE RESEaRCH REVIEW C Concussion: a clinical primer for chiropractors by shaWn thistle neuropathological changes, but the acute clinical symptoms largely reflect a functional distur-bance rather than structural injury. Concussion results in a graded set of clinical syndromes that may or may not involve loss of conscious-ness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. Step 2: Light aerobic exercise to in-crease heart rate (HR): less than 70 per cent HR maximum activities only (ex. walking, swimming, cycling), no weight-training at this stage Step 3: Sport-specific exercise (add-ing movement): skating, running, no head impact drills (as in soccer) Step 4: Non-contact training drills: more complex drills, can begin pro-gressive resistance training Step 5: Full-contact practice: follow-ing medical clearance Step 6: Return to normal game play The literature pertaining to chiro-practic management of concussion, overall, is sparse at this point. DCs manage patients with head trauma from sports, motor vehicle accidents and falls, with assessment stages ranging from on-field assessment to late-stage rehab. Despite the current lack of high quality research evidence, concussions can result in many symp-toms and conditions that DCs com-monly assess and treat, including: headache, vertigo, neck pain and back pain. Therefore, DCs have a variety of important roles to play for concussion patients: provide rational and efficient on-field or clinical assessment; iden-tify high risk patients and manage accordingly; facilitate/participate in multidisciplinary care; provide nutri-tional support/advice; manage recov-ery expectations and monitor symp-tom improvement; educate and support patients during recovery and graded activity protocols; and deliver individualized manual treatment in accordance with emerging evidence. (Above is a recap of my presentation at the 2014 OCA Conference on Oct. 25. Watch for more concussion-related topics at upcoming seminars offered through Research Review Service.) www.canadianchiropractor.ca oncussion in sporting en-vironments is common, but this injury can also occur in occupational set-tings, motor vehicle colli-sions, falls and so on. Practising chi-ropractors should have a working knowledge of contemporary evalua-tion and management issues sur-rounding concussion, as this form of mild traumatic brain injury can result in long-term disability or even death. On-field and clinical assessment, as well as treatment and management of concussion are becoming more evi-dence-based as new literature emerges to address best practices and support clinical decision-making. Because athletes are often eager to return to play and potential serious injury may result if they return too early, it is important that concussion be man-aged using current practice guidelines to ensure best practices are followed. The Consensus Statement on Con-cussion in Sport defines concussion as “a complex pathophysiological pro-cess affecting the brain, induced by traumatic biomechanical forces.” Several common features that incor-porate clinical, pathological and bio-mechanical injury constructs may be utilized in defining the nature of a concussive head injury: • Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. • Concussion typically results in the rapid onset of short-lived impair-ment of neurological function that resolves spontaneously. • Concussion may result in • The timing of concussion assess-ment can range from acute on-field situations to the clinic setting. As al-ways, chiropractors should immedi-ately manage emergent concerns on-field and subsequently conduct a complete history and physical exami-nation when possible and appropriate. The cornerstone of concussion management is immediate physical and cognitive rest until acute symp-toms resolve. Cognitive rest involves no reading, homework, watching TV, smartphone/tablets, social contact. Then, a graded program of progres-sive exertion should be supervised prior to medical clearance and return to play (for athletes) or integration into normal activities (for other pa-tients). Below is a general outline for pro-gressively increasing activity for a patient who has suffered a concussion. Patients should proceed to subse-quent levels if they maintain asymp-tomatic status at the current/prior level. If symptoms arise, back up one level after 24-hours rest and proceed again to subsequent levels, as stated above. Each step should take from 24 hours to a week, if all goes well. Step 1: No activity DR. ShAWN thIStle owns and operates Research Review Service Inc., helping clinicians integrate scientific evidence into practice through subscription-based service (researchreviewservice.com), online courses (onlinecourses.researchreviewservice.com) and seminars (epicureanscholar.com). 50 Canadian Chiropractor December 2014
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