Archives for May 2012

Concussion Conference

Being a strong proponent of active care I encourage many people to become more active, to move with better quality, and to then move more frequently.  For the majority, I think this is quality advice, but as with all clinical interventions a key component lies in knowing when not to apply that strategy.  Active care may be contraindicated in a few different conditions, but one is in those experiencing concussion symptoms.

Recently I had the opportunity to attend the 9th Annual Sports-Related Conference on Concussion and Spine Injury (May 18, 2012). While I must admit that my background in concussion management is not as strong as I would like it to be, I felt compelled to attend to strengthen my understanding so I would better be able to discuss this hot button topic with my patients and community.  Ultimately I see my role as a chiropractor in recognition of symptoms, prescription of sparing advice, reassurance, and referral for appropriate monitoring.  To do this effectively I needed to know more.  I found this conference to be a top notch assembly of exceptional health care professionals, former elite athletes, and researchers.  I left with an appreciation for all that goes into studying and managing concussions and appreciating that there is still a lot to learn.  Some points of interest, reviewed concepts, and things that peaked my curiosity below.

From William Meehan III, MD, the history of concussion was discussed.  It was known from the slaughterhouse that rotational acceleration was necessary to stun the animal and that blunt head trauma alone (head stabilized during the trauma) did not produce the dazed reaction they were looking for.  {Upcoming post on how often we know things before science catches up…. Soon.}  The role of second impact syndrome or repeated concussion is a hot topic these days, but was first described by Gronwall in 1975 who noted in his research that the 2nd concussion commonly took longer for recovery of symptoms.  Why are we sometimes so far behind ourselves?

(Overview) Management of a concussion:

  1. Rule out other injury (on the field ABCs, then consider fracture, intracranial hemorrhage, and other life threatening conditions)
  2. Physical rest (avoid working out so ATP & glucose is not stolen from the brain where it is needed for recovery efforts.)
  3. Cognitive rest (avoid mental activity using precious ATP & glucose that’s needed for healing.)
  4. Emotional rest (same rationale as above)
  5. Follow up and reassess for patient to be symptom free.
    1. Evaluate with PCSS- Post Concussive Symptom Scale
    2. BESS Balance Error System Score:  Double leg stance, Single leg stance, Tandem Stance (20s)
    3. Neurocognitive (ImPACT and similar tools):  Verbal memory, visual memory, processing speed, & reaction time
  6. When symptom free return to participation (RTP) stages
    1. Rest (physical, emotion, cognitive; as described above)
    2. Light aerobic
    3. Sport specific (low intensity) training
    4. Non-contact training drills
    5. Full contact
    6. Game play

 

Neuropsychologist Alex Taylor, PsyD reminded us that concussion is a silent disease.  Those suffering with it often appear healthy and normal.  Considering that 90% of concussions do not involve a loss of consciousness, MRI and/or CT are likely to be negative, and there are no dramatic outward signs (seizures, emesis, blood, bruise, cast, splint, etc), these injuries can often go under appreciated.  Particularly in students this can include parents, teachers, coaches, and friends.

He also noted significant role of computer based testing.  His explanation was that this testing was more sensitive than symptom reports only, but he emphasized the greatest sensitivity when combining the two:

–       64% accuracy with symptom reporting
–       83% accuracy with neuropsychologic (computer) testing
–       93% accuracy when combining both (the comprehensive approach is best).
–       As each individual recovers differently, evaluation and reevaluation is essential.

From Robert Cantu, MD – Ways to prevent concussions:

–       avoid taking unnecessary hits (non-contact practice)

  • CTE is more about repetition that significance of trauma; observe the most frequent positions in football – linebackers & lineman; mores than receiver.
  • Consider ‘hit’ count for kids, similar to pitch count in baseball.  Considering that pitching produces surgically repairable injuries and head trauma causes irreparable damage this should be given strong consideration.

–       proper technique (don’t lead with the head)
–       adequate hydration
–       having the right genetics  (good luck modifying this risk factor)
–       rules changes
–       strengthen your neck   *** see discussion below***

My side comment: (Note: I have no strong evidence to support this, just my thoughts.) 
Dr. Cantu was not the first or last to note ‘neck strength’ as a primary factor in concussion prevention during the conference.  As this was discussed my mind immediately jumped to the role of ‘core strength’ in prevention of back pain.  Core strength is/was commonly discussed as being preventative for back pain.  Research on this tends to be less decisive than the commonly accepted statement that a ‘strong’ core is protective for the back.  I wonder if this statement on ‘neck strength’ is equally well liked for it’s plausibility, but will also result in marginal or less than perfect correlation during research.  I suspect that the role of ‘timing’ of neck muscle activation plays a more significant role that ‘strength’. 

This was demonstrated well in Cholewicki’s work. [Here or even more clearly here.] To look at this in more common terms, let’s compare it to a car accident. I don’t think the ‘strength’ of the brake is the best determinant of injury during a motor vehicle accident, it is much more likely that the ‘speed’ or ‘timing’ of applying the brake has a more significant correlation on how well injury can be avoided.  Particularly when considering the role of external perturbation in Cholewicki’s study and the fact that some of the concussion-causing trauma is unanticipated.  The natural timing and response of the cervicocranial stabilizers appears to have the best chance of being protective by mitigated rotational forces.  (Again, this is just my speculation.)  During a brief conversation with Dr. Cantu he noted that he was unaware of any research done on concussions and cervical timing.

Childhood concussions with Dr. Gerard Gioia – a wealth of info, but this one resonated with me as it sounds much like what we (should) do to properly manage so many NMS conditions.  Have them do activities they can tolerate, help them learn what they can and can’t do, and “Teach them the sweet spot”. This results in active rest and active management which is then gradually increased.

Clinical Pearls:

-Younger brains need to be managed more conservatively.

-For unknown reasons, concussed females show a greater decrease in neuropsychological scores than males.

 

Ted Johnson (former NFL All-pro middle linebacker (paraphrased):

 

This is an exciting time for medical providers and scientists with all the new research.  It’s a terrifying time for patients as there is much attention, but so little is known.

Most of my concussions came in practice, not in games.

Players don’t know the long term effects of concussions.  I didn’t know & don’t tell me I did!

Before meeting my current concussion specialist, I was recommended for electroconvulsive therapy (ECT) because they didn’t know what else to do with me.

 

Links of interest:

Ted Johnson @ Harvard Concussion Conference NESN story & video

Ben Utecht:  Tell me if his story makes you wonder about the significance of these injuries.  Not only did he not recall being at his friends wedding, he didn’t recall that he sang at the wedding.  Doesn’t seem like an occasion you should need photographic evidence to refresh your memory.  http://espn.go.com/nfl/story/_/id/7966792/concussions-affect-now-singer-ben-utecht-life

CDC Concussion info (with good video for the lay public)

Mass Dept of Health Concussion resources

Sports Legacy Institute

 ImPACT testing

Addition by subtraction

I had a new patient enter the office recently who had been under the care of another chiropractor.  This was an interesting visit as often times when a patient comes from another health care provider there is a reason.  Perhaps they are in some way dissatisfied, not improving as fast as they would like, have a new condition, recently moved, etc.  This one was different.  The patient was thrilled with their current health care provider.  You may be thinking the same thing as I was, “why make a change when you’re extremely satisfied?”.  Here’s the answer I was given (paraphrased):  “I love my current doctor, but cannot drive all the way to see him more than 1x/week due to gas prices and time.  I’ve had these symptoms for 3 months, I lived with it for 8 weeks and then have been receiving treatment 1x/week for the past 4 weeks.  I am gradually getting better, but if I could be seen more often, I would get better faster.”   Sounds logical, if some is good, more must be better.

Patient history includes back pain and left sided leg symptoms (S1 sensory changes).   No signs of ominous pathology.
Prior treatment: weekly instrument assisted manipulative therapy with mild improvement each week.  Patient was also stretching at home.

So at this point the question is what to do.  First, I’ll say that  when I take over care for a patient who believes their current treatment regimen is working, I rarely change it initially unless I have significant concerns.  I instead work with it and make gradual changes in most cases.  I believe that what the patient thinks will make them better often does.  Their confidence in their treatment is an important part of the puzzle. (Is this approach right or wrong?  Feel free to weigh in.) 
Next issue is what to change in the treatment to make it more effective… the frequent debate is with whether to mobilize or stabilize first.  From Boyle’s Joint by Joint approach we have some general guidance as to what tends to need to be mobilized and what areas tend to need stability.  From FMS/SFMA (& others) we have the general concept that mobility is necessary before stability.  While I agree that mobility is often needed first, this is not a rule as much as it is a guideline.  Frequently, I’ve seen that providing stability where needed allows the nervous system to reduce the ‘tightness’ of other areas.  As stability is restored, the nervous system stops drawing upon ‘prime movers’ to act as stabilizers and mobility is restored.  To determine what type of treatment is most likely to benefit an individual patient, I follow this model, as outlined by Dr. Craig Liebenson.  Its brilliant simplicity is applying a McKenzie (MDT) concept to active care, including mobility & stability exercise.  While the mobility vs. stability debate will continue on, there is a more important first step that is at times overlooked. So let’s go back to this patient I saw and the case at hand.  I did provide instrument assisted manipulative therapy, similar to what the patient had previously received.  The patient was satisfied with this portion of care.  I also reviewed the patient’s current stretches.

After realizing that the patient was performing positions that involve common back injury mechanism (repeated or prolonged end-range loading, in this case lumbar flexion), I simply asked that she stop doing 2 of the 4 stretches the patient was doing on her own each day to try and remedy her condition.  (Picture on right was #1, a seated version with legs spread was #2.)

The outcome:  Patient returned 2 days later and was 50+% improved.  After 3 months of symptoms, I consider that a positive outcome.  Please realize, this is not a post about me, how good a job I did, or the quality of care I strive to provide.  It is also not a post to say, look at what someone  else was doing wrong.  (I hate these types of blog posts and FB posts.  We’re all on the same team.)  In fact, if you reread this you’ll see that I actually did very little.  I simply duplicated someone’s treatment.  The only thing that was changed is I followed the advice of one of the Prague school pioneers.Karel Lewit

“The first treatment is to teach the patient to avoid what harms him.”  Karel Lewit, MD

Patients who are not well informed as to what harms them are unlikely to respond favorably. Removing offending movements, positions, and activities is essential.  Sparing advice trumps mobility, stability, balance, etc.  (In reality it often includes bits and pieces of all of them.)  At times patients have a hard time understanding how important and powerful this part of treatment is.  I’ve heard and use the following story, “If you came here with thumb pain, I could treat your thumb any way imaginable, but if it hurt because you were hitting it over and over again with a hammer, wouldn’t you agree that teaching you to swing the hammer differently is most important?”  Change hammer & thumb to anything that resonates with the person in front of you and I think you’ll have a productive first interaction.

Don’t skip step 1:  “Teach the patient to avoid what harms.”  (Added note: Don’t let step 1, become ‘avoid activity’, be specific.)

Sparing strategies:

A) For repeated movements: ergonomic advice, teach/train better quality movement, and improve joint centration. 

B) For prolonged loads: microbreaks.  If you stand, sit. If you sit, stand.  Examples:  Brugger’s postural relief position.  McGill’s overhead reach.  McGill's overhead reach