Case Study: Concussion

Patient: 15 year-old girl

Chief complaint: Constant headache, neck pain and dizziness after a concussion 2+ months ago

Back Story: The high school athlete sustained a concussion in Feb during a soccer game. At the ER, she was diagnosed concussion and was prescribed Ibuprofen. Her mom was proactive, and quickly got her involved in several rehab programs and therapies. By the time she saw me, she had gone through about 10 weeks of physical therapy, vestibular training, vision therapy, massage and chiropractic care. At that time, her neurocognitive testing (ImPACT test) had improved, but she continued to have constant headache on the top of her head, average 2-4/10 pain, and 6/10 at its worst. She also continued to have dizziness and neck pain.

Results

After 2 visits, her headache was gone for the first time in 11 weeks, and because of that, her emotional irritability also improved.

During the first month of specific Neuro-Structural Chiropractic Care, she was also undergoing speed and agility training prescribed by her MD a couple times a week. The problem was the jolting movements in this training always left her dizzy for quite some time after.

After we tweaked her vestibular exercises and gave her only a couple very specific eye exercises to do at home, she had no dizziness for the first time in weeks, and continued to be headache-free.

After 1.5 months of treatment (12 visits), she had no headache, dizziness or neck pain, and was cleared by her MD to return to play.

Discussion

1. Realistic expectation of recovery timeline

This is somewhat counterintuitive, but research has shown that young athletes recover from concussion more slowly than older athletes. ⁽¹⁾ If your child sustains a concussion, this is what you can expect. It is unlikely for the child to return to play within a couple days (2.5% probability). Most adolescent athletes make their way back to the sports within about a week (71.3% chance). ⁽²⁾ However, if your child is not able to return to play within 10 days, there is a good chance that he/she will have a prolonged recovery, which is the case for the girl in our case study. In this case, seek professional help as soon as possible.

2. Not all vestibular rehabs are the same.

Many of my post-concussive patients are slightly apprehensive when they hear vestibular rehab, because in their experience, the exercises often make them dizzy and they feel awful afterwards. But then they thought to themselves, I have to feel worse before I feel better, right? WRONG. When your rehab makes you feel worse afterward, this is a good indicator that the intensity and/or duration of the exercises are too much for your brain to handle. Less is more. Again. Less. Is. More.

Conclusion

1. If your child had a concussion, and was cleared by his/her physician to go home. Rest him/her for the first week. If he/she is not able to return to play after the first 7-9 days, seek professional help.

2. Although research suggests that the chance of return to play beyond 21 days post concussion does not increase, we beg the differ by what we see clinically. With the right therapies, the child can still make a relatively smooth recovery.

References:

1. Nesmith JD. Sports concussion in the child and adolescent athlete. J Ark Med Soc. 2010 Nov;107(6):111-4. [PubMed]
2. McKeon JMM, et al. Trends in concussion return-to-play timelines amon ghighscholl athletes from 2007 through 2009. J Athl train. 2013 Nov-Dec;48(6):836-843. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

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The post Case Study: Post-Concussion Headache, Neck Pain And Dizziness – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

First Things First, To Rest Or Not To Rest?

For those who don’t get better in 7-10 days, the universal recommendation used to be “continue to rest in a dark room”, and I still hear this from time to time.

Unlike the acute care immediately after concussion, as of 2016, there is still no consensus for treating chronic post-concussive symptoms. ⁽³⁾ Although conventionally, doctors tend to tell their patients to rest as long as symptoms still exist, new research suggests that it’s not a good idea to simply rest beyond the first few days after concussion. ⁽⁴⁾

This makes a lot of sense from a neurological perspective. Our brain is an ever-changing organ that constantly remodels itself based on the stimulations it receives from the environment. Deprivation of sensory stimulation, albeit temporarily necessary, hinders rather than aid recovery in the long run.

While uncontrolled activity will most likely exacerbate the symptoms ⁽⁴⁾, emerging evidence suggests that controlled physical and cognitive exercises can aid recovery ⁽⁵⁾.

Is Post-Concussive Headaches Driving You Crazy?

As I mentioned before, headache is the most commonly reported symptom after concussion. Ironically, there is a serious lack of research and very little evidence supporting any particular treatment for post-traumatic headache. ⁽⁶⁾

So meanwhile, the researchers basically say until we know more about it, forget about the label “post-traumatic headache” for a second, simply categorize these headaches, just like we do other headaches, and treat accordingly. ⁽⁷⁾ And that’s what we do in our practice, and we find success with many cases.

Most of the headaches from concussion are migraine or tension type, but they can also be related to peripheral nerves (occipital neuralgia), to the neck (cervicogenic headache), and to medication overuse. ⁽⁸⁾ Whether you are seeking medical treatment or conservative care, there is really not one treatment that would be effective for all post-concussive headaches. If you are not getting better with treatment, maybe, just maybe, the treatment you are receiving is not specific enough. The key to an effective treatment plan is rigorous evaluation and diagnosis ⁽⁸⁾, and taking a comprehensive approach to address all possible causes of headache ⁽⁹⁾.

In my experience, headaches related to peripheral nerve irritation resolve the fastest. Sometimes, within a few visits. Tension headache and headaches coming from the neck are also fairly simple to treat. If your headaches have migrainous features, it will take a bit longer to stabilize.

Is Your Post Concussion Dizziness Lingering As Well?

If you have a concussion and immediately experience dizziness at the time of your injury, then chances are you will have a prolonged recovery (>21 days). ⁽¹⁰⁾ And chances are strict rest is not going to fix your problem. This type of concussion requires targeted therapies. ⁽⁵⁾

Without going into too much detail, the therapies are basically designed to reintegrate three of your systems that are responsible for balance—vision, muscles, and vestibular system. Therapies typically involve a lot of eye exercises, head eye coordination exercises, visual stimulations, and balance training.

Why Aren’t The Vestibular Rehab And Vision Therapy Working?

It used to be that patients had never even heard of these therapies. Now, most of the patients who came to me had already gone through a course of vestibular and vision therapy, but the relief was limited.

These therapies are a must when rehabbing post-concussive patients, but somehow they don’t always work. After talking to my patients and having all of them show me the exercises they were given, it becomes apparent why these therapies had failed them, and we are able to make changes accordingly.

1. Neglecting the neurological hierarchy. One thing I’ve learned very quickly when I started practicing is that less is more. There is a hierarchy within the nervous system. Often, one primitive function serves as the building block of a more sophisticated function. So, when it comes to rehab, you do one thing at a time, and build from the bottom up. Personally, I do not progress my patients to a more sophisticated exercise if they fail to perform the basic exercise. Too many exercises all at once are often unnecessary and counterproductive.
2. Neglecting the fatigability of the brain. Concussive brains are fragile. They get tired faster, like a muscle that hasn’t been used in a while. If you train too hard, your brain pukes out, and you continue to train, it is like lifting over and over again with bad form that makes your trainer pull his hair out. It facilitates bad patterns=bad pathways in your brain, and, again, it is counterproductive. When my patient tells me that he/she gets super dizzy for 30 minutes after his/her previous rehab, then there is something wrong. Knowing when to stop is half the battle.
3. Neglecting the imbalance between the systems. Anyone who has seen a vestibular test report knows that there can be imbalance between the right and the left vestibular system. These imbalances often become more profound in those who had sustained a concussion. So why is it that in therapy the right and the left are almost always stimulated equally? It doesn’t make sense, and we need to be more specific instead of giving every patient generalized stimulations to both sides and all directions.

If your vestibular and visual therapies don’t seem to be working for you, don’t give up. You are on the right track. You may just need to find someone who can be more specific and fine-tune your exercises for you.

Don’t Forget About Your Neck

Concussion is an acceleration/deceleration injury, ⁽¹¹⁾ so as whiplash. Concussion doesn’t really happen unless the impact generates a minimal acceleration of 70-75g. ⁽¹¹⁾ On the other hand, it only takes as little as 4.5g to cause a whiplash. ⁽¹²⁾

In other words, the impact that causes a concussion is certainly enough to cause a whiplash. If you have a concussion, get your neck checked as well.

References:

1. DePalma RG. Combat TBI: history, epidemiology, and injury modes. In: Kobeissy FH, editor. Brain Neurotrauma: Molecular, Neurophysiological, and Rehabilitation Aspects. Boca Raton (FL):CRC Perss/Taylor & Francis;2015. Chapter2. Frontiers in Neuroengineering. [PubMed]
2. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for sports medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. [BMJ]
3. Hadanny A, Efrati S. Treatment of persistent port-concussion syndrome due to mild traumatic brain injury: current status and future directions. Expert Rev Neurother. 2016 Jul 4:1-13. [PubMed]
4. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. PM R. 2016 Mar;8(3 Suppl):S91-S100. [PubMed] http://www.ncbi.nlm.nih.gov/pubmed/26972272
5. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sport Med. 2015 Apr;34(2):213-31. [PubMed]
6. Kjeldgaard D, Forchhammer HB, Teasdale TW, Jensen RH. Cognitive behavioral treatment for the chronic post-traumatic headache patient: a randomized controlled trial. J Headache Pain. 2014 Dec 2;15:81. [PubMed]
7. Theeler B, Lucas S, Riechers RG 2^nd, Ruff RL. Post-traumatic headaches in civilians and military personnel: a comparative, clinical review. Headache. 2013 Jun;53(6):881-900. [PubMed]
8. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):263-9. [PubMed]
9. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part 1—evaluation of pediatric post-traumatic headaches. Pediatr Neurol. 2015 Mar;52(3):270-80. [PubMed]
10. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011 Nov;39(11);2311-8. [PubMed]
11. Broglio SP, et al. The biomechanical properties of concussions in high school football. Med Sci Sports Exerc. 2010 Nov;42(11):2064-2071. [PubMed]
12. Panjabi MM, Nibu K, Cholewicki J. Whiplash injuries and the potential for mechanical instability. Eur Spine J. 1998;7(6):484-92. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Post-Concussion Syndrome: When Symptoms Persist – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

Primary headaches, on the other hand, are a lot more elusive. The intensity of a primary headache may not be any less than a secondary headache, but there isn’t a blood test or MRI that can confirm a primary headache.

Not all primary headaches are the same. The pain can come from nerves, joints, or muscles of the neck, scalp, TMJ, tissues that cover the brain (meninges), or arteries in the brain. Most of these pain generators promote pain through isolated or combined trigeminal (sensory system for the face and head) and cervical mechanisms.

It is essential for the practitioner to understand the nervous system, particularly the trigeminal system, and how it interacts with the structures and nerves of the neck to lead to different headache presentations.

Case Study: Headaches

Patient: 61 year-old female

Chief complaint: Debilitating headaches for 30 years

Back Story: This is a patient who experienced headaches all her life, and were significantly worsened after a car accident when she was 31. Her headaches had a helmet-liked distribution, and were relentless. In 2015, she ran out of sick days at the beginning of the year due to constant 5-7/10 headaches. She had seen many traditional chiropractors, massage therapists, physical therapists, and orthopedists throughout the years, and nothing ever helped the headaches. Even when therapies provided temporary relief, they often flared her up and she would end up with a severe headache the next day. Many of her therapists eventually gave up and told her that she must be doing something wrong in between her visits. Overall, she said her headaches had not gotten better or worse in the past 30 years. In her own words, it was a “rollercoaster”.

Results

After the second treatment, the helmet-liked distribution of her headache changed, which had never happened before.

After the third visit, she was able to control the intensity and duration of her headaches with very simple breathing technique, which had never happened before, either.

By her 14^th visit, she felt that she was 80% better. Despite the stress related to a job change, her headaches were non-existent or minimal. Even when she had occasional headaches, they were fleeting.

When I last saw her, she reported no headache at all between her visits, which at the time, was at a two-week interval.

One thing that is worth mentioning is that she experienced essentially no flare-ups with specific neuro-structural treatments. To be completely honest, she did have a 7/10 headache the day after the first treatment, because her brain could not tolerate the treatment intensity. However, once we figured that out, she had no more flare-ups with any subsequent treatments.

Take Home Message

1. We must assess the stability of a patient’s nervous system, and know how much it can handle. Sometimes, less is more. Sometimes, we only know through trial and error. However, we must do this quickly, so we can attain therapeutic effects and minimize adverse responses. In other words, my job is not just knowing what to do, but when to do what and how much.

2. Understand the neurological interactions among head and neck structures. During the intensive phase of treatments, she often came into the office with different headache presentations. It is absolutely crucial to have an in-depth understanding of our dynamic nervous system, so we know exactly what to do at each specific instant. I never quite knew what exactly our sessions were going to look like until I saw her. A cookie cutter approach is not likely to work for a case like this, because the therapies are not adapting to the ever-changing nervous system and meeting its needs to heal.

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Case Study: Headaches – Chiropractor In Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

One of the most common reasons people seek care at our office is chronic musculoskeletal pain.

More often than not, they have been around the block. The physical therapist said it’s muscle imbalance; The chiropractor said it’s bone misalignment; The massage therapist said it’s tight muscles; The general practitioner said everything looked fine, and take this pill.

Still, the patients have chronic pain.

The traditional healthcare model is stuck in a structural pathology paradigm

Healthcare providers who treat musculoskeletal problems are trained to understand human STRUCTURES—bones, joints, ligaments, muscles, and fascia—NOT human neurology.

A structural problem, such as a fracture, a tear, and a bone spur, is easy to identify and easy to comprehend… but not always the cause of pain, especially in the case of chronic pain.

The structural-pathology paradigm fails to explain why diagnostic findings match up poorly with people’s pain and dysfunction. It also fails to explain why pain persists in some individuals, when the tissues had already healed.

Pain is a neurological phenomenon

By definition, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

What that really means is that pain is an experience that can happen without structural damage. In this case, understanding human neurology becomes imperative in dealing with chronic pain clinically.

We now know that, BOTH the central and peripheral nervous system play an important role in facilitating pain. This article focuses only on the central mechanism.

What happened to the brains of those who are chronically in pain?

1. More sensitive to pain

What may seem like a benign stimulus to others can be painful to those suffering from chronic musculoskeletal pain. This is called central sensitization.

2. Sensory processing issues

Chronic neck pain, back pain, wrist pain, knee pain and tendinitis can change how the brain processes sensory information for the worse. The brain processes sensation slower, locates it incorrectly, and loses its accuracy in identifying some sensations.

3. Motor control issues

When pain changes areas of the brain that deal with sensation, spatial orientation and motor control, it also affects how well the brain controls the muscles. It is well known that the brain loses proper activation of the deep spinal stabilizers in chronic low back pain patients.

4. Blurry brain map

The part of the brain representing the body part that is in pain literally shrinks, and blurs together with adjacent parts of the brain. In short, there is a distortion of body image.

5. Perception and behavioral changes

Significant structural changes are found in brain areas that deal with behaviors and psychological processes. These changes result in a vicious cycle where pain, behavioral changes, and fear-avoidance feed off one another and eventually lead to disability.

Take Home Message

1. Central sensitization is reversible.

2. Surgeries are not the best option for those who are hypersensitive to pain.

3. Distortion of body image found in chronic low back pain and carpel tunnel patients is also associated with more severe pain conditions, such as phantom limb pain and complex regional pain syndrome.

4. Specific exercises can normalize brain activation of low back muscles, while walking is not beneficial.

5. Repetitive unskilled exercises do nothing to rehab the brain.

6. Rehabilitation for both the brain and the body may improve treatment success.

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post Your Brain May Be Causing Your Chronic Pain – Chiropractor in Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.