CASE SERIES

Improvement in Post-Concussion Syndrome in Two Females Using Low-Force Upper Cervical Care: A Case Series & Review of the Literature

Jonathan Chung D.C.1

ABSTRACT

Objective: The purpose of this report is to describe the positive health outcomes of two patients with persistent post- concussion syndrome presenting to a chiropractic clinic utilizing a low-force upper cervical technique.

Clinical Features: A 16-year old female with vertigo, brain fog, and headaches for 3 months after head trauma from a fall off a horse was diagnosed with post-concussion syndrome by a neurologist. A 30-year old female with headache and vertigo following a motor vehicle accident where she struck her head against the steering wheel. Both patients had no previous history of vertigo or headache prior to the described head trauma.

Intervention and Outcomes: Both patients were managed by a medical neurologist and had previously received Diversified-style chiropractic adjustments. At the time of presentation to the upper cervical chiropractor, there was no change in symptoms reported for vertigo or headache. Both patients reported reduction in frequency and intensity of headache and vertigo episodes shortly after beginning upper cervical chiropractic care. At a one-year follow up, the 30- year-old female experienced full resolution of headache and dizziness symptoms while the 16-year-old female experienced a re-occurrence of symptoms that resolved after upper cervical adjustment.

Conclusion: Low-force upper cervical technique to correct atlas subluxation complex may be an effective intervention for patients with post-concussion syndrome of cervicogenic origin. More studies are needed to determine the role of chiropractic in the care of patients with post-concussion syndrome.

Key Words: post-concussion syndrome, post-traumatic headache, atlas, NUCCA, adjustment

Introduction

Concussion is a form of mild traumatic brain injury (mTBI) have symptomatic recovery within 10 days, approximately that is described as a head trauma resulting in disorientation, 10% of patients will experience symptoms lasting beyond the impaired or loss of consciousness lasting 30 minutes or less in normal recovery period and become diagnosed with post- combination with a number of unspecific neurological and concussion syndrome (PCS).3 cognitive symptoms.1 There is an estimated cost of $17 billion dollars each year for the care of people with mTBI in The chronic effects of brain injury have been made more the US, with an estimates of 1.6 to 3.8 million cases of brain aware in recent years due to media coverage of well-known injury related to sports activities.2 While most patients will athletes who have committed suicide after extended bouts of

1. Private Practice of Chiropractic, Royal Palm Beach, FL

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chronic traumatic encephalopathy. The first histopathological treatment and discontinued care. Her duration under findings of an NFL player were documented in 2005 that acupuncture management was not noted. She stated that she described pathological indicators that resembled Alzheimer’s felt no improvement in dizziness or headaches from any of the disease.4 The exact mechanisms for neural degeneration mentioned therapies but had some relief in her neck following a head injury remain unknown. discomfort with acupuncture treatments.

Chiropractic and PCS At the time of consultation in the upper cervical chiropractic office, she presented with steadily worsening symptoms of Literature on the effects of chiropractic and concussion is dizziness and brain fog. She rated the symptoms at a 6/10 sparse despite chiropractors being one of the most common severity on average, and 8/10 at it’s worse. She stated that the providers seen after a concussion.5 A search through the dizziness got bad several times per week. She had been seeing indexed chiropractic literature will show papers on a physical therapist, acupuncturist, ENT, and neurologist since chiropractic’s position statements on head injury in sports,6 the injury but has not had improvement in her symptoms. She scoring concussion severity,7 and managing return to play,8 stated that the dizziness and brain fog prevent her from horse but papers detailing the effects of chiropractic intervention riding and has made it very difficult to focus at school. She consists of case reports. Four case studies describe stated that she is unable to sit down and study for more than 5- improvements in patient symptomatology while receiving 10 minutes without losing focus. She also stated that she was chiropractic care.8-11 Two of the papers dealt specifically with reluctant to go out with friends because of her headaches. patients receiving upper cervical chiropractic care for the Early impressions suggested post-concussive syndrome or reduction of the atlas subluxation complex.9,12 possible tonsilar ectopia.

The following cases detail the improvements of two female Pre-adjustment Examination patients under upper cervical chiropractic care with post- concussion syndrome that was slow to respond or treatment A full chiropractic examination was performed to identify the resistant to high velocity, low amplitude spinal adjustments. presence and magnitude of the atlas subluxation complex (ASC). The examination procedures are based off the Case Report One protocols of the National Upper Cervical Chiropractic Association.13 Neurologic components of the ASC are History identified and measured primarily by observation of postural control. Postural control is measured in weight bearing A 16-year-old girl presented to a chiropractic clinic with position by transverse plane measurements of the head, dizziness, ringing in the ears, headaches, and brain fog for 3 shoulders, and ilia. It is also measured in non-weight bearing months following a concussion injury. She stated that the position via supine leg length evaluation. Abnormal postural symptoms began after she fell from a horse and she struck her control is determined when the shoulder and hip levels are head on the ground. She was taken to the ER with concussion measured beyond ¾ of a degree. Surface electromyography symptoms and was discharged after a CT Scan ruled out and paraspinal thermography are also performed to obtain intracranial bleeding. It was recommended that she rest and baseline readings for neurological function in the patient’s have her symptoms monitored for any progression. pre-adjustment physiology.

After two months, the patient still had dizziness and poor In the presence of postural distortion, Pre-adjustment concentration. Her mother stated that she was missing school radiographs are taken to measure and visualize the days, and she couldn’t read or study for more than 20 minutes craniocervical junction in three dimensions. A lateral C-spine at a time. The patient sought a consult from a neurologist. is taken to measure the angle of the posterior arch of atlas for Exam findings were unremarkable except for a positive Dix- accurate central ray placement for the nasium x-ray. The Halpike maneuver. She was referred for a brain MRI and nasium x-ray is an AP skull view to measure head tilt in the vestibular testing. She was also told to resume normal frontal plane, lower cervical translation in the frontal plane, schoolwork but to refrain from horseback activities. and atlas movement in the frontal plane. The vertex x-ray is taken through the crown of the skull to visualize atlas rotation The brain MRI was read as unremarkable. However, the and the neural canal. radiology report did discuss nonspecific periventricular hyperintensities around the frontal horns of the lateral Pre-Adjustment Exam Findings ventricles. The radiology report noted that it is a common sign of an aging brain, or one that is found in pediatric migraine The patient presented with a contracted right leg measured at cases. 3/8” using table ruler on a supine leg length exam. Her posture shows right cervical translation, right low shoulder 2 degrees, Vestibular testing showed a 63% unilateral weakness on a and left low hip 1 ½ degrees. Measurement of the pelvic and caloric test characteristic of a peripheral canal lesion. Based shoulder girdle were measured using a digital caliper tool on these findings, she was recommended vestibular therapy placed on the acromion on each side and the highest point of with a physical therapist. She began receiving treatment from each iliac crest on each side. Weight distribution was an acupuncturist, vestibular therapist and a chiropractor measured at 59 lbs on the right and 51 lbs on the left for a approximately two months after the injury. She reported difference of 8 lbs. Palpation shows bilateral C1 tension, left seeing the chiropractor and vestibular therapist for one month trapezius tension, and right scapular tenderness. but did not report any symptomatic improvement while under

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X-ray analysis and line drawing performed using NUCCA concentration. She stated that the times where she does feel protocols. Alignment shows structural distortion with atlas dizzy, it’s not as frequent or as intense as when she first began laterality measured at 1.08 degrees to the left, the head tilting care. She was able to achieve her goal of being able to ride her to the left by 1 degree, left lower angle measurement of 2.51 horse again and compete, and she was also able to study for 2 degrees, right angular rotation measured at 2.19 degrees, and hours at a time without dizziness or discomfort. atlas rotation measured at 3.69 degrees anteriorly. Line drawing and angular measurements were performed on Viztek A re-exam was performed on March 24th. Her second set of OpalRad Software which allows for measurement recording post x-rays showed atlas laterality was reduced to 0.49 into 1/100th of a degree. degrees, head tilt to 0 degrees, angular rotation to 0 degrees, and atlas rotation reduced to 1.30 degrees. Prior to beginning Intervention upper cervical chiropractic, her recorded Visual Analog Scale scores were measured at 6/10 for dizziness and balance The atlas subluxation complex was corrected using a problems and 6/10 for headache. On the re-examination, VAS procedure called a NUCCA adjustment. The patient is placed scores showed a 3/10 for dizziness/balance and 1/10 for on a low side-posture table with the head placed on a solid headaches. head piece that serves as the fulcrum of movement for the skull. The x-ray provided a height and rotation measurement At a one-year follow-up, the patient stated that she was not that is measured from the tip of the patient’s transverse able to receive treatment from a chiropractor using a low-force process. The doctor’s pelvic and shoulder angulation are upper cervical technique and reported a return of headaches derived from the vector measurement on the x-ray. The doctor and dizziness symptoms 4 months after her last visit. The places pisiform of the hand contacting the patient on the tip of patient was adjusted using the same x-ray listing from her the atlas transverse process, and the other hand is clasped previous visit and the headache and dizziness resolved once around the contact hand to provide support. more.

A series of low force impulses with a depth of 1/16” to 1/8” Case Report 2 are made in the line of drive provided by the doctor’s set up to reposition the atlas onto the occipital condyles of the skull. History Following the adjustment, leg length was re-evaluated and found to be balanced. Standing postural evaluation showed A 30-year old woman presented with a chief complaint of level shoulders, even pelvic level, and an absence of head tilt. chronic migraine headache and vertigo following an Post-adjustment x-rays were taken, and the patient was then automobile accident. She stated that her vehicle was rear- allowed to rest on her back for 10 minutes while her x-rays ended and caused her car to roll over the top of the vehicle in were analyzed. front of her. She stated that her head struck the head rest and was diagnosed with a concussion and cervical sprain injury in Post-adjustment nasium and vertex x-rays were taken the emergency room. Since the accident, she reported daily immediately after the first corrective visit. Atlas laterality was migraine headaches with aura and vertigo. She also had neck measured at 0.82 degrees on the left, head tilt at 0.31 degrees pain, back pain, fatigue, anxiety, sleeping problems, and to the left, lower angle at 0.72 degrees to the right, angular depression. She stated that she had no history of migraine rotation at 0.41 degrees to the left, and atlas rotation at 2.44 headache or vertigo prior to the accident. Her pre-examination degrees. The adjustment was deemed successful and the VAS scores were recorded for headaches at 8/10 on average patient was dismissed. She was recommended a schedule of 2 and 8/10 at worst. She rated her vertigo symptoms as a 6/10 on visits per week for 8 weeks for follow up appointments. average and 6/10 at worst.

Outcome The patient had been seeing a chiropractor for her neck pain and was under pharmacologic management for the headaches The patient was seen for 14 times from February 12th to March by her neurologist. After 3 months of chiropractic care, 26th and was checked each visit for leg length inequality and utilizing full spine diversified adjustments, the chiropractor postural distortion. Out of the 14 visits, she required an referred the patient for upper cervical chiropractic adjustment on 6 visits. The patient reported mild pain and management, because the headache and vertigo symptoms soreness in her shoulders following the first visit, but reported were not changing. no change in her focus, headaches, or dizziness. On her third visit she reported substantial improvement in dizziness and Pre-Adjustment Exam Findings brain fog following her 2nd adjustment. On her third week of care, she stated that she was able to do her homework for 2-3 The patient presented with a contracted left leg at 1/4” as hours without a problem, and that she was able to sit measured using a table ruler. Her posture showed left low hip comfortably and ride on a horse for the first time since the one degree, right head tilt, and left low shoulder 1 degree. head injury. By her 5th week of care she stated that she was Palpation showed lower cervical tension, left C1 fixation, and able to ride in an equestrian competition and placed in the top generalized sensitivity in the cervical spine. Weight 10 of her age group. At the end of her initial phase of care, she distribution is measured at 56 lbs on the right and 68 lbs on the reports a 60% improvement from her initial evaluation. left for a difference of 12 lbs. Orthopedic testing showed positive cervical compression and positive Jackson’s She verbally reported a 60% improvement in dizziness, 100% compression on the left for local cervical pain without improvement in headaches, and 60% improvement in radiculopathy. Cervical ranges of motion were measured at 50

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degrees in flexion, 62 degrees of extension with pain, 45 Discussion degrees of left lateral flexion, and 45 degrees of right lateral flexion, 75 degrees of left rotation, and 73 degrees of right The previous case reports describe the improvement of two rotation. female patients with post-concussion syndrome with the correction of the Atlas Subluxation Complex. Both cases Cervical spine x-rays were taken based on the NUCCA presented with post-traumatic headache and dizziness for protocol. A lateral, nasium, and vertex view were taken. greater than three months after head injury. Both patients were Alignment shows structural distortion with atlas laterality also treated by chiropractors utilizing high velocity, low measured at 2.41 degrees to the right, the head tilting to the amplitude spinal adjustment with no improvement in PCS right by 1.75 degree, left lower angle measurement of 2.4 symptoms at the time of presentation to the upper cervical degrees, right angular rotation measured at 1.75 degrees to the chiropractor. left, and posterior atlas rotation measured at 3.42 degrees. Both patients began to show symptomatic improvement within Post-Adjustment Findings their first week of upper cervical chiropractic care. However, due to the nature of case reports it cannot be ruled out that the Post-adjustment nasium, and vertex x-rays were taken patients may have experienced a delayed response to HVLA immediately after the first corrective visit. Atlas laterality was adjustments or experienced a natural regression to the mean as measured at 0.79 degrees to the right, head tilt at 0.63 degrees is common in many cases of post-concussion syndrome. to the right, lower angle at 1.1 degrees to the left, angular rotation at 0.94 degrees to the left, and atlas rotation at 0.85 Post-Concussion Syndrome Pathophysiology degrees posteriorly on the left. The adjustment was deemed successful and the patient was dismissed. She was Large advances have been made in the study of concussion recommended a schedule of 2 visits per week for 8 weeks for pathophysiology, but the focus has largely been placed on the follow up appointments. acute phase. Efforts to study the pathophysiology of PCS have been less fruitful. Outcome PCS is largely a vague clinical entity that relies heavily on the The patient was seen 17 times from February 11th to April 15th presence of non-specific symptoms in conjunction with a and was checked each visit for leg length inequality, precipitating traumatic event. Currently there is no reliable paraspinal temperature asymmetry, and postural distortion. imaging or blood biomarker to determine the presence of PCS. The patient was adjusted on 10 of the 17 visits. She reported The accepted pathophysiologic mechanisms related to post- feeling an improvement in headache intensity following the concussion syndrome have been divided into two main first adjustment. By her 6th visit, she reported a 50% categories: axonal shear and metabolic insult. improvement in headache intensity, but frequency remained unchanged. Axonal Shear

At visit 12, she verbally reported an 80% improvement in The brain resides in a closed system using the skull as a headache intensity and that she no longer had any vertigo primary protection element against blunt force trauma. associated with the headache. She also stated that migraine Cerebral spinal fluid surrounds the brain providing for frequency was reduced down to 1x/week. On a re- transport of nutrients, removal of waste products, and examination, the patient recorded a VAS score for headache at protection from rapid movement of the head. Biomechanical 3/10 on average and 6/10 at its worst. She rated her vertigo models have shown that linear and rotational acceleration of symptoms as a 0/10 on average and 0/10 at its worst. The the head play a large role in creating shearing forces of the patient was released from care after her 17th visit due to brain.14 These forces play a role in large prevalence of mTBI improvement in migraine and dizziness. during motor vehicle collisions.

The patient continued to have neck pain and non-migraine The axons of a neuron are particularly prone to damage from type headaches stemming from her occipital region. An MRI stretch forces. Damage to the cytoskeletal elements of the was taken of her cervical spine and showed a C5/C6 disc axon can disrupt the ionic channels and disrupt the normal herniation with foraminal encroachment. At her 16th visit, the depolarization of the cell, and it can also interfere with axonal patient reported that she no longer had migraine headaches transport of biochemicals necessary for synaptic and that the headaches seemed they were stemming from the transmission.15 Although this can disrupt normal neuronal persistent cervical spine pain. The patient’s neurologist function, it usually does not cause cell death. This explains referred her for a surgical consult to address the cervical disc why structural damage is typically not seen on conventional herniation. VAS scores for headache MRI. Studies using diffusion tensor imaging and magnetic resonance spectroscopy have shown greater sensitivity in At 1-year follow-up, the patient reported a successful surgical detecting white matter lesions from axonal damage in patients management of C5/C6 disc related pain. She also reported that with mTBI.16 she had no further episodes of migraine or vertigo following her final visit in the upper cervical chiropractic clinic. Neurometabolic Insult and Neuroinflammation

The metabolic cascade associated with concussive injury has been summarized well by Giza and Hovda15,17. In animal and

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human models, brain injury has been found to disrupt normal The anatomy of the upper cervical spine has unique ionic balance, create energy deficits with altered cerebral implications that allow for therapeutic considerations. It’s metabolism, increase free radical production, induce chronic been suggested that the mobility of the upper cervical spine, cerebral hypoperfusion, and create inflammatory and the dense proprioceptive input into the vestibular and environments within the cranium. visual system can make it prone to injury resulting in post- traumatic vertigo.23 In addition to proprioceptive insult, injury Concussion research has generally been focused on the to the upper cervical spine can cause pain-related mechanisms neurometabolic mechanisms of injury, in hopes of developing that lead to headaches. The upper cervical spine has afferents pharmacologic treatment strategies to address the chronic that fire into the trigeminocervical nucleus, which is a well- sequelae of head injury. Of particular interest is the impact established mechanism for cranio-facial pain.21 that concussion has had in the development of neuroinflammation. The concept of aberrant proprioceptive/nociceptive input from the cervical spine is new in field concussion literature; it has The inflammatory response has been shown to play a role in been a biological rationale for the use of spinal adjustments in almost every neurological disease. In concussion, it has been chiropractic for some time through a concept known as connected to an increase in free radical production, alterations dysafferentation.24 Traumatic injury is one of the primary in the permeability of the blood brain barrier, recruitment of mechanisms causing the chiropractic subluxation/joint monocytes/macrophages, and activation of astrocytes and complex dysfunction, which is theoretically reversed through microglia.18 However, developing treatment strategies based the chiropractic adjustment/. However, on the inflammatory response has proven to be difficult for joint fixation and dysafferentation alone do not adequately concussion patients compared to other neurological disorders. explain why an upper cervical low force (UCLF) procedure The inflammatory responses in the early stages of concussion may have reduced symptomatology in these PCS patients have been hypothesized to provide a neuroprotective and when it appeared that they were treatment resistant when neuroregenerative effect while long term cytokine exposure receiving HVLA adjustments in the cervical spine. has a well-documented history of damage. Since general anti- inflammatory strategies using NSAIDs have been mostly UCLF procedures are part of a subset of chiropractic ineffective in protecting the brain from damage, efforts are techniques within upper cervical chiropractic as described by being made to target the inflammatory cascade of concussion Woodfield et al.25 While dysafferentation is primarily by understanding when inflammation is neuroprotective for concerned with motion and spinal fixation, it’s been suggested the brain and when it is neurotoxic.18 by upper cervical chiropractors that errors in head positioning may affect the loading into the joints of the craniocervical The Role of the Cervical Spine in Post-Concussion Syndrome junction resulting in aberrant mechanoreception.

The role of the cervical spine in PCS has been a topic of an There is also speculation that malpositioning of the head and area of greater study in recent years due to work by Collins neck may impact neurovascular structures near the and Leddy. Collins et al showed that neck strength may be a craniocervical junction. A 2007 randomized clinical trial of modifiable risk fator in prevention of concussion in high the effects that NUCCA care had on hypertension showed a school athletes.19 Leddy et al used graded treadmill exertion blood pressure reducing effect equivalent to two anti- testing to differentiate patients with classical post-concussion hypertensive medications.26 The study raised questions as to symptoms of neurometabolic origin against those who had whether atlas misalignment and the NUCCA procedure could symptoms of vestibular or cervicogenic origin.20 Leddy also be affecting blood pressure by altering blood flow at the demonstrated that cognitive symptoms could not be used to craniocervical junction. differentiate between groups since whiplash patients have been known to develop cognitive symptoms resembling A review article by Flanagan discussed theoretical concussion. hydrodynamic and neurologic impact that anomalies or disruption of the craniocervical junction may create.27 Evidence for the treatment of the cervical spine following a Disruption to the normal anatomic relationship of the concussive injury is limited. Marshall et al discussed the craniocervical junction by injury, misalignment, and treatment of 5 patients with post-concussion syndrome by malformation may affect secondary venous drainage from the utilizing treatments for the cervical spine. These treatments cranial vault. Flanagan hypothesized that these hydrodynamic included high velocity spinal manipulation, low force changes can create an environment of oxidative stress, normal mobilization, active release therapy, and proprioceptive pressure hydrocephalus, cerebellar tonsilar ectopia, and exercise for the neck.21 chronic ischemia leading to neurodegeneration.

Ellis, Leddy, and Willer proposed an evidence-based Damadian and Chu observed clinical evidence of this classification system for patients with PCS. The authors phenomenon in a study about multiple sclerosis.28 Another suggested that PCS should be classified as either physiologic, study supporting Flanagan’s findings show that cervical vestibulo-ocular, or cervicogenic based on findings from a whiplash injury is associated with increased incidence of patient’s exam and history. Exam findings that may help cerebeller tonsilar ectopia compared to non-traumatic identify PCS of cervicogenic origin included tenderness to controls29. Media reports of former NFL star Jim McMahon’s palpation at the craniocervical junction, the presence of neck improvement of neurodegenerative symptoms while receiving pain, abnormal head posture, head positioning errors, reduced upper cervical chiropractic has raised questions as the role of cervical range of motion, and cervical hypolordosis.22 upper cervical chiropractic may have in helping patients with

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neurodegenerative illness following head trauma.30 concussion symptoms.

Altered venous drainage has been observed in patients with Conclusion migraine headache31 and mild traumatic brain injury.32 Normal venous drainage in a recumbent position occurs The preceding case series describes the improvement in 2 primarily through the internal jugular veins. In both studies, female patients with post-concussion syndrome utilizing the the mTBI and migraine population showed increased venous NUCCA procedure. Both patients reported a chief complaint drainage through secondary veins such as the epidural and of post-traumatic headache and post-traumatic vertigo vertebral veins. The clinical meaningfulness of this finding has following their concussive injuries. Both had also received a yet to be elucidated, but it’s been hypothesized that altered course of chiropractic adjustments to the neck for at least 1 venous drainage may affect intracranial compliance. month using diversified technique with no reported improvement in the chief complaints until after beginning Woodfield et al performed a study on the NUCCA procedure upper cervical chiropractic care. on intracranial compliance in patients with migraine headache.33 Although the patients showed improvements in The importance of the cervical spine dysfunction in the headache frequency and health related quality of life, there etiology of post-concussion syndrome has gained recognition was no significant change observed on phase contrast MRI in in the last year. The unique features of the cranial cervical intracranial compliance in relationship to correction of the junction may play an important role in the development of atlas. Advanced analysis is currently being performed on the post-concussion symptoms and is deserving of further study. phase contrast MRI to see if any flow changes were observed in the jugular veins or secondary venous drainage routes. The current study is limited by small sample size and a lack of controls so no causation can be inferred. Controlled trials must The role of the craniocervical positioning in as a modifiable be performed to evaluate the effectiveness of the NUCCA risk factor in vascular dysfunction is a concept that is still in procedure for patients with post-concussion symptoms. its infancy. A group of Italian investigators showed that anterior intrusion of the atlas vertebra correlated with the References development of chronic cerebral spinal venous insufficiency in patients with multiple sclerosis.34 The authors proposed that 1. National Center for Injury Prevention and Control (2003) rotation of the atlas vertebra may allow the muscular Report to Congress on Mild Traumatic Brain Injury in the attachments to the transverse process to encroach the vascular United States: Steps to Prevent a Serious Public Health structures of the neck. The same group also performed an Problem. Atlanta, GA: Centers for Disease Control and uncontrolled prospective study showing that knee chest Prevention; 2003. adjustments to the C1-C2 region improved radiological signs 2. Langlois JA, Rutland-Brown W, Wald MM. The of atlas subluxation in addition to clinical improvements in epidemiology and impact of traumatic brain injury: a brief multiple MS symptoms.35 overview. J Head Trauma Rehabil 2006; 21: 375-8. 3. Willer B, Leddy JJ. Management of concussion and post- Similar mechanisms may be at work in the pathogenesis of concussion syndrome. Curr Treat Options Nurol. 2006 post-concussion syndrome. A malpositioned atlas vertebra Sep;8(5):415-426. may be the reason that patients with mTBI and 4. Omalu BI, DeKosky ST, Minster RL, et al. Chronic display altered venous drainage patterns. Flanagan proposed Traumatic Encephalopathy in a National Football League that “malformations and misalignments of the craniocervical Player. Neurosurgery 2005; 57: 128-134. junction may play a role in chronic ischemia and edema that 5. Hartvigsen J, Boyle E, Cassidy JD, Carroll LJ. Mild may lead to a neurodegenerative process.”25 The consequences traumatic brain injury after motor vehicle collisions: what of this process may reflect some of the post-inflammatory are the symptoms and who treats them? A population- brain syndrome hypothesis of post-concussion symptoms based 1-year inception cohort study. Arch Phys Med discussed by Rathbone et al.36 Rehabil. 2014 Mar; 95(3 Suppl):S286-94. 6. Moreau WJ, Nabhan DC. Development of the 2012 The importance of positioning of the craniocervical junction American Chiropractic Board of Sports Physicians on the neurovascular structures of the neck may help explain position statement on concussion in athletes. J Chiropr why upper cervical adjustments to restore atlas alignment Med. 2013 Dec; 12(4):269-273. resulted in a favorable symptomatic outcome for vertigo and 7. Shane ER, Pierce KM, Gonzalez JK, Campbell NJ. Sports post-traumatic headache while generalized spinal chiropractic management of concussions using Sport manipulation to the cervical spine did not. Concussion Assessment Tool 2 symptom scoring, serial examinations, and graded return to play protocol: a Limitations retrospective case series. J Chiropr Med. 2013; 12(4): 252-259. The current study is limited by small sample size and a lack of 8. Porcher NJ, Solecki TJ. A narrative review of sports- control so no causation can be inferred. The patients may have related concussion and return-to-play testing with had a delayed response to previous medical and chiropractic asymptomatic athletes [review]. J Chiropr Med. 2013; treatment in addition to upper cervical care. The patients may 12(4): 260-268. also have improved due to length of time from the initial injury. Controlled trials must be performed to evaluate the effectiveness of the NUCCA procedure for patients with post-

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9. Mayheu A, Sweat M. Upper cervical chiropractic care of 26. Bakris G, Dickholtz M, Sr, Meyer PM, Kravitz G et al. a patient with post-concussion syndrome, positional Atlas vertebra realignment and achievement of arterial vertigo, and headaches. J Upper Cervical Chiropr Res. pressure goal in hypertensive patients: a pilot study. J Win 2011; 1(1): Online access only p 3-9. Hum Hypertens. 2007; 21(5):347-352. 10. Pfefer MT, Cooper SR, Boyazis AM. Chiropractic 27. Flanagan MF. The roole of the craniocervical junction in management of post-concussion headache and neck pain craniospinal hydrodynamics and neurodegenerative in a young athlete and implications for return-to-play. Top conditions. Neurology Res Int. 2015; Article ID 794829, Integr Health Care. 2011; 2(3): Online access only 6 p 20 pages, 2015. doi:10.1155/2015/794829. 11. Slak JM, Price K. Symptomatic and cognitive 28. Damadian RV, Chu D. 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Post-Concussion Syndrome J. Upper Cervical Chiropractic Research – August 19, 2019 54

Table 1. Pre and Post Adjustment X-ray Measurements

Pre-Adjustment Post-Adjustment

Patient 1 Laterality 1.08 degrees left 0.82 degrees left

Patient 1 Rotation 3.69 degrees anterior 2.44 degrees anterior

Patient 1 Angular Rotation 2.19 degrees right 0.41 degrees left

Patient 2 Laterality 2.41 degrees right 0.79 degrees right

Patient 2 Rotation 3.42 degrees posterior 0.85 degrees posterior

Patient 2 Angular Rotation 1.75 degrees right 0.94 degrees right

Pre-Adjustment Post-Adjustment Pre-Adjustment Post-Adjustment

VAS Headache VAS Headache VAS Dizziness VAS Dizziness

Patient 1 6/10 1/10 6/10 3/10

Patient 2 8/10 3/10 6/10 0/10

55 J. Upper Cervical Chiropractic Research – August 19, 2019 Post-Concussion Syndrome