CASE SERIES Improvement in Post-Concussion Syndrome in Two Females Using Low-Force Upper Cervical Chiropractic 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 migraine 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 Post-Concussion Syndrome J. Upper Cervical Chiropractic Research – August 19, 2019 48 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 49 J. Upper Cervical Chiropractic Research – August 19, 2019 Post-Concussion Syndrome 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.