On October 27-28, 2022 the 5th Concussion Consensus Conference was held in Amsterdam. Usually held every 4 years, this meeting slated for Paris 2020 and then Paris 2021 had been frustratingly delayed by COVID-19. Interestingly though, during the 2 year delay the volume of research in many aspects of sports related concussion (SRC) had increased exponentially to match the same volume as the prior 4 years leading up to 2020. However, around 80-85% of the research in SRC is being conducted in North America (USA and Canada), which is a problem when trying to establish a global population study cohort. Other notable contributing countries are UK, Australia and New Zealand, all nations who play collision sports like rugby and AFL. Furthermore, what is of increasing urgency is the dearth and in many cases, an absence of literature in the 5 to 12 year old age group and in para-athletes.
The conference was broken down into 7 different domains covering all aspects of SRC, from the understanding and definition through to the longer-term implications. One area that will be of greater interest at future conferences, which received less airtime at this conference, is the potential role of the upper cervical spine. This is an area where chiropractors have a key role to play.
The Neck and Concussion
It is agreed upon that symptoms of SRC are non-specific to concussion and can be seen in other conditions. Symptoms common to SRC such as post traumatic headache / migraine headache, dizziness, blurred vision, neck pain, fatigue, difficulty sleeping, difficulty concentrating can be seen in many different conditions but they are also commonly seen in whiplash injury to the neck. It is postulated that during a collision impact the neck may undergo whiplash type forces, with or without a head impact, resulting in injury to the upper cervical spine facet joints, ligaments and/or muscles. Resultant injury to the upper cervical spine may then damage the positional sensors in the neck muscles and ligaments called “proprioceptors”.
If these positional sensors are damaged it results in the muscles/ligaments sending aberant or wrong positional information to brain. The brain, neck, eyes and balance system in the ears called the “vestibular system” all work together to keep our head looking towards an objective, our eyes fixed on that object and our head stable/level. As we move our head, the positional sensors in our upper neck send signals to our brain to indicate our head has moved. The brain then sends signals to the eye muscles activating and inhibiting certain muscles to keep our eyes focused on where we are going, and our vestibular system adjust the “crystals” (endolymph) in our ears to keep our head level. This is essentially a simplified explanation of something called the “vestibular-ocular reflex”.
Returning to the positional sensors in the neck, if they are sending wrong information to brain because of injury, that incorrect information is processed by the brain as being correct and then signals the eyes and vestibular systems to make adjustments believing the positional information to be correct. This in turn may lead to blurred vision and balance disturbances as the eyes and balance system are making incorrect adjustments due to the aberrant information arising from the positional sensors in the upper cervical spine, especially where there is a normal eye examination and no apparent central vestibular injury. Resulting in a logical peripheral cause (not a central brain injury) of blurred vision and dizziness seen in SRC especially in the absence of a direct head impact (ie. brain injury). Furthermore, neck pain and post traumatic head / migraine headache may accompany whiplash injuries, lending support that in part the upper cervical spine may well play a role in some of the symptoms seen in SRC, as opposed to the notion that all symptoms associated with SRC are the result of a brain injury.
What Are Chiropractors Doing About This?
Currently, chiropractic representation in SRC is low when compared to other medical and health fields. At the Amsterdam conference, to this authors knowledge there was only one other chiropractor present. Although we have a small contribution to SRC research, primarily in the form of systematic reviews examining mTBI by academics who do not treat or work with concussion athletes, we are being outperformed by our physical therapy/physiotherapy and athletic trainer colleagues particularly in the area of the upper cervical spine. Additionally, as seen by the apparent absence of chiropractors in attendance at the conference there appears to be a general lack of integration into the traditional sports medicine paradigm for treating SRC athletes. That is not to discredit the work of chiropractors who successfully work with athletes and sports teams, but more to highlight if well trained chiropractors are having successful outcomes with SRC athletes they need to integrate and share their knowledge within the broader sports medicine paradigm. Integration, knowledge transfer and learning from our peers are the keys to a successful team care approach in achieving optimal patient/athlete outcomes.
Where To from Here For Chiropractors?
Appropriately trained chiropractors and chiropractic researchers are in a wonderful position here to push forward our understanding of how the upper cervical spine may play a role in SRC symptoms and to help develop more evidence-based assessment techniques, guidelines and treatment interventions of the upper cervical spine and vestibular-ocular systems. Additionally, chiropractors need to integrate themselves within the sports medicine community and share any knowledge they have gained through their research and work with SRC athletes. Dr. Jon Patricios, a sports and exercise medicine physician, co-chair of the Concussion Group in Sport and scientific committee and Dr. Shannon have taken a deeper dive into this area and have a paper currently under review.
To find out further information on how Dr. Shannon approaches assessment, treatment and rehabilitation of the upper cervical spine in SRC click here. To make an appointment for a whiplash or upper cervical spine concussion assessment click below. Our Melbourne CBD chiropractic clinic is conveniently located on Collins Street, opposite the Melbourne Town Hall.