It is with great pleasure that the Shannon Clinic – Melbourne Chiropractic and Sports Care is able to announce the publication of a pivotal paper authored by Dr. Shannon and Dr. Jon Patricios titled “Sport Related Concussion: Critically assessing the comprehension, collaboration and contribution of chiropractors“. This paper explores the current understanding and contribution of chiropractors to sport related concussion (SRC) as well as the potential role the upper cervical spine may play in SRC.

The impetus for the paper was born out of emerging evidence that SRC in the athletic population may involve injury to the upper cervical spine either as a comorbid condition with a head impact or in isolation where a head impact is absent. This creates an opportunity for chiropractors, who are well versed in treating upper cervical spine injuries; especially whiplash disorders to be involved with the multi-disciplinary team in the assessment, diagnosis and management of SRC.

With such a positive opportunity presented for the chiropractic profession, Dr. Shannon and Dr. Patricios set about understanding where chiropractors currently sit with their knowledge, understanding and clinical/research contributions to SRC, how the cervical spine may contribute to some of the more common symptoms seen post concussion, and what chiropractors need to do to step up into this space. As co author, Dr. Patricios was well suited to assist in this process; Dr. Patricios is a sports medicine physician working with athletes in SRC, an advisor to World Rugby, a panellist on the Concussion in Sport Group (CISG), a member of the CISG consensus paper, an author/co-author on multiple SRC papers in the athletic population.

Their paper found that although chiropractors have a wonderful opportunity to create a niche role for themselves as experts in assessment, diagnosing and treating upper cervical spine injuries in SRC, chiropractors currently have suboptimal knowledge compared to their peers; there is an absence of structured formal SRC training and education programs; the profession is lagging in contributions to SRC research in the athletic population, as well as contributions to the consensus process within the CISG compared to other professions.

It is hoped this paper draws attention to the opportunity that is currently in front of chiropractors whilst helping to highlight the changes the profession requires to be able to take that next step to join the multi-disciplinary sports medicine team in the assessment and management of SRC in the athletic population. The next steps in Dr. Shannon and Dr. Patricios’s eyes are for the profession to develop an official SRC consensus statement; formulating educational and training programs at an undergraduate and postgraduate tertiary level which are in line with other professions including physiotherapy, athletic trainers and sports medicine; increasing their involvement in research and contributions to the CISG. You can find out more on the whiplash and concussion services available at the Shannon Clinic – Melbourne Chiropractic and Sports Care here. If you are interested to learn more about the longer term effects of head impacts Melbourne city sports chiropractor worked with Jon to put together an update look at the evidence on chronic traumatic encephalopathy.

Access to the paper can be found here at the Chiropractic and Manual Therapies Journal.

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”.

Vestibular-Ocular Reflex

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.

Chronic Traumatic Encephalopathy (CTE) is a complex, evolving area of neurology and sports medicine. In one corner we have experts who definitively state that CTE is a delayed and progressive neurodegenerative disease directly linked to repeated head impacts with onset of symptoms later in life; while in the other there are those who suggest the evidence is currently insufficient to provide such a definitive statement.

High levels of post-mortem histology neurodegenerative change where first described in boxers in 1928 and termed ‘dementia pugilistica’ which, by 1949 would give rise to the term chronic traumatic encephalopathy. These neurodegenerative changes visible in the brain at autopsy are thought to occur from repetitive head impacts and include axonal disruption/injury, myelin degeneration, white matter loss, the presence of p-tau proteins (p-tau pathology), neurofibrillary tangles (NFT), astrocytic tangles (AT), beta-amyloid plaques (Aβ) among others. The distribution of these deposits is in clusters around small blood vessels of the cortex, typically at the sulci depths. Such changes are proposed to result in mood, behaviour, cognitive changes and dementia. Theories regarding the pathogenesis include disruption to the blood brain-barrier resulting in ischaemia within the brain and the presence of neuroinflammation following head impacts.

Head impacts such as sports related concussion can be disturbing to witness; the acute, delayed and prolonged symptoms can be distressing and challenging for an individual to work through. This has created space for the media to leverage clicks and views off through movies and stories using the narrative that sport related concussion is directly linked to CTE.

The first assumption in such a narrative this is that we definitively know that sport related concussion is exclusively a head impact injury, where symptoms are directly associated with injury to certain areas of the brain. For if this statement were not true how could we confidently link repeated head impacts to long term neurodegenerative change?

Our current understanding of sport related concussion is improving however, it is based on animal and motor vehicle occupant studies which are not representative of sports related concussion; head impact sensors are not as consistently accurate as required and, although blood biomarkers look increasingly promising their presence is nowhere near definitive. Furthermore, many symptoms of sport related concussion may not be directly associated with the brain and can be seen in whiplash patients leading to the plausible theory that sport related concussion may potentially include involvement of the upper cervical spine and area with Melbourne sports chiropractor Dr. Shannon has published work. There is no doubting that direct impacts to the head, such as a head-to-head contact results in a brain injury however, our understanding and ability to accurately diagnose sports related concussion is still limited and evolving.

The second assumption is that we can definitively identify the symptoms of CTE to make an accurate diagnosis. Presently there is no way to diagnose a living person with CTE, all diagnoses have been made via autopsy. Although recently there have been attempts to establish research diagnostic criteria for diagnosing traumatic encephalopathy syndrome, the clinical disorder suggestive of CTE. Moreover, there have been a series of pathohistological diagnostic criteria put forth by Omalu in 2011 which were broad and non-specific for CTE, nor did it include specific characteristics of p-tau pathology, a key feature of CTE; By McKee in 2013 which was based on a comparison study of 68 cases aged match to 18 control cases without a known history of mild traumatic head injuries and although they identified unique patterns and distributions of tau pathology in CTE; the criteria has not been statistically tested, there are blurring between stages, as well as overlaps with other comorbid conditions.

In 2016, a consensus panel of neuropathologists established a preliminary criteria for diagnosing CTE which as they stated, is limited and requires further research; additionally the methodology they used was at risk of selection bias nor were any epidemiologists were involved in developing that methodology. Furthermore, a key issue at present is that many of the histopathological findings seen in those with suspected CTE can also be present in other neurodegenerative conditions, and have been present in those who have not participated in contact sports.

This is not to say that neurodegenerative changes do not occur in those exposed to repetitive head trauma; there is evidence that shows athletes involved in contact sports have a higher risk of developing neurodegenerative diseases such as Dementia, Alzheimer’s, Parkinson’s and Motor Neuron Disease. Furthermore, the consensus panel found potentially distinctive p-tau pathologies unique to individuals with CTE. However, there is still much that needs to be learned about sports related concussion and CTE, as well as the relationship between the two.

Currently, there are too many unanswered questions to support a definitive link between sports related concussion and CTE. Further research including longitudinal studies are needed to develop and evaluate blood biomarkers and imaging to help identify, diagnose and monitor sports related concussion and CTE, as well as determining what histopathological findings are specific to CTE, is CTE a specific disease entity or is it related to other neurodegenerative diseases like Alzheimer’s disease and is there a dose-effect, ie. a number or size of head impacts that are required before neurodegenerative change occurs.

The next time a headline splashes across the news linking contact sports to long term neurodegenerative changes in the brain, it is important that we take a step back for a moment and appreciate that our awareness and ability to identify those who have had a suspected sport related concussion has improved greatly, with immediate removal from play, and no return to play on the same day rules in place; sport governing bodies are continuously evolving rules to protect the heads of athletes; although more work needs to be done in junior sport, awareness among the community is improving. Additionally, we need to be look at ways we can encourage people to participate in sports safely, as opposed to frightening people off sport, with evidence supporting longer life expectancies in elite athletes including those in team sports. As we can continue to advance how we protect our athletes’ heads, we further mitigate the risk of any longer term changes that may occur in the brain.

With thanks to Dr. Jon Patricios

If you are suffering post-concussion symptoms or have suffered a whiplash injury Melbourne city chiropractor Dr. Shannon at the Shannon Clinic Melbourne Chiropractic and Sports Care is well placed to assess whether your upper cervical spine may be playing a role in your symptoms. If you would like to read more about neck pain our blog post has some insightful information. You can book below and will find our Collins Street practice in the Melbourne CBD is easily accessible by trains, trams and car.