Dr. Kevin Leach:  If you’ve been suffering from symptoms that you have from a concussion for more than 10 to 14 days or you’ve been diagnosed with post-concussion syndrome this video is definitely for you. Hey everyone, Dr. Kevin Leach here. Welcome to The Chiropractic Deep Dive Podcast and this is The Upper Cervical Research Show. This is show #5 so with Dr. Evans. He and I will be going over a paper going over post-concussion syndrome and how the neck is involved and most likely involved with post concussion syndrome. Okay, welcome back everyone to The Upper Cervical Chiropractic Research Show. This is episode #5. I’m Dr. Kevin Leach and I’m here once again with Dr. Tyler Evans. How are you sir? 

Dr. Tyler Evans:  I’m well, good to see you again. 

Dr. Leach:  Fantastic. This episode’s research review is titled “The Role of the Upper Cervical Spine in Post-Concussion Syndrome” by Cameron M. Marshall et al published in the journal “The Physician and Sportsmedicine” which is a peer-reviewed journal indexed in PubMed. Dr. Evans as usual you want to give us a little overview of the paper and it’s what it’s trying to explain and its goals? 

Dr. Evans:  Yes. This is an amazing paper that was done by – I believe they’re all medical doctors and the one that I know of is John Leddy. He is one of the foremost concussion specialists in the country and he was involved heavily with the NFL’s studies. When all this started to come out with the NFL it was probably 15 years ago. He’s been involved in the concussion discussion across the country now for a long time. He was the guy that developed the buffalo concussion treadmill test which is one of the kind of foundational heart rate tests for post-concussion work. I really believe in the upper cervical profession and in the chiropractic world that this is a paper that every chiropractor should know. This is a paper that anyone that deals with concussion patients, they should know this paper and they should know the information in. It can help you better take care of your patients. This paper just starts out by listing some of the statistics about concussions. Mild traumatic brain injury or concussion has an estimated prevalence of about 3.8 million per year. That’s 3.8 million people. In the majority of cases concussions symptoms resolve within 7 to 10 days. However in roughly 10% to 15% of the concussion patients these symptoms prolong and they go long longer than a month. When they do that’s what we call post-concussion syndrome. That’s an important thing because if the symptoms aren’t healing it’s really important that we take another look and we change our course of treatment or care to get the patient the best result. In our office and I’m sure in your office you probably work with other healthcare professionals who deal in this sort of realm. We worked with a guy in our area in the Seacoast of New Hampshire and he’s one of the leading head neck injury guys in the area. When a child comes in and they’ve had a concussion he checks them out and so we brought this paper to him. We wanted to make sure he was aware of it because it’s important for doctors that are dealing with these patients to know that the neck might actually have a big part to play in these symptoms prolonging and not getting better. In this paper Dr. Leddy and the handful of other doctors here, Cameron Marshall and the other doctors, they go through and really look… looking at it now there’s a chiropractor here. Department of Graduate Studies of Canadian Memorial Chiropractic College – that’s Cameron Marshall. It’s got a chiropractic filter that we’re looking through. When we look at the spine we look at alignment. If the bones in the spine are out of alignment it can affect how the body works and the nerves especially. So in this paper they immediately break down the g’s. So that the force that is put through the neck when there is a concussion and when you have a concussion you have a massive amount of energy and force that’s put through the head as well as the neck. In this they outline that roughly 60 g’s to 160 g’s is what it takes to get a concussion. That’s a lot of force. I pulled it up right here on Wikipedia which may not be the best source but I mean we’re gonna be in the ballpark here. An untrained individual not used to the g straining maneuver can black out between 4 g’s and 6 g’s if they’re in a plane. For example pilots 4 g’s and 6 g’s blacks out a pilot. We’re talking about 60 g’s to 160 g’s of force. Obviously that’s going to cause some damage. They always look in the brain. If we’re having a concussion we look at the brain. In this paper they outline maybe the neck is involved, maybe we should look at the neck and they talk about examining whiplash associated disorders. Whenever we talk about whiplash we’re not talking about the name. Whiplash isn’t the name of the problem, whiplash is the name of the way that the problem occurs. So whiplash associated disorders are what occur after you have a whiplash type accident. In a whiplash type accident it only takes 4.5 g’s to damage or change the ligaments and soft tissue of the neck. That’s a big red flag if you’ve had a head or neck injury. If you’ve had a head injury and you’ve had a concussion more than likely you have had a whiplash injury as well. A whiplash associated disorder. They’re saying if we look at these symptoms…. if you look on the second page of this paper… and if anyone out there needs access to this paper we can help you find it because I believe that it is tough to find now online. When I found it initially it was right there in PubMed.. but these symptoms overlap. When you talk about signs and symptoms of concussion or post-concussion syndrome and then we talk about signs and symptoms of whiplash associated disorders you get headache, headache, numbness, pressure in the head, headache, numbness and tingling numbness and tingling, nausea and dizziness, dizziness and unsteadiness. They’re very similar. They’re overlapping so it’s really hard to suss out unless you’re doing a physical exam on a patient and seeing – do they have a problem in their neck or is there something in the neck that might actually be going on causing these symptoms as well. Obviously the brain is a big part of this so when we have the shearing of the tissue in the brain and we have the cascade of chemicals that then are released in the brain that’s initially what we think is part of that brain concussion. We think it’s the tissue that gets injured but the neck might have a lot to do with this and a big reason why patients aren’t getting well outside of this 30-day criteria. The paper goes on and it talks about the four cases that they study. They study 4 cases where they.. sorry there’s 5 cases there.. and I believe that in almost all of those cases they had some sort of neck intervention for some sort of either soft tissue therapy or spinal manipulative therapy which would be an adjustment from a chiropractor. The patients did observe a good change in their symptoms. It’s just a great breakdown from John Leddy. A great breakdown from this amazing source of information for post-concussion syndrome. They address there might be something going on in the neck when this stuff isn’t getting better. 

Dr. Leach:  When we think about that 10% to 15% of that small percentage of concussion patients that go on to have the pcs or post-concussion syndrome it’s easy to say those are the ones that need to get their neck checked out. But as you just said 60 g’s to 160 g’s of force can cause a concussion and I think in the paper it says 4.5 G’s as little as they’ve seen to cause a neck injury it begs the necessity of actually getting everyone’s neck checked who has a concussion. I think that’s huge. With the work that we do with upper cervical chiropractic and working in the Craniocervical Junction it’s once again a missing piece of the puzzle that should be checked. I say this because even if somebody goes through the concussion and gets 100% resolution of symptoms it doesn’t mean they didn’t get a neck injury that’s just not creating symptoms now that could create problems in the future. How many times have you had a patient come in and you ask about accidents, injuries, and car accidents and they say no. I then take some x-rays and you see that they’ve definitely had damage and injury to their spine over time. Unfortunately a lot of these people they’re not told that they need to have their spine checked. They need to have their spine checked because it creates problems in the future. I always tell people it’s the straw that broke the camel’s back. They say they’ve never had neck pain until six months ago and they’re 45 but you look at the neck on the x-ray and you’re thinking this has been a problem for decades now and it’s the straw that broke the camel’s back. This is just one of the mechanisms of whiplash that people should consider getting their spine and their neck checked for an injury and get it treated accordingly. 

Dr. Evans:  Absolutely 

Dr. Leach:  I wrote down a couple discussion points here. They put in the paper the definition of pcs or post-concussion syndrome is the persistence of three or more symptoms for four weeks. Now why does it say four weeks when it says that concussion symptoms should resolve within ten to fourteen days. Why is there a discrepancy there? Do you know anything about that? 

Dr. Evans:  I think that part of the problem is that concussion is such a gray science still they’re still learning. If you talk to you know this doctor they might play under these rules of this is what concussion is or this is what post-concussion is. I’m not saying that we’re not agreeing that post-concussion syndrome..

Dr. Leach:  It makes sense with the vast amount of symptoms that you could possibly have with a concussion. Especially when you’re dealing with head stuff, dizziness, vertigo, headache, and all that kind of stuff. How many different providers treat those symptoms?

 Dr. Evans:  I think a part of the problem too is, I think in our healthcare and in our daily lives there’s a lot more emphasis put on genetics or I was made this way. This is how I was made and so there’s no way for me to do anything about this other than through drugs or surgery. What Dr. Leddy is stepping out in this paper, what he’s doing is he’s saying accidents occurring in life may actually affect the spine. There has been differences of opinion over the last hundred years as to whether or not the spine can actually even go out of alignment. I think John Leddy is probably a little bit ahead of his time in terms of a medical doctor who’s putting himself out there and saying there may be some good science behind getting the spine worked on in a conservative means to help the brain and the body work better. Where does your research come from? Where do your studies in PubMed come from? I think it just depends on the source and then what their training is and what their background is. I think Dr. Leddy has a very progressive and more conservative view. He wants to get the word out there that if this stuff isn’t getting better then go get checked out by a manual therapist. Get checked out by somebody who’s gonna work on the spine, work on the muscles, and help that part of the body. 

Dr. Leach:  Let’s go over the mechanism here. People might think let’s just connect some dots as far as a cervicogenic, meaning coming from the neck, component too. That’s what the paper is all about. It’s proposing when it’s not the brain anymore it’s the neck. You could injure the soft tissues in the neck from a whiplash, which would be a whiplash associated disorder. Just real simply, we’re not gonna get into anatomy lessons here, when you think about coming from the neck and how it can be affected the paper talks about two main ways that an injury to the neck could create these problems. The two main ways are pain related and and the other is proprioceptive related. When they talk about a pain related mechanism coming from the neck and neck pain, we know that pain from the neck can cause headaches and it’s called a cervicogenic headache. We know that those exist and we see those patience all the time. That connection is pretty simple there. Then there’s the proprioceptive related mechanisms. For those listening who don’t know proprioception or mechanoreception, these are the mechanisms inside the joint inside the body that sends signals to the brain letting it know where the body is. When we think about that mechanism being involved with dizziness you can make sense if there’s nerves and there’s things telling the brain where the body is in space… I tell patients all the time when I talk about this I just have them close their eyes. I say close your eyes and they close their eyes. Then I ask do you know where your left hand is? They answer yes. How do you know that when you’re not looking at it? Your body’s telling your brain where things are. When these proprioceptive mechanisms can be injured or interfered with that’s when you can get that sense of either a dizziness unbalanced sense of vertigo because that proper communication between your brain and wherever that injured tissue is could be interfered with. This would give you that symptom and that’s where these neck injuries can be correlated to these symptoms that people are having after that window of concussion into post-concussion syndrome. Any comments on that? 

Dr. Evans:  Yeah. I’ve sat in at the Cantu Institute. Robert Cantu, he’s in my opinion kind of the other very progressive very open conservative research guy for concussion especially for the NFL. He was right there with John Leddy I believe way back if I’m in the right zone. I believe I am but Cantu puts on once a year, at least one of the hospitals down there around him in Boston, puts on a concussion symposium. I’ve gone down to two of them and it’s fascinating because they have a whole hierarchical way that they describe concussion. I know we’ve got the neurometabolic cascade.. 

Dr. Leach:  Which is actually it described in… sorry to cut you off but it’s described as a figure one the whole cascade effect of the concussion and what happens. 

Dr. Evans: Right. It’s an energy mismatch and that’s really why we have fatigue, that’s why we have the memory loss. We’ve got all these weird brain symptoms but then why do these problems persist? If the patient doesn’t get better will they break it down and they put it into this hierarchy of how should we treat the patient? They want to get results and they see some of these cases do really great with vestibular therapy. Some of these cases do really well with ocular therapy or a special optometric help which is either light lens, different lens colors, or different exercises for the eyes. Then there are the cervicogenic ones, so maybe a chiropractic adjustment. Oftentimes this is more in the physical therapy realm so they’re talking about doing PT to the neck which is great and all but we’re approaching this from a neck situation. In this model the neck can actually drive the eyes, the inner ear, and the brain to have dysfunction. When we look at the neck it’s a big part of a “three-legged stool”. So you have the inner ear, you’ve got the eyes, and then you’ve got the cervical spine. The cervical spine drives a lot of input into the brain, into the eyes, and into the ear about where things are out in space. You can have the trigeminal cervical nucleus driving that input into the brain. The trigeminal cervical nucleus is the largest input for that nerve into the brain as well as then you can have a cervicogenic vestibular problem because the neck is actually causing the inner ear to be off. You can also have what’s called a cervico-ocular reflex. This is where the neck is causing the eyes to be off right and so then you get visual disturbance as you go. You probably see it all the time. I see it as well. I work with these therapists that focus on these areas and if I’m not getting a patient well I send them to the eye person or I send them to the inner ear person. Between the handful of us we can get good results but alone it’s not as great. This is just about getting better results for patients. We see that the neck is a big component and it can drive a lot of these other symptoms as well as a lot of these other problems that are the stool legs for balance and proprioception in the body and in the brain. 

Dr. Leach:  Just because we did the hydrodynamics paper recently.. 

Dr. Evans:  Yeah. 

Dr. Leach:  I was thinking about that choking off of the CSF fluid etc. When we look at the whole cascading effect, oxidative stress, the neuron imbalancing, and the ion imbalancing that happens with the concussion. The point is the body needs to heal through that for 7 to 14 days. The people that don’t know that the neck could be a contributing factor to these post-concussion symptoms, they talk about how there are four mechanisms to try to explain it. One of them is the continued decrease in ATP and metabolic production. Number two is the continued axonal dysfunction. Number three is a continued ANS dysfunction or autonomic nervous system dysfunction. Then the fourth one is altered blood flow. It’s important to understand that just as a real quick side note that during a concussion its mechanical damage not structural damage to the neurons. Right? If we think about mechanical meaning the ions and things that are functioning. It’s not the actual breakdown or damage to the actual nerve. So it’s not structural but it’s more mechanical.

Dr. Evans:  That’s right. 

Dr. Leach:  Anyway, it talks about that last one, altered blood flow, being a potential ongoing symptom and we can tie that into the interference of the hydrodynamics of the entire spine from the misalignment – from the injury. This means that even if it’s not an injury to the actual proprioception or the pain reception in the neck that’s causing these problems, if there was a misalignment and if that is choking off the CSF flow and the secondary venous outflow in that whole system that could lead to an extended period of concussion symptoms as well. Which could be also categorized as the post-concussion syndrome. All this is coming in full circle to explain these mechanisms and all of this makes sense to anyone who knows how the body works. I hope that this research gets more and more spread out to people, like what you’re doing and like what I’m doing, so we can co-manage these patients and really find the mechanism of that individual and get everything corrected. Doing intervention to get things back to fully functioning in every way.

Dr. Evans:  Absolutely.

Dr. Leach:  Which sometimes can be just getting rid of the cause and fixing the injury and sometimes you need more therapy. Therapy like ocular therapy, the balance therapy, or things like that to try. Retrain and rehab the body back to where it should be. So I thought that was a good point to bring up.

Dr. Evans:  Oh yes. Absolutely. That’s a great point and that’s why it’s important to understand this literature especially for the doctors. It’s still good for the patients but great for other chiropractors and other neurologists to understand. The guy that we work with here in the Seacoast area is an osteopath. He works at a rehab concussion center and this is top of the crop good research. Obviously it’s not a randomized controlled trial but there’s a great layout here of all the research to look at and in five case studies where we saw good changes in symptoms. It wasn’t just one therapy but it was many different things put together and the neck was a foundational support for it. 

Dr. Leach: That’s what they did in this paper right? With the five different patients. Sometimes it’s difficult when five or six things are done immediately for one thing to really understand what was the problem but important that they got better with whatever it was. The only thing I think about is time and cost effectiveness of potentially doing all of those things initially when maybe they’re not all necessary. However you probably agree with me about this… A lot of patients will come in and they’ll ask what are the percentages or what are the chances that this is going to help. I always tell them I can do an exam for your spine to see if there’s an issue with your spine that I can help you with to get your body functioning better. Whether that’s going to be the factor of correcting the symptom and getting that symptom correct that you’re looking to get corrected, I have no idea. We have to get your spine fixed and give it time to see how much it corrects and if it doesn’t then we can try some other things or refer you over here for some therapy or go that way. I don’t know of any exams that can really pinpoint specifically meaning you have headaches so let’s do this exam to see if it’s related to your spine. Do you see what I’m saying?

Dr. Evans:  Yeah. With concussion patients I we go through the saccades, vestibular ocular reflex, and you can test vertical and horizontal saccades. If those are popping up, if you’re having convergence insufficiency, if someone’s having a pretty positive Romberg test where they’re just off to one side real quick. That’s a very quick indicator that one they have a brain injury, two their cervical spine is probably not giving good information into their brain, their inner ear might be a little bit off, and the eyes might be a little bit off too. Then you just start a course of treatment and keep testing and see if that is changing. If it’s not then we can go down a treatment path for the issue. So I always tell my patients to give it 4 to 8 weeks and we’ll do a re-exam to see where things are at. We’ll then refer out based on how you’re feeling and what you would like to accomplish next but I always say you got to keep your neck in alignment to continue the momentum and keep the stability of what we’ve done. You want to maintain that momentum but we want to see those neurological tests get better. We almost always do. Percentage-wise I know that our post-concussion syndrome patients don’t get 100% better with us every time but we see a good 60% to 70% of people get good results. Then the other 30% to 40% they need some other therapies and maybe 10% they’re really affected in some other way. So just keeping their spine in alignment is helpful but it’s not going to be the thing that it’s going to get them to home base but it’s a big piece of the puzzle. You’re talking about the cervical spine; it’s the foundation of the head and the brain. It’s a big driver. 

Dr. Leach:  Yeah. Awesome. Any other points that you think we’ve missed with the paper? Anything else to discuss or any details that we might want to go over? 

Dr. Evans:  I think getting imaging for this is really important. Just to reiterate, we’ll probably talk about this on our next video so check out the next video, getting radiographic imaging of some sort whether it be X-ray, MRI, CT, or cone beam CT because that sort of information can help you suss out what else is going on here. Is there some whiplash problem that’s been going on for a long time and this has made it worse. We’ll talk about the importance of x-ray in the next video but for a chiropractor taking care of someone’s spine you need good imaging for measuring the misalignment, specifically in doing a specific correction and especially especially especially in the craniocervical junction where every millimeter counts and every millimeter matters. So getting good imaging whether it be upright MRI, digital motion x-ray, or good upper cervical x-rays that will give you a better treatment plan and better course of action. 

Dr. Leach:  Yeah. So what would you say if someone’s listening to this and they are suffering with that post-concussion syndrome and they’re thinking this is me. What’s their first step to getting help? 

Dr. Evans:  Definitely look up an upper cervical chiropractor in your area. You can go to upcspine.com and then there’s a doctor/practitioner locator. Uppercervicalcare.com, that’s the other one and that has a doctor locator as well. That’ll be a good way to get started. Most of our cervical chiropractors are going to be a good guide and help you find the care that you need, especially those that are involved with NUCCA, Blair, Atlas Orthogonal, Advanced Orthogonal, EPIC, Knee Chest, and Toggle. These are the techniques that you’re going to want to look for and I hope I didn’t leave anyone out there.

Dr. Leach:  I was going to say we did a video on a Precise of Upper Cervical. So whoever’s listening that didn’t see that, they can go and listen to that. They can get a better idea of how to find and how to know that you’re in an upper cervical chiropractic office. 

Dr. Evans:  They’re gonna be a good guide for you. They’ll really help you navigate this. It’s a scary thing and I had three people this morning that have gotten fantastic results in our office as well as with some of the referrals that we’ve given them. I had a guy this morning that’s playing guitar again. It’s been three years since he got kicked in the head by a kid, he’s an occupational therapist, and he hasn’t been able to play guitar. He hasn’t been able to play with his kid and he’s playing with his kid again. He’s playing guitar. He brought his son in and his son is laughing and having a good time. It’s like people get their lives back. 

Dr. Leach:  Awesome, love it. Any last thoughts or conclusions with the paper here?

Dr. Evans:  No, I think that’s good.

Dr. Leach:  Awesome. Thank you once again for your time, good sir. Once again anybody who’s listening drop a like. Likes really really help the videos and if it’s helped you drop a like or drop a comment. Subscribe and all that. The more that you interact with the video the more people just like you if you’re getting help with this are going to find the videos as well. We really appreciate that. That’s why we’re doing this. We’re trying to bring value to the community, to the world, and to people who need this kind of help to change lives just  like you said, Tyler. Great. Thank you for your time and we’ll see you soon.