Society for Science-Based Medicine

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Why chiropractors should not treat concussions: A case report

Chiropractors claim that they can effectively treat concussions and that they are competent to return concussed athletes to play. Lacking evidence that this is actually the case, they have turned to the state legislatures to elbow their way onto the list of health care practitioners who are permitted by law to sign off on returning student athletes to play following a concussion. Fortunately, just this year, legislators in Kansas and Oregon saw through their hyperbolic claims that their education was the equivalent of an MD and rejected these efforts.

We know little of the diagnostic procedures and treatment protocols a chiropractor would actually use when presented with a patient suffering from a concussion, if such protocols even exist. What we do know is that some chiropractors like Ted Carrick promote dubious concussion treatments, including spinal manipulation, for concussions. The overwhelming majority of "certified sports chiropractors" believes manual therapy is appropriate in concussion treatment. There is, in fact, zero evidence that spinal manipulation has any beneficial effect on concussion and there is no plausible theoretical basis upon which to construct a case that it should.

A recent case report in the Journal of Chiropractic Medicine adds to the body of evidence that chiropractors shouldn't be allowed to treat concussions or to return athletes to play. You know you're in trouble right off the bat when the article title doesn't match the abstract, which doesn't match the description of the treatment, which doesn't match the conclusion.

The title is "Chiropractic Management of Musculoskeletal Symptoms in a 14-year-old Hockey Player with Postconcussion Symptoms: A Case Report," which leads the reader to believe that the chiropractor was treating the boy's aches and pains. But then, in the abstract we learn that

"A 14-year-old male hockey player presented to a chiropractic clinic with postconcussion [PCS] syndrome 13 days after his initial injury. He experienced an occipital headache with a pain rating of 8/10, upset stomach, blurry vision, nausea, dizziness, balance problems, a 'foggy feeling,' difficulty with concentration, difficulty with memory, fatigue, drowsiness and irritability. Prior to seeing the doctor of chiropractic, the patient was monitored by a medical doctor . . . A the time of presentation at the chiropractic clinic, he had failed to progress toward return to play, and his computerized neurocognitive testing scores had not improved. . . At the conclusion of the [chiropractic] treatments the patient's neurocognitive testing scores had improved, and the patient was returned to play. . .This case demonstrates the improvement of postconcussion syndrome in a 14-year-old male hockey player under chiropractic treatment."

So, is the chiropractor claiming his treatments resolved the boy's postconcussion syndrome? It certainly sounds like it from the abstract.

Actually, no, he's not.

If we read on to the last 3 paragraphs of the case report, we find:

". . . causation cannot be implied. It is not evident that the athlete benefitted from chiropractic vs natural progression of PCS. His recovery still fell within what the literature suggests is the normal time frame for PCS."

In the body of the article, we learn that the patient was being monitored by his primary care physician until his return to play was cleared by the MD and had been seen by a physical therapist. Their treatment was in accordance with current concussion guidelines.

Yet, the chiropractor did his own extensive diagnostic testing, despite the fact that the patient was already under medical care, and "diagnosed [the patient] with PCS" despite the fact that his MD had already diagnosed him with PCS.The patient was then subjected to 5 sessions of

"multimodal manual therapies . . . which included spinal manipulative therapy, myofascial release, and instrument-assisted soft tissue mobilization in the form of Graston Technique"

over a 20-day period.

So, at this point in the case report, are we back to the idea that the chiropractor is treating the patient for musculoskeletal symptoms, as is implied by the title?

No, we aren't. As the authors explain, the patient had not received "any hands on therapy to address vertebral or soft tissue dysfunction" during physical therapy. Why would this be appropriate? According to the authors,

"In concussion injuries, it is proposed that headaches and dizziness, again so prevalent in mTBIs [mild traumatic brain injuries], may be the result of cervicogenic mechanisms due to a concomitant whiplash injury suffered at the same time the athlete sustained a concussion."

In other words, we are now operating on the theory that the real cause of the patient's symptoms actually "may" be a whiplash injury, so

"This presents an excellent opportunity for chiropractors to play a role in the integrative approach to helping the athlete recover from a concussion."

Hence, spinal manipulation. There are two problems with this. One, there's not any good evidence that spinal manipulation is effective for whiplash (also here, here and here) even if we were to accept the assumption that they boy had whiplash in the first place.

Two, the authors are clearly promoting the idea (disavow it though they might) that chiropractic treatments improved his neurocognitive test scores, which include verbal and visual memory, impulse control and reaction time. The "whiplash theory" wouldn't account for all of those improvements. 

So, in sum, we thought we were going to read about a chiropractor managing the musculoskeletal symptoms of a boy with postconcussion syndrome. Then we were led, in the abstract, to believe that chiropractic treatment improved his neurocognitive test scores, meaning they resolved his postconcussion syndrome. But, no, we next learn, in the body of the article, that the boy really/probably/maybe suffered from whiplash, from which the chiropractor could possibly help him recover with spinal manipulation, lack of evidence notwithstanding. Finally, in the last few paragraphs, while disclaiming any proof of causation between the chiropractic treatments and resolution of his PCS, the authors just can't help noticing that

"the data display that his [neurocognitive test] results improved quickly and substantially after chiropractic intervention. There was nearly a 50% improvement in his total symptom score only 3 days after chiropractic intervention started."

So, on to the authors' conclusion, in the very last paragraph of the article, which leads us right back to the same impression as presented in the abstract:

"A 14-year-old male hockey player with symptoms of PCS was managed in a chiropractic clinic with concurrent medical observation. Throughout the course of his case, his symptoms resolved and his neurocognitive computer-based testing scores improved. He as eventually cleared to play following the correct return-to-play guidelines."

Here's what the conclusion should read:

A 14-year-old male hockey player diagnosed with PCS recovered within the normal timeframe and in accordance with the natural progression of the syndrome. Although under competent medical management by a physician treating him according to established guidelines, he was subjected to extensive testing and chiropractic treatment despite the fact that there is no credible evidence that either would improve his outcome. Treatment of patients with concussions should not be within the chiropractic scope of practice. 

Points of Interest 09/26/2016
Points of Interest 09/24/2016

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