In the Aug. 1, 2014 issue of Dynamic Chiropractic, I reviewed some of the literature demonstrating the role of the chiropractic adjustment in post-concussive care.1 A year later, I presented a series of brief cases demonstrating patient improvement in reverse digit span – an outcome measure related to attention span – under chiropractic care.2 This series included patients with and without concussion.In the process of preparing these articles, as well as organizing material for postgraduate courses, I naturally found myself reviewing much of the biomedical and chiropractic clinical literature relevant to concussion and the vertebral subluxation complex (as defined in Redwood, 1997).3 Let's try a few simple thought experiments and then discuss why a new classification term – the concussion-subluxation complex – may be warranted.
Two Thought Experiments
Try these two thought experiments (experiments conducted entirely within the confines of your own mind); I believe the results will speak for themselves.
- Thought Experiment #1: Imagine every possible injury that could cause a concussion. What percentage of these injuries left the vertebral column unharmed and unsubluxated?
- Thought Experiment #2: I invite you to examine the table. The clinical features of concussion are drawn from the Zurich Statement (McCrory, et al., 2012),4 the Centers for Disease Control and Prevention (CDC),5 Eckner, et al. (2011 and 2013),6-7 and Kontos, et al. (2013).8 I have left the column labeled "Vertebral Subluxation Complex" blank. Based on your personal clinical experience, and your understanding of the clinical literature and basic science, please fill in this column. How many times did you write "No"?
|CONCUSSION AND VERTEBRAL SUBLUXATION COMPLEX COMPARED|
|Clinical Feature||Commonly True of or Present in
|Commonly True of or Present in Vertebral Subluxation Complex? (Please fill in)|
|May be caused by a blow to the head, face or neck, or elsewhere on the body, with an impulsive force transmitted to the head||Yes|
|Clinical signs and symptoms largely refl ect a functional disturbance – pathophysiology, not gross anatomical disruption||Yes|
|Balance problems, dizziness||Yes|
|Fatigue, sleep disorders||Yes|
|Impaired concentration & attention||Yes|
|Slowed reaction time||Yes|
Rephrasing the Obvious
In your experience (and verified by the exercise above), have you found a concussive injury likely (if not certain) to cause vertebral subluxations and/or exacerbate pre-existing subluxations? Have you found robust clinical overlap between the mechanism of injury, signs and symptoms of the two conditions?
Please pardon me for asking questions with such obvious answers. I do so only because I hope to rephrase the obvious in a way that reveals the non-obvious. To many of our fellow health care providers, the role of the doctor of chiropractic in helping the concussed patient is not obvious. This is also true of many governmental and organizational decision-makers, as well as some members of the general public. To allow such ignorance to sideline the practitioners who can best address the vertebral subluxation complex does a great disservice to the concussion patient. If anything, the role of the doctor of chiropractic as a member of the concussion victim's health care team should be central.
To rephrase what is obvious to us in a way that reveals what is non-obvious to others, I propose the term concussion-subluxation complex. This term is intended to capture the common traumatic origin and interacting pathophysiology of concussion and the vertebral subluxation complex. Combined with educational efforts within and beyond the chiropractic profession, this term may help clarify the unique contribution of chiropractic care for patients with acute concussion and post-concussion chronicity. This clarification may well prove useful in formal research efforts in this field ,as well as the work of explaining the role of chiropractic care to the concussed patient, key health care decision-makers and the general public.
Concussion-subluxation complex: "A constellation of mutually exacerbating pathophysiological manifestations of concussion and vertebral subluxation complex. (The vertebral subluxation complex can be generated by the same trauma that caused the concussion, or a pre-existing vertebral subluxation complex can be activated or exacerbated by this trauma.)"
- Masarsky CS. "Post-Concussion Patient Care: Relevance of the Chiropractic Adjustment." Dynamic Chiropractic, Aug. 1, 2014.
- Masarsky CS. "Reverse Digit Span: A Useful Assessment Tool for Patients With and Without Concussion." Dynamic Chiropractic, Aug. 1, 2015.
- Redwood D. Contemporary Chiropractic. New York: Churchill Livingstone, 1997: p. 333. Definition of vertebral subluxation complex: "Subluxation at one or more spinal levels resulting from mechanical, chemical, or emotional stressors, and resulting in functional and eventual pathologic changes in the constituent tissues of the involved motion segments. Functional and eventual pathologic changes may also occur in distant tissues influenced by the resultant neural disturbance."
- McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012. Br J Sports Med, 2013;47:250-258.
- "Facts for Physicians About Mild Traumatic Brain Injury." Centers for Disease Control and Prevention.
- Eckner JT, Kutcher JS, Richardson JK. Effect of concussion on clinically measured reaction time in nine NCAA Division I collegiate athletes: a preliminary study. PM&R, 2011;3:212-218.
- Eckner JT, Kutcher JS, Broglia SP, Richardson JK. Effect of sport-related concussion on clinically measured simple reaction time. Br J Sports Med, 2014 Jan;48(2):112-18.
- Kontos AP, Kotwal RS, Elbin RJ, et al. Residual effects of combat-related mild traumatic brain injury. J Neurotrauma, 2013;30(8):680-686.
Click here for previous articles by Charles Masarsky, DC, FICC.