Can a Chiropractor help someone with a concussion ?
December 28, 2015 12:00AM
ST. LOIS, Mo.
Earlier this year, Jeanette, a 17-year-old high school senior, came to my office after her third "concussion" in three years.
She had been bumped in the head during volleyball practice, but not knocked out, then developed headaches that went away after two weeks. A nurse practitioner in her pediatrician's office benched her for the season. But Jeanette wanted to play; it was her senior year, after all.
I have been a pediatric neurologist for 40 years and , over the past five years, I have evaluated dozens of children for potential neurological complications of concussion. Most, like Jeanette, had no serious problems.
Obviously, concussions are a real concern. But what's also worrisome is that excessive fear of concussions may discourage parents and medical professionals from letting kids play healthy team sports.
Such fear may already be having an effect: From 2008 to 2012, participation in basketball, soccer, baseball and football among children ages 6 through 17 fell by about 4 percentage points, according to one study. An ESPN Sports poll found that a quarter of all parents have considered barring their children from a sport because of fears about head injuries. This is upsetting, since the Centers for Disease Control and Prevention reports that a third of American children are overweight, in part because of physical inactivity.
Of course, severe head trauma certainly can lead to permanent brain damage. Consider the history of boxing. In 1928 a pathologist identified brain abnormalities in "punch drunk" boxers, who had developed neurological problems as they aged. The severity of their illness correlated, in part, with the number and intensity of blows over their careers.
Dr. Bennet Omalu, a neuropathologist, and his colleagues have identified similar brain abnormalities, known as CTE -- chronic traumatic encephalopathy -- in autopsies of professional football players who had played for years. The disease has also been identified in elite soccer and hockey players, as well as combat veterans exposed to roadside bombs.
The real issue is that data about brain damage in adult professional athletes can't be applied to children playing these sports over a shorter period of time. As far as I know, detailed post-mortem brain examinations looking for CTE have been conducted only on military veterans, adult athletes who played for years and others with known neurological problems.
To make more informed decisions about whether children should play these sports, we would need to know whether CTE can be found in adults who played contact sports as kids but for shorter periods of time. But no well-designed study has yet addressed what severity or recurrence of head injury is needed to cause CTE. Obtaining this type of information in a scientific manner will be difficult, and will probably take years.
We've gotten into this "crisis" in part because a concussion has acquired a looser definition over the years. In 1977, a standard medical text, "Principles of Neurology", defined a concussion as a temporary loss of consciousness after minor head trauma. In 2013, the American Academy of Neurology broadened its definiton to include a variety of possible symptoms caused by mild head trauma, including headaches, amnesia and sensitivity to light and sound -- but not necessarily loss of consciousness. Unfortunately, theses symptoms are not specific, and have been reported in high school athletes with no recent concussions.
This doesn't mean we shouldn't be smarter about sports-related head injuries. No one doubts that a child should immediately be removed from a game if she experiences any neurological symptoms after an impact. And it's common sense to require her to sit out the remainder of the game.
My advice has been to require a patient to stay symtom-free for a week before she can return to contact-free practice. If the patient is still asymptomatic after two weeks, she can return to normal play. But if an athlete experiences two concussions in a single season, she must sit out the remainder of the season and possibly return the next year. (Unfortunately, this hasn't been the standard of care for many college and professional athletes.)
There is a way to exercise such caution without exaggerating the scope of concussions. The American Academy of Pediatrics and the American Academy of Neurology should redefine mild head trauma that produces only headaches as a "noncussion". The definition should emphasize that symptoms go away within seven to 10 days, and children should withdraw from full play for at least two weeks. If the athlete, family and coaches all agree that the child has fully recovered, it would not be necessary to consult a pediatrician or neurologist.
These recommendations should apply to elementary- and middle-school students whose parents and doctors have barred them from low-risk sprots like soccer, baseball, basketball, volleyball and cheerleading over concerns of recurrent brain damage. While there may be outliers whose brains are vulnerable to minor impact because of subtle varioations in brian anatomy, it would be nearly impossible to identify them in advance.
In the meantime, we have a disconnect. At the elite professional level, men and women who suffer obvious brain injury are being left on the field. Meanwhile, too many teenagers who face little chance of long-term brain injury are being kept from playing in healthy organized sports out of an excessive sense of caution.
Steven M. Rothman directed the pediatric neurology divisions at Washington University in St. Lois and the University of Minnesota. He wrote this for The New York Times.