Management of Concussion – Dr. Trent Wittal

In this in-service, we have had the opportunity for Dr. Trent Wittal from Catalyst Clinic who is currently a practicing Chiropractor to present to us on concussion diagnosis and management. Dr. Trent Wittal graduated from the University of Fraser Valley in 2012 and went on to obtain his Doctorate of Chiropractic at the Palmer College of Chiropractic West in 2015. He continues to practice as a chiropractor today and has specialized in post-concussion assessment and care to help treat many of his patients who have suffered from concussions.

A concussion can be defined as:

• A complex pathophysiological process affecting the brain caused by traumatic biomechanical forces
• The mechanism of action is direct trauma to the head, face, and neck or elsewhere on the body with forces transmitted to the head.

Signs and Symptoms:

• Mainly due to functional disturbance in the brain
• Visible symptoms to look out for include:
  • Loss of consciousness
  • Lack of motor control
  • Vacant Gaze
  • Disorientation
  • Head/Neck Injury
  • Headaches
• Confusion
• Sensitivity to light and/or noise
• Dizziness
• Headache/Pressure
• Loss of Balance or coordination
• Difficulty concentrating and short-term memory

The mechanism of action in a concussion injury involves acceleration/deceleration forces that can lead to axonal shearing. This leads to a neurometabolic cascade that increases glucose metabolism and decreases cerebral blood flow. This causes damage to the mitochondria and decreases the ability to produce ATP in the brain. An increase in lactic acid build-up in the brain continues to damage the mitochondria and becomes a vicious cycle where the brain is in a constant inflammatory state.

A concussion can be clinically diagnosed with several different tests including:

• SCAT V (Standardized concussion assessment tool)
• King Devick (Online number naming assessment that evaluates impairments in eye movement, language, and attention.
• imPACT (Online Concussion Assessment tool)
• Vestibular/Ocular Motor screen (Smooth pursuit, horizontal/vertical saccades, vestibular ocular reflex, convergence, visual motion sensitivity)
• Reaction time

It is suggested that one single test can not completely rule in or out a concussion. A combination of the tests is most appropriate to accurately assess an individual.

Acute Concussion Treatment:

There are many factors that can continue to contribute to persisting symptoms post-concussion. In an acute concussion case, an individual should rest for the first 24 hours, which includes limiting screen time and staying within a quiet and dark environment to prevent provocation of symptoms. This should typically be followed by very light sub symptom aerobic activity to help promote healing via increased blood flow to the brain. Limiting inflammatory foods such as sugars, simple carbohydrates, and processed foods can be beneficial. Increased consumption of protein, vegetables, and healthy fats can be beneficial. Supplementation with vitamins including zinc, magnesium, Omega 3 (high in DHA), and N-Acetyl Cysteine can also be beneficial in improving recovery.

Rest is beneficial and important, however active recovery has been suggested to be largely beneficial, in which light activity 24-48 hours post-incident helps to improve recovery. Prolonged rest can be detrimental leading to deconditioning, reactive depression, and metabolic changes. Recovery can be limited and prolonged in this case.

Concussion or head injury in young adolescents needs to be considered as well as there are higher risks and potential long-term consequences. The central nervous system is not as developed in younger adolescents leading to potentially affecting continuing development. Weaker neck musculature and thinner cranial bones increase the risk for greater trauma and fracture. This leads to a longer return to school and activity, where on average it can take 10-14 days to recover.

Post-Concussion Syndrome

Post-concussion syndrome (PCS) occurs when 3 or more of the following symptoms continue to persist, including:

• Headaches
• Dizziness
• Fatigue
• Sensitivity to noise/light
• Irritability
• Depression and/or Anxiety
• Emotional Instability
• Concentration and/or memory difficulties
• Insomnia
• Reduced alcohol tolerance
• Hypochondriacal concerns

An increased risk of PCS can include high severity of symptoms at onset, being female (more susceptible than males), age (60+), history of anxiety and/or depression, and history of chronic pain. The previous history of concussion does not increase the risk of PCS. Persisting symptoms are a result of not just one single mechanism but are contributed by different variables that can affect outcomes. In this presentation, Dr. Trent Wittal mainly focuses on cervicogenic variables that can contribute to PCS within this presentation.

Cervicogenic 

• Issues that result from whiplash related injury with head trauma (symptoms and MOA of whiplash injury are similar to that of concussion)
• Hyperextension/Hyperflexion leading to sprain or strain or cervical tissues
• Cervicogenic Dizziness
  • Vasomotor changes due to irritation of the cervical sympathetic chain leading to altered proprioceptive input or otherwise known as an imbalance
  • May or may not have neck pain or stiffness.
• Cervicogenic Headaches
  • Referral from facet joints and muscles in the neck
  • Suboccipital muscles are typically irritated/inflamed due to changes in sensorimotor functions

The most common area of referral is at C2-C3, which is where the attachment of the suboccipital muscle is. The suboccipital are high in muscle spindles and function to receive and send information from the CNS. This allows for coordination between vision and neck movement. Thus, when the suboccipital muscles are in a constant state of contraction and compression, that can alter those functions.

The neck typically is the area involved in treatment; however, it is also important to take further consideration how other areas of the kinetic chain can contribute to PCS. An example is if there is injury or damage to the shoulder joint, this can cause overcompensation from the upper trap, which could further alter the symptoms experienced at the cervical spine.