Case Study 2:
Patient Slipped on Ice

Mild traumatic brain injury (mTBI) has gained media attention over the effects of repetitive head injuries on brain development and health in both athletes and trauma patients. Approximately 75% of the 1.7 million brain injuries in the United States are classified as concussions or mTBI annually. [1] This figure reflects the sharp increase in mTBIs incidence from 521.0 reported injuries per 100,000 people to 823.7 per 100,00 from 2001 to 2010. [2] The mechanism of injury is largely attributed to local head trauma from biomechanical forces. [3] Currently, there is a large focus on a young, athletic population with injuries from contact sports, although the majority of mTBIs occur after traumatic falls and motor vehicle crashes. [4] As a result of the trauma, current evidence suggests that there is a rapid hyperglycolosis in the neural tissue followed by a prolonged period of hypoglycolysis, altered permeability of the blood brain barrier, increased inflammation, and a rise in interleukin levels. [5] Symptoms arising from these cellular events include nausea, dizziness, headache, tinnitus, acute pain, and cognitive deficits. [6] Symptoms typically resolve over weeks to months, although 36% of patients diagnosed with mTBI continue to report persisting symptoms for 6 months or longer. [7] In addition, the Centers for Disease Control and Prevention reported that as many as 15% of patients with diagnosed mTBI experience persistent, disabling problems associated with concussive symptoms. [8]

Consistently, the literature reports rest as the most common treatment method for mTBI symptoms. [5, 9–13] Symptom education and material on future prevention are also commonly given as postconcussive treatment especially in an athletic population where return to play is a major focus. [6, 13] Although rest and education have been found to reduce some mTBI symptoms, these can be insufficient as a treatment strategy in an adult, working population where symptoms often can be triggered by occupational duties and can greatly impact daily activities. Pharmaceutical treatment options, such as DDAVP, have demonstrated little positive effect on symptoms. []5, 13, 14 Self-management with over-the-counter options like nonsteroidal anti-inflammatory drugs has also been shown to be ineffective in symptom reduction despite the inflammatory cascade that occurs during mTBI. [5]

Chiropractic management of mTBI has a prominent focus on an athletic population within the literature. Multiple reviews outline the high incidence of mTBI and indicated that chiropractors as first-contact providers should have awareness of symptoms, educational materials for patients, and stress rest before a return to play or activities. [1, 15, 16] In addition, manual adjustments both with and without soft tissue therapies have been shown to be effective in the treatment of some mTBI symptoms including somatic pain related to mTBI, whiplash, headache, migraine, loss of motion in the cervical spine, and additional sequelae from trauma. [17–20]

In Traditional Chinese Medicine (TCM), it is theorized that external trauma such as in mTBI often causes a TCM condition known as blood stasis which causes pain and dysfunction in the injured area and can be alleviated with TCM treatments such as acupuncture. Acupuncture has been found to have longer-lasting therapeutic effect for acute headache after trauma when compared with pharmaceutical options. [21–25] Local needling produces analgesic effects in areas of injury by locally increasing the blood supply through the release of vasodilatory neuropeptides and thereby increasing local oxygen and cytokines along with reducing inflammation. [26, 27] Acupuncture also has been indicated as having a positive therapeutic effect on other mTBI-related symptoms such as headaches, neck pain, and nausea. [28–31]

Because of the prevalent nature of mTBI injuries, there is need for additional treatment protocols to be available for injuries sustained by adults in nonathletic situations. The purpose of this case report is to describe the management of an adult patient with mTBI injury through the use of manual cervical chiropractic manipulation, soft tissue therapy, and acupuncture.