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Osteopathic Manipulative Treatment for Post Concussion Syndrome

The modern definition of “concussion” aka mild traumatic brain injury (TBI) is a physical force to the body resulting in, however briefly: loss of consciousness or an alteration of consciousness, for example, “seeing stars”; feeling “woozy”, nauseous, dizzy, disoriented, faint, numb, “shocked”; memory loss; balance impairment; difficulty speaking; blurred or double vision. While a blow to the head is most often associated with these symptoms, a hard fall on the pelvis or a “whiplash” might also result in these problems.

 

Post-concussion syndrome (PCS) refers to a complex disorder of ill-defined causation in which the aforementioned symptoms persist for weeks, months, or even years after a concussion or mild TBI. Additional symptoms may include cognitive difficulties, fatigue, sleep disturbance (too much, too little), hypersensitivity to light and/or sound, mood changes, and even personality changes. The overt signs (observable physical changes) accompanying PCS are lability of blood pressure, disturbed heart rate variability; and persistent sweating (regardless of the environmental temperature)—all of which may be understood as resulting from malfunction of the autonomic (“involuntary”) nervous system.

 

Osteopathic medicine offers a unique approach to managing or even resolving the symptoms of PCS. Central to that approach is Osteopathic Manipulative Medicine (OMM), which includes unique methods for evaluating musculoskeletal malfunction known as palpatory diagnosis. In turn, Osteopathic Manipulative Treatment (OMT) is a hands-on approach that aims to restore optimal function to the musculoskeletal system (MSS), specifically potential motion. An additional osteopathic appreciation is that the cranial/facial bones are mobile structures and must be included as an integral part of the MSS. While that appreciation is an essential aspect of care for the entire MSS, it is particularly important in treating PCS (mild TBI).

 

Osteopathic Cranial Manipulative Medicine (OCMM)

 

The “cranial concept” recognizes that there

 

  1. is spontaneous (active) rhythmic motion of the central nervous system (CNS) that is most prominently felt by skilled practitioners at the cranium and the sacrum. This motion is referred to as the “Cranial Sacral Rhythmic Impulse” (CSRI). In turn, the CSRI is thought to play an important role in generating optimal fluid flow within the CNS.

 

  1. are biomechanical properties of cranium that allow for or inhibit the optimal CSRI. The cranial and facial sutures are understood to be joints at which small, but important, motions occur in response to the CSRI as well as other forces that change intracranial pressure as well as on the surface of the face and skull.

 

Misconceptions about the “cranial concept”

  1. The “cranial concept” has been dismissed by many as “non-scientific” for two main reasons:

 

  1. The cranial/facial sutures “fuse” within the first few years of life.

 

  1. If there are motions of the bones at the sutures, the motions are too small to have any influence on the function of the body.

 

Neither of those critiques are valid.

 

  1. “Words matter!” It is correct that the widely open sutures at birth close, but they do not fuse, as the sutures persist throughout life and the bones remain separable (with one exception in which the two frontal (forehead) bones coalesce into one bone). Furthermore, the intra-sutural contents include not only veins, arteries, lymph but also connective fibers including elastic fibers—consistent with the understanding of the sutures as joints.

 

  1. Smaller motions have great significance in health: most notably the three small bones of the middle ear vibrate on one another, smaller motions than those potentially occurring at the sutures. When a middle ear joint fuses, hearing stops. Surgeons actually reconstruct middle ear joints to restore hearing.

 

  1. Historically most practitioners of cranial are taught to use extremely gentle touch to diagnose and treat cranial dysfunction and that more forceful techniques should never to be used. This approach has also been taught to non-physicians as “cranial sacral therapy.” While those “light touch” methods have application in certain clinical conditions, they reflect an incomplete (and thus scientifically invalid) approach as sufficient force must be used to investigate and treat the elastic properties of the cranium and indeed the entire musculoskeletal system.

 

As is the case with all OMT, before performing cranial mobilization techniques, practitioners conduct a comprehensive evaluation of each patient, taking into account their medical history, lifestyle factors, and psychosocial factors as well as an examination of functional biomechanics. Practitioners are trained to recognize any risks associated with cranial osteopathic techniques. They may modify or avoid certain techniques based on the patient's condition or medical history to increase safety.

 

Applicability of OCMM to Post Concussion Syndrome

 

All healing requires that nutrition be supplied and waste removed from injured structures. Only in recent years has an important waste removal mechanism within the CNS been identified. It is known as the “glymphatic system”. While the arterio-venous system within the CNS functions independently (in the absence of serious pathology), optimal flow of the cerebrospinal and glymphatic fluids is understood within the “cranial concept” to be driven by the CSRI. By optimizing motion at the sutures, and thus nutrition and waste removal via a more robust CSRI, damaged neural (including autonomic) structures have greater opportunity to heal.

 

It's important to note that while OMM including OCMM can be a valuable component of comprehensive care for PCS, it often requires integration with other healthcare providers as needed, such as neurologists, physical therapists, and psychologists. Each case of PCS is unique, and treatment strategies need to be tailored to address the specific symptoms and functional limitations experienced by the individual.

 

Conclusion

 

OMM is rooted in the concept of optimizing whole body functional biomechanics including the cranium/face, rather than focusing solely on symptoms or associated areas of dysfunction. By optimizing whole body potential motion, OMT aims to support the body's natural healing processes including those of the CNS impaired by physical traumas which result in PCS.

William James Brooks DO

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