Post-concussion syndrome and concussion incidence improved in a pro rugby player following cervical spine rehab: case study and 6-year follow-up

Aim: To report improvements in post-concussion syndrome and concussion incidence following cervical spinal alignment correction. Case presentation: A 27-year-old professional rugby player with 20 documented concussions presented with abnormal cervical spinal alignment and post-concussion syndrome. After 30 sessions of cervical rehabilitation, health outcomes improved. Post-treatment radiographs showed improved cervical lordosis from -13.5° to -37.4° (ideal is -42°) and right head translation from -22.7 to -11.3 mm (ideal is 0 mm). 2-year follow-up radiographs and 6-year follow-up health outcomes showed post-treatment improvements were maintained. The patient reported two documented concussions in the 6 years following treatment while maintaining the same lifestyle and professional rugby career. Conclusion: Correction of abnormal cervical spinal alignment may help athletes with post-concussion syndrome and reduce risk of concussion.

concussion experienced greater cognitive impairment than athletes who reported no history of concussions [8].In addition, out of 22 documented PCS symptoms, headaches (57%) and neck pain (47%) were of the most common reported in South African collegiate male rugby players following a concussion [9].
As of 2020, no evidence-based guidelines exist for pharmaceutical therapy in the treatment of PCS.However, pharmaceuticals including over the counter anti-inflammatories and analgesics, amantadine, onabotulinumtoxinA (BOTOX R ) and prescription antidepressants such as selective serotonin reuptake inhibitors and amitriptyline have been explored to address PCS symptoms [3].Nutraceutical supplements have been investigated for potential benefits in PCS therapy.Antioxidants, B vitamins, omega-3 fatty acids, vitamin D, progesterone, melatonin, vitamin C and others have shown to provide protection and(or) aid in PCS recovery [3].In select case reports, neurofeedback therapy, cognitive behavioral therapy, ocular rehabilitation, prescribed rest, physical therapy, osteopathic cranial manipulation, hyperbaric oxygen therapy and chiropractic manipulation have been associated with reduced or resolved PCS symptoms [3,10].
Since the biomechanics of concussions can involve complex acceleration/deceleration impacts and inertial loads applied to the cervical spine, skull, brain and neural tissue, it might be relevant to look at cervical spine alignment as a potential contributing or mitigating variable in the onset and sequelae of concussions.Studies have discussed the sagittal plane alignment of the cervical spine relative to cognitive dysfunction in whiplash injuries [11] and sports related cervical neurologic stinger injuries (spear-tacklers spine) [12].However, there seem to be no studies investigating the effects of spinal alignment on concussion and(or) PCS.The objective of this study is to report on the effects of structural rehabilitation of the spine and posture using Chiropractic BioPhysics R (CBP R ) on symptoms, disabilities and quality of life associated with PCS of a 27-year-old professional rugby player with a history of repetitive concussions.

Case presentation
An informed consent form for publication of this case was completed by the participant in this study.All procedures performed in this study were in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Patient presentation
A 27-year-old Caucasian male with an athletic muscular build, a height of 193 cm, and a weight of 114 kg reported moderate-to-severe neck and headache pain he scored 7/10 on a scale of 0 (no pain) to 10 (maximum pain) resulting from a history of concussions.The patient was a starting forward professional rugby player for 6 years.Each year's season consisted of approximately 30-40 rugby matches from June/July through May of the following year lasting 80 min per match.

Patient history
The patient reported experiencing 20 documented diagnosed concussions in the previous 6 years, averaging one concussion per 11 matches every 16 weeks, as an elite professional rugby player who played for a national rugby team.On returning to play, the patient was required to pass 2 days of return to play protocol.Magnetic resonance imaging (MRI) of the head revealed normal signal from the brain, brainstem and cerebellum with no evidence of cerebral injury or extra-axial collection, no mass lesion, infarct or hydrocephalus, patent intracranial vessels and blood sensitivity.The patient stated that not all concussions resulted from head trauma, but those that did result from head knocks were sometimes followed by immediate amnesia which might last for differing amounts of time and approximately 1 day of irritability.The patient stated that he had been playing with the PCS symptoms documented.He reported previous treatments, including therapeutic exercises and physical therapy modality treatments from athletic trainers and physical therapists and traditional spinal manipulation from chiropractors, were not effective in relieving his post-concussion symptoms.These previous treatments were ongoing throughout his professional rugby career.

Neck Disability Index
The Neck Disability Index (NDI) is used to assess the day-to-day impact of neck pain and to quantify and qualify disability due to neck pain [15].NDI was administered at pretreatment, post-treatment and 6-year follow-up exams.NDI changes of 21% are considered clinically meaningful [16].On pretreatment NDI, the patient scored a 52% indicating severe disability in daily activities due to neck pain (Table 1).
Headache Disability Index The Headache Disability Index (HDI) is used to assess the day-to-day impact of headache pain and to and to quantify and qualify disability due to headaches [17].HDI was administered at pretreatment, post-treatment and 6-year follow-up exams.HDI changes of 29 points are considered clinically meaningful [18].On pretreatment HDI, the patient reported a headache frequency of more than one headache per week and scored a 42 indicating moderate disability in daily activities due to headaches (Table 1).

Short-form 36 health related quality of life questionnaire
The Short Form-36 (SF-36) is a 36-question survey that provides scaled scores for health-related quality of life (HRQOL) in nine different domains from 0 (lowest HRQOL) to 100 (highest HRQOL) [19].SF-36 was administered at pretreatment, post-treatment and 6-year follow-up exams.SF-36 changes of 5 points are considered clinically meaningful [20].Pretreatment SF-36 showed: Physical Functioning (PF) was 45, Bodily Pain (BP) was 22.5, Role limitations due to physical health problems (RP) was 0, role limitations due to personal or emotional problems (RE) was 100, mental health (MH) was 92, social functioning (SF) was 100, energy/fatigue or vitality (VIT) was 85, general health (GH) was 85 and change in health status ( H) was 50 (Table 1).

Radiographic analysis
A valid and reliable way to evaluate abnormalities, aberrant posture and spinal alignment is by radiographic analysis.Spinal abnormalities include 'rotations and translations of the head, rib cage and pelvis from a normal position in a 3D coordinate system' [21][22][23].Measurements from the spinal radiograph analyses are used to determine the best strategies for structural spinal rehabilitation [22,23].
A neutral lateral cervical (NLC) radiograph of the patient was examined per the Harrison Posterior Tangent Method [24,25] in accordance with the Harrison Spinal Model [26-28].On lateral spinal radiographs, juxtaposed posterior tangent lines of the vertebrae provide intervertebral and spinal region angles.C2-C7 posterior tangents provide the absolute rotation angle cervical lordosis measurement (ARA C2-C7).Horizontal displacements of a spinal region are measured at a superior vertebral landmark from a vertical sagittal axis from an inferior vertebral landmark.These spinal measurements are compared with valid, normal, ideal values [21][22][23][24][25][26][27][28].
A shorthand identifies spine alignment.Positive or negative measurements indicate the rotation (R) around or translation (T) in the three axes (x, y or z) of the head (H), thorax (T) or pelvis (P) or any specific vertebra.

Treatment
Over a period of 16 days, the patient underwent 30 sessions of CBP R Mirror Image R spinal adjustments, exercises and traction in a private practice under the care of a doctor of chiropractic with advanced training in CBP R which includes 190 hours of combined lecture and practical instruction as well as a case presentation of clinical success in practice subject to peer review.To correct spinal alignment and posture, Mirror Image R future science group 10.2217/cnc-2023-0004 structural spinal rehabilitation requires placing the patient into the corrected or overcorrected alignment and postural position [21,23].

Mirror Image R adjustments
Mirror Image R spinal adjustments are given with the patient positioned in their corrected or overcorrected spinal alignment and posture and stimulate mechanoreceptors and proprioceptors [21,23,29] to train the patient's CNS to change [23,29].
Mirror Image R adjustments were administered using an OMNI elevation drop table and an Impulse R adjusting instrument (Impulse R Adjusting Instrument, Neuromechanical Innovations, AZ, USA).Mirror Image R adjustments consisted of left head translation and cervical extension.

Mirror Image R exercises
Mirror Image R exercises strengthen and lengthen respective muscles that have maladapted to abnormal spinal alignment and posture [21,23].The patient was trained to perform the exercises and was observed while doing so.Left head translation and cervical extension were performed with cycles of contraction and relaxation for a total of 8-10 minutes.The patient was directed to contract for 15 seconds in the Mirror Image R posture and then relax for 5 seconds.

Mirror Image R traction
Mirror Image R traction creates long-term, restorative plastic deformation of the spine [22,23,29] by loading spinal connective tissue and initiating muscle creep resulting in long-lasting correction [22,23,29].Mirror Image R spinal traction consisted of left head translation and cervical extension using Denneroll TM Spinal Orthotics (Denneroll TM Spinal Orthotics, New South Wales, Australia) and CBP R Mirror Image R Blocks (CBP R Seminars, Inc., ID, USA) [29].The patient started with 8 minutes and worked up to 15 minutes of traction per setup with each session.

2-year follow-up radiograph findings
The patient did not receive corrective spinal rehabilitation following his 30 visits.In the 2 years following treatment, the patient continued to compete as an elite professional rugby player.The patient was a starting forward for a professional rugby team competing in approximately 30-40 rugby matches from June/July through May of the following year in matches lasting 80 min.NLC and APLC radiographs showed that post-treatment improvements in ARA C2-C7 and Tx C2-T3 were maintained at 2-year follow-up (Figure 1C & 2C & Table 2).

6-year follow-up exam findings
Neck and headache pain QVAS, NDI, HDI and SF-36 showed that post-treatment improvements in neck and headache pain and disability and HRQOL were maintained at 6-year follow-up (Table 1).
The patient reported that since his re-exam 6 years prior, he had sustained two documented diagnosed concussions while maintaining the same lifestyle and competing in the same sport at the same level, position and playing time.The patient stated that both his spinal and general health had significantly improved.He claimed to have occasional, minimal pain but otherwise to be enjoying life and able to carry out activities of daily living and extended activities without restrictions.

Discussion
This case shows maintained improvements in PCS symptoms and significant reduction in concussion incidence of a professional rugby player following corrective spinal rehabilitation of cervical spine.

Cervical spine, concussion & post-concussion syndrome
According to Wolff 's Law, reduced cervical curvature causes substantial increased vertebral pressure, resulting in spinal compression, arthritis and degeneration [32].These skeletal changes create biomechanical instability requiring the connective tissues that support the neck to work harder resulting in muscle and soft tissue weakness and injury, per Davis's Law [39,40].Furthermore, the vasculature within the spine will be subjected to prolonged abnormal stresses and strains [41][42][43].
Vertebral artery hemodynamics [44] and cerebral blood flow (CBF) [45] has been linked to cervical lordosis.Improved of cervical curvature increases cerebral blood flow, which is consistent with the notion that spinal biomechanics affects physiology [45].Data shows as cervical lordosis improves, so too does CBF [45].Arteries lose their elasticity and stiffen as a viscoelastic response to increased tension from cervical hypolordosis or kyphosis [46,47].
Since the cerebral arteries supply blood to the brain [48], cervicogenic headache may be connected to altered cerebral vascularization in addition to its relation to abnormal cervical spine structures [38,49].Wang et.al. identified that athletes with concussions showed a reduced CBF compared with controls who demonstrated no change [50].Increased CBF following sports related concussions decreased the extent of symptoms 'suggesting a potential prognostic indication for CBF as a biomarker' [51].
CBP R spinal rehabilitation is an effective, conservative method of correcting abnormal spinal alignment and posture [21][22][23]29,30]. In this case study, restoring cervical spinal alignment and posture was associated with improvefuture science group 10.2217/cnc-2023-0004 ment in PCS symptoms, pain, disabilities and concussion frequency.It stands to reason that improved cervical spine and posture alignment decreased unhealthy biomechanics affecting neuromuscular tissues [32,52].It is possible that correction of the cervical lordotic curvature and improvement in our patient's lateral head translation were associated with an increased ability of the cervical spine to attenuate loads transferred to the brain tissue via the impact responsible for concussions and PCS.In this manner, spinal curvatures are the primary shock absorbers [53].Thus, the reduction in the number of concussions from 20 to 2 over the same time period (6 years before corrective care versus 6 years following spine correction) in our patient might be related to improved biomechanics of the cervical lordosis and the neutral spine.At the very least, this warrants further biomechanical investigation.

Study limitations
As is true for case reports, this study has limitations in being able to draw conclusions about correlation, causation or applying the findings to broader spectrum of varying demographics.While the detrimental health effects of reduced cervical curvature are evident [22,28,30,[33][34][35][36][37][38]45], there are no studies on the effects of cervical curvature as it relates to concussion and PCS. Clincal trials involving patients with concussions and spinal alignment, structural spinal rehabilitation, medical and surgical management and control groups with long-term follow-ups are needed.Investigating the relationship between cervical spinal alignment and vascular, neurological and other system changes would be beneficial for considerations for spine, concussion and PCS management.

Conclusion
This case study contributes to the growing body of research showing that structural rehabilitation of the spine and posture using CBP R can be an effective long-term, conservative treatment without the use of pharmaceuticals or surgery for neurological, muscular and skeletal conditions as well as non-musculoskeletal conditions including pain, disability and reduced HRQOL.This study is the first to indicate that improvement in symptoms, disabilities and HRQOL from PCS as well as a decreased frequency of concussions may be associated with correction of abnormal cervical spinal alignment.Structural spinal rehabilitation could be utilized to avoid degenerative spine diseases and their consequences.Further research is necessary to evaluate the clinical significance of this, including rates and susceptibility for PCS, concussions and traumatic brain injury.

Summary points
• Concussion in rugby is common and a history of participation in rugby or concussions are associated with neurocognitive deficits.• Since the biomechanics of concussions can involve complex acceleration/deceleration impacts and inertial loads applied to the cervical spine, skull, brain, and neural tissue, it might be relevant to look at cervical spine alignment as a potential contributing or mitigating variable in the onset and sequelae of concussions.
• This case study reports on a 27-year-old professional rugby player with 20 documented concussions over 6 years and post-concussion syndrome who underwent 30 treatment sessions of cervical rehabilitation using Chiropractic BioPhysics R .• A 27-year-old professional rugby player with a history of concussions and PCS reported improvements in concussion incidence and post-concussion syndrome symptoms including neck and headache pain and disability and quality of life following correction of sagittal and frontal cervical spinal alignment.• A 2-year follow-up examination of a 27-year-old professional rugby player with a history of concussions and PCS showed that post-treatment improvements in sagittal and frontal cervical spinal alignment were maintained.• A 6-year follow-up examination of a 27-year-old professional rugby player with a history of concussions and PCS showed that post-treatment improvements in the neck and headache and disability and quality of life were maintained.• A 27-year-old professional rugby player with a history of 20 concussions over 6 years and PCS reported that in the 6 years following correction of sagittal and frontal cervical spinal alignment he had sustained only two documented diagnosed concussions while maintaining the same lifestyle and competing as a professional rugby player at the same level, position and playing time.• Correction of sagittal and frontal cervical spinal alignment allows the cervical spine to function as a primary shock absorber and increases its ability to attenuate loads transferred to the brain tissue via impacts responsible for concussions which may reduce the risk of concussions.
33. Moustafa IM, Diab AA, Hegazy F, Harrison DE.Demonstration of central conduction time and neuroplastic changes after cervical lordosis rehabilitation in asymptomatic subjects: a randomized, placebo-controlled trial.Sci.Rep. 11(1), 15379 (2021).• A randomized, placebo-controlled trial with a 3-month follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on sensorimotor integration and central conduction time in an asymptomatic population at short and long-term follow-up.34.Moustafa IM, Diab AA, Harrison DE.The efficacy of cervical lordosis rehabilitation for nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial with 2-year follow-up.J. Clin.Med.11(21), 6515 (2022).• A randomized controlled trial with a 2-year follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on nerve root function and pain rating in patients with cervical spondylotic radiculopathy at short and long-term follow-up.35.Moustafa IM, Diab AA, Taha S, Harrison DE.Addition of a Sagittal cervical posture corrective orthotic device to a multimodal rehabilitation program improves short-and long-term outcomes in patients with discogenic cervical radiculopathy.Arch.Phys.Med.Rehabil.97(12), 2034-2044 (2016).10.2217/cnc-2023-0004 Concussion (2023) CNC107 future science group • A randomized controlled trial with a 1-year follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on neck pain and disability and latency of somatosensory evoked potentials in patients with discogenic cervical radiculopathy at short and long-term follow-up.36.Moustafa IM, Diab AA, Harrison DE.The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.Eur.J. Phys.Rehabil.Med.53(1), 57-71 (2017).•• A randomized controlled trial with a 1-year follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on dizziness, neck pain, disability and cervicocephalic kinesthetic sensibility in patients with cervicogenic dizziness at short and long-term follow-up.37. Moustafa IM, Diab AAM, Hegazy FA, Harrison DE.Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects?J. Back Musculoskelet.Rehabil.937-941 (2017).• A randomized controlled trial with a 3-month follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on cervical spine segmental flexion and extension end range of motion kinematics in patients with cervical spondylotic radiculopathy at short and long-term follow-up.38.Moustafa IM, Diab A, Shousha T, Harrison DE.Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: a 2-year pilot randomized controlled trial.Heliyon 7(3), e06467 (2021).•• A pilot randomized controlled trial with a 1-and 2-year follow-up shows that rehabilitation of the cervical sagittal alignment and posture has a direct influence on headache frequency, pain and disability in patients with cervicogenic headaches at short and long-term follow-ups.

Table 1 .
Pretreatment, post-treatment and 6-year follow-up outcome assessment evaluations.