Everything you Need to Know about Post Concussion Syndrome
What is Post Concussion Syndrome?
Post concussion syndrome is a neurological disorder defined by brain, pain and health problems that persist for weeks or months following a head or neck or neck injury.
If you are looking for a concussion specialist, one of the most frustrating things is getting an accurate diagnosis.
What you may not know is that there is no single test to diagnose post concussion syndrome. It is actually considered a “diagnosis of exclusion,” which means that after you have the original CT and MRI scans to rule-out brain swelling, bleeding or fracture, your concussion specialist cannot explain what you are experiencing.
Since, you are diagnosed with “post concussion syndrome.”
… But what if there’s more to it than just a head injury, which is the reason why your concussion specialist can’t quite find what is going on.
And what if there was a natural treatment that could help in your recovery?
Read to find out more.
Post Concussion Syndrome Symptoms
There is no single symptom or pathognomonic test that can identify post concussion syndrome. The way that a concussion specialist typically diagnoses post concussion syndrome is when you experience a combination of the symptoms following a head or neck injury:
- Head, neck, face, jaw, shoulder or body pain
- Dizziness or vertigo
- Blurry vision
- Insomnia or other sleeping problems
- Chronic fatigue
- Muscle weakness or twitching
- Problems with your memory
- Problems with your ability to concentrate (commonly described as “brain fog”)
- Moodiness, anxiety or depression
- Or even a variety of symptoms that affect your organ health.
The reason the symptoms of post concussion syndrome can be so varied is because your brain health affects your entire body. Therefore, your symptoms can vary depending on which part of your brain is affected.
Again, what if that is not the full story for your post concussion syndrome?
Did you know that the symptoms of a brain injury are identical to those of a neck injury?
The overlap is so huge that concussion specialists and researchers now recommend for people who experience post concussion syndrome to have their neck health assessed by an expert in neck health or cervical spine specialist.
So let me ask you if you are experiencing post concussion syndrome symptoms: have you had your neck health assessed?
What kinds of tests have you had there?
Post Concussion Syndrome Fog
“What is this ‘brain fog’ that I’m feeling?’ Concussion specialists believe that the brain fog feeling that people experience may be due to disruption of normal fluid flow within the brain.
There may be three potential types of fluid involved:
- Arteries to the brain. When your brain does not receive the proper supply of blood, it may cause you to feel lightheaded (dizziness or vertigo) or unable to focus. Of special mention are the vertebral arteries that supply blood to your brainstem, visual and balance centres. These particular arteries pass directly through the vertebrae in your neck, and it may be possible that changes with the alignment of these bones may disrupt the normal flow to your brain.
- Veins from your brain. When you lie down, blood from from your brain drains primarily from your jugular veins on the front of your neck. However, when you sit up, drainage occurs through the vertebral veins, which follow the same course as the vertebral arteries. Therefore, a constriction due to a problem with the alignment in your neck may cause blood to congest or pool backwards into your brain. This may feel like a fulness or congestion at the base of your skull that may feel like a headache, neuralgia or sinus blockage.
- Cerebrospinal fluid around your brain. The cerebrospinal fluid carries oxygen and nutrients in order for your brain to function. Disrupted flow has been associated with a wide variety of neurological symptoms even including conditions including post concussion syndrome, multiple sclerosis and Alzheimer’s dementia.
What is most fascinating is that these same concussion specialists are showing through research that by correcting misalignments of the vertebrae in the neck - with special emphasis on the atlas vertebra, aka C1 vertebra at the base of your skull - can actually restore blood and CSF flow in the brain!
In other words, your post concussion syndrome symptoms may not be the result of permanent brain damage.
You may simply need treatment to restore the function of your neck health, which may allow your brain to heal and start working again the way it is meant to!
Post Concussion Syndrome Trigger Points
One of the most common symptoms that people develop with post concussion syndrome are pain and trigger points through the back of the head, neck, jaw and shoulders.
Concussion specialists looking at post concussion syndrome in children discovered that over 90% of sufferers actually had problems that could be attributes to dysfunction in the neck:
- 99% had posture abnormalities
- 98% had myofascial pain, or trigger points in their muscles
- 86% had problems with movement in their neck
- 62% had muscle weakness associated with pain
- An unknown percent had issues with balance or joint position associated with neck injury.
Pretty amazing numbers, especially if you’ve never realised before the connection between post concussion syndrome and your neck!
So you may be wondering why concussion specialists haven’t found these problems with you before.
Well, let me ask you again: when you suffered your injury, did you have any tests at all? X-rays? CT scans? MRIs?
But were they of your head or of your neck?
Even if they were on your neck - and even if you have had someone look at your neck - what level of detail of tests have you had?
Many misalignments in the neck are only 2-5 millimetres in size. However, when you consider that the joints in your neck move only 10-20mm total, such misalignments could represent a 10-50% displacement!
The consequences of these type of misalignments is that they may produce abnormal tension on your muscles, nerves and even brainstem. If so, it actually makes sense that you would experience pain!
The thing about it that unless you have very specific tests - ones that consider the unique shape of the vertebrae in your own neck - it is exceptionally common for many of these misalignments to be undiagnosed.
Post Concussion Syndrome Pain
The part of your brainstem and spinal cord that filters pain information from your body is called the periaqueductual grey matter, or PAG. If this structure in your brain or spinal is traumatised due to an injury, you may begin to experience chronic pain in all areas of your body:
- Face pain
- Neck pain
- Chest pain
- Back pain
- Legs pain
It is because the PAG is the primary processing filter for pain information in your brain. It is also associated with your brain’s ability to filter information so that you can sleep.
In other words, if the PAG centre of your brainstem is affected with post concussion syndrome, it can also affect your ability to sleep.
And, of course, if you don’t sleep well, it can compound the sense of fatigue and pain that you already experience as the result of post concussion syndrome.
Post Concussion Syndrome Cause
The three major types of injuries that can cause post concussion syndrome, whiplash and a neck injury are auto injuries (i.e., car crashes), sports injuries and work injuries.
- Auto - Contrary to common belief, neither the speed nor the severity of a motor vehicle accident (MVA) are associated with the severity of post concussion syndrome. Many people who experience even a “minor” fender bender - if it is at just the wrong angle - can suffer an injury that causes neck damage and the symptoms of post concussion syndrome.
- Sports - You can still suffer a concussion even if you do not lose consciousness. The two most common sports in Australia associated with whiplash, concussion and neck injury are men’s AFL and women’s soccer. Concussion specialists have identified that women are actually more likely to experience concussion in contact sports. However, any sport that involves physical contact (e.g., rugby or hockey) or the potential for a “wipeout” (e.g., skateboarding, surfing or skiing) may have the potential to cause a neck injury and the symptom of post concussion syndrome.
- Work - Any sudden injury that affects your head or spine - including a fall on your tailbone - can cause a ripple affect that affects your neck and spinal cord. Typically, computer work does not cause post concussion syndrome because there is no specific injury. However, if you work in front of a computer all day, the strain on your eyes plus the repetitive-stress position of your neck can certainly increase the severity of your condition. In other words, computer work may aggravate your symptoms if you experience post concussion syndrome.
It is unfortunate that so many people who experience neck injuries never receive the proper care that they need immediately after the injury. As a result, many people suffer much longer than they have to - weeks, months or even years - before they finally discover the help that they need to recover from post concussion syndrome.
Post Concussion Syndrome Facts and Statistics
Awareness about concussion and post concussion syndrome have increased in recent years spearheaded by the NFL and NHL player’s associations in North America. Still, awareness - and more importantly treatment strategies for post concussion syndrome in Australia are still widely known.
Let’s look at a few statistics that illustrate the full scale of the post concussion syndrome challenge:
- Only 10% of concussions actually result in a loss of consciousness
- 89% of mild traumatic brain injury (MTBI) injuries are not assessed by a medical professional or concussion specialist
- In the USA, there are an estimated 38 million concussions that occur every year. This number scaled for Australia calculates as 2.8 million concussions every year.
- Young children are most likely to suffer concussions
- 15-24 year olds suffering sports-related injuries are the largest group suffering concussions
It is also believed that the development of MTBI and post concussion syndrome may be accumulative: i.e., injuries suffered in youth may not manifest until later in life when an additional, seemingly innocent injury such as a trip, fall or minor car accident tips the threshold.
Post Concussion Syndrome Risk Factors
There are many risk factors associated with neck injury and post concussion syndrome:
- Whiplash - A whiplash injury is any injury that occurs where you neck snaps in opposing directions, like cracking a whip. Specifically, injuries that you did not see coming and did not have time to brace for are the worst. Concussion specialists believe that when you see that an injury is about to happen, you unconsciously engage your muscles for impact. The result is that your muscle absorb much of the force. However, if you don’t see the injury coming, the impact force goes directly into your ligaments and nerves, which typically results in more pain and complications.
- Head Injuries- Contact sports are the most common, such as boxing or martial arts. However, incidental head injuries are also common in swimming and cycling. It is because an unexpected collision with the a sandbar in the ocean, the wall of a pool, or the pavement after an unexpected crash can be just as severe as any contact sport injury.
- Previous Concussion - It is not necessarily the frequency of previous injuries, but the severity of previous concussions that matters most. Typically, a history of multiple concussions is associated with a greater risk of developing neurodegenerative conditions including chronic traumatic encephalomyelomyeltis (CTE), Alzheimer’s dementia, Parkinson’s and multiple sclerosis.
- Female - Concussion specialists have identified that women are at a greater risk of suffering post concussion syndrome than men. The exact reason is unclear, but it is believed to be due to differences in ligament strength: i.e., women’s joints and bodies are typically more flexible than men.
It is yet another reason why the neck - specifically the upper neck is so important in post concussion syndrome care. It is because it is the most flexible area in the entire spine … but also the most delicate, thus susceptible to injury.
Post Concussion Syndrome Diagnosis
Post concussion syndrome is known as a “diagnosis of exclusion.” In other words, it is not a discrete thing that you can see on an x-ray, CT or MRI scan.
In fact, for many people who experience post concussion syndrome, their concussion specialist medical reports come back as saying “No abnormalities detected.”
If your tests also included scans of your neck, they may describe “curve or degenerative changes changes in the neck.” However, many concussion specialists may not recognise the potential significance of these subtle findings.
What is essential for your concussion specialist to understand also is that it is impossible to tell the difference between a head injury and a neck injury based on your symptoms alone.
In a recent study, concussion researchers concluded the following:
“Given that concussion and cervical injury share similar causes and symptoms, this information alone may be insufficient to diagnose a concussion. Clinical assessments, such as the cervical joint-reposition error test, smooth-pursuit neck-torsion test, head-neck differentiation test, cervical flexion-rotation test, and physical examination of the cervical spine, can be performed after a head and neck pathomechanical event to identify the presence of cervical injury.”
In other words, doing a series of physical and neurological tests of the neck is of supreme importance in the care and management of post concussion syndrome.
In our own practice, we focus specifically on the health of your neck, and how that may be affecting your spine, brain and body health. The tests that we perform include static palpation (for pain or tenderness) joint motion, neuromuscular and posture assessments, and also nerve screening assessments. … In other words, we test the exact types of things that the concussion researchers recommend.
In addition, we also perform a customised series of 3D x-rays, which allow us to identify the exact direction and degree of any injuries affecting the alignment of the bones in your neck.
With this additional information, we are able to take a different approach that is unlike any other post concussion syndrome therapy.
Post Concussion Syndrome Medication
Where brain health is concerned, there is seldom a single “magic pill” or “magic solution” that fixes post concussion syndrome.
Instead, it is often a combination of different concussion treatments working together that ultimately allows people to recover from post concussion syndrome.
Because many concussion specialists aren’t able to identify a definitive cause - in part because they often aren’t considering the neck - their only treatments are medications prescribed to manage pain:
- Anti-anxiety drugs
- Antidepressant drugs
- Beta blockers
The unfortunate side effect for so many people who take these medications for post concussion syndrome describe that they only cause them to feel groggier without even doing much to help their pain. Moreover, the over-prescription and over-dependence on these medications have been linked with the “Opioid Crisis” which has become a massive health problem in the USA and Australia.
It is not to say that medication does not have its place. It does: especially when people are experiencing acute pain, drugs may be necessary to provide symptom relief.
However, if are the kind of person who prefers to do your own research and make up your own mind, then you probably think that medication can only treat the symptoms of post concussion syndrome: and it may not be able to do anything to actually help improve the underlying condition.
I believe that there is a time, place and necessity for certain types of medication in post concussion syndrome treatment. However, I also believe that to rely 100% on medication to solve your post concussion syndrome will not get you the outcome that you want.
You have to do more.
Post Concussion Syndrome Treatment
Many therapies for post concussion syndrome focus on brain rehabilitation.
- Physical exercise, which involves basic activities such as walking or swimming
- Vestibular exercise, which involves tracking eye movements to rehabilitate your brain
- Meditation and other mindfulness activities
- Post traumatic stress disorder (PTSD) activities because physical brain and neck injuries often produce emotional problems such as anxiety or depression
All of these activities are essential in the care and recovery from post concussion syndrome.
However, I believe that these exercises work best when your body is also structurally clear.
If you are doing exercises for post concussion syndrome, it is essential for your neck to be properly aligned so that you can get the best possible results and the greatest chance of recovery.
There are many therapies that treat the neck including massage, acupuncture, chiropractic, osteopathy and physiotherapy.
When it comes to precision care for your neck health and post concussion syndrome, a unique form of healthcare that focuses on the alignment of your atlas - the C1 vertebra at the base of your brain - is a natural, drug free and powerful solution that could be one of the most important things in helping you with post concussion syndrome.
Post Concussion Syndrome Natural Remedies
An atlas chiropractor, otherwise known as an upper cervical chiropractor, is a different type of chiropractic doctor that focuses on the alignment on your neck - with special emphasis on the top two vertebrae, the C1 (atlas) and the C2 (axis) bones.
The way that atlas chiropractic works is by correcting the alignment of the bones in your neck, which can affect your brain health:
- Blood flow to your brain, and also drainage back to your heart
- Circulation of cerebrospinal fluid, which provides energy for your brain
- Protection of your brainstem and upper spinal cord, which are the master control centres of your body (including the primary sensory, balance and pain filtering centres, which are affected in so many people with post concussion syndrome)
- Motor control, emotional regulation and other functions of the upper brain have also been shown to be affected by your neck health
One of the major differences is the level of precision that goes into an atlas correction. Unlike many forms of spinal manipulation, there is no twisting, cracking or popping the neck.
The tests that an upper cervical or atlas chiropractic doctor uses means that any treatment you receive is custom-tailored for your own neck, and as a result does not require any twisting or cracking.
By restoring normal alignment and movement through the top of your neck, this unique form of healthcare has been able to successfully help many people with post concussion syndrome using a completely natural and drug-free approach.
Post Concussion Syndrome Pain Relief
When it comes to healing from post concussion syndrome, even treating your neck with something as powerful as an atlas alignment or upper cervical care may be only the first step in the process.
Remember that your brain and body need to heal from the injury.
It is one reason that we recommend a combined therapy approach when helping people with post concussion syndrome, including working with concussion specialists who may recommend a range of therapies:
- Upper cervical care to help take care of your neck so that your brain and body have a better opportunity to heal
- Physiotherapy to help you with exercises that allow your brain to rewire and heal
- Pain management strategies that include meditation, mindfulness, breathing exercises, and PTSD exercises if your injury has also produced an “emotional scar”
- And yes, even medication - as little as possible - to assist you in the process as your body heals.
The process can be simple, but still requires time and your commitment.
One thing I know with certainty is that your body is always working to heal you. Therefore, even if you are dealing with significant challenges associated with post concussion syndrome, like you’ve hit a block in the road. Nevertheless, there may still be answers out there for you that you have not yet discovered.
Living with Post Concussion Syndrome
When it comes to healing from post concussion syndrome - or any chronic health challenge for that matter - I do understand how emotionally draining it can be.
Some days, the only thing that may keep you going is the hope for a better tomorrow.
Personally, I don’t believe in giving people false hope. That’s painful and dangerous.
I believe in real hope that there is a solution for you. I realise there is nothing I can say to make it easier. When it comes to your post concussion syndrome, the odds are that it isn’t just a matter of finding one “magic cure” that will fix it all. You are actually trying to solve a combination lock.
So even if you have done all kinds of treatments so far - you’ve seen all kinds of the concussion specialists and spend all kinds of time and money - even if you haven’t felt any different, you may actually HAVE solved part of the puzzle.
However, because you still haven’t solved the final piece, that is why you haven’t felt any different.
If the final piece of the puzzle in your post concussion syndrome so happens to be your neck - or even if it is only the first piece of the puzzle - I hope I’ve been able to offer you in this article is a a different approach - something that makes logical and emotional sense - and a different direction for you to take in your healing.
Gulla B. Concussion statistics. The concussion place. 7 May 2015. Accessed 27 Jan 2020. https://theconcussionplace.com/concussion-statistics/
Meehan WP 3rd. Medical therapies for concussion. Clin Sports Med. 2011;30(1):115–ix. doi:10.1016/j.csm.2010.08.003. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359788/
Morgan CD, Zuckerman SL, King LE, et al. Post-concussion syndrome (PCS) in a youth population: defining the diagnostic value and cost-utility of brain imaging. Childs Nerv Syst. 2015 Dec;31(12):2305-9. doi: 10.1007/s00381-015-2916-y. Epub 2015 Sep 29. https://www.ncbi.nlm.nih.gov/pubmed/26419243
Panwar J, Hsu CC, Tator C, Mikulis D. Magnetic Resonance Imaging Criteria for Post-concussion Syndrome (PCS): A study of 127 PCS Patients. J Neurotrauma. 2019 Dec 10. doi: 10.1089/neu.2019.6809. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/31822164
Tator CH, Davis HS, Dufort PA, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016 Nov;125(5):1206-1216. Epub 2016 Feb 26. https://www.ncbi.nlm.nih.gov/pubmed/26918481
Baker M, Quesnele J, Baldisera T, et al. Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion. Musculoskelet Sci Pract. 2019 Jul;42:193-197. doi: 10.1016/j.msksp.2019.04.002. Epub 2019 Apr 18. https://www.ncbi.nlm.nih.gov/pubmed/31047873
Bussey MD, McLean M, Pinfold J, et al. History of concussion is associated with higher head acceleration and reduced cervical muscle activity during simulated rugby tackle: An exploratory study. Phys Ther Sport. 2019 May;37:105-112. doi: 10.1016/j.ptsp.2019.03.012. Epub 2019 Mar 23. https://www.ncbi.nlm.nih.gov/pubmed/30928840
Carmichael JP, Staton EW, Blatchford PJ, Stevens-Lapsley J. Epidemiology of neck injuries accompanying sport concussions in youth over a 13-year period in community-based healthcare system. Int J Sports Phys Ther. 2019 Jun;14(3):334-344. doi: 10.26603/ijspt20190334. https://www.ncbi.nlm.nih.gov/pubmed/31681492.
Cheever K, Kawata K, Tierney R, Galgon A. Cervical Injury Assessments for Concussion Evaluation: A Review. J Athl Train. 2016 Dec;51(12):1037-1044. doi: 10.4085/1062-6050-51.12.15. Epub 2016 Nov 11. https://www.ncbi.nlm.nih.gov/pubmed/27835042
Elkin BS, Elliott JM, Siegmund GP. Whiplash Injury or Concussion? A Possible Biomechanical Explanation for Concussion Symptoms in Some Individuals Following a Rear-End Collision. J Orthop Sports Phys Ther. 2016 Oct;46(10):874-885. https://www.ncbi.nlm.nih.gov/pubmed/27690834
Ivancic PC. Neck injury response to direct head impact. Accid Anal Prev. 2013 Jan;50:323-9. doi: 10.1016/j.aap.2012.05.008. Epub 2012 May 20. https://www.ncbi.nlm.nih.gov/pubmed/22613632
Kennedy E, Quinn D, Tumilty S, Chapple CM. Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskelet Sci Pract. 2017 Jun;29:91-98. doi: 10.1016/j.msksp.2017.03.002. Epub 2017 Mar 14. https://www.ncbi.nlm.nih.gov/pubmed/28347935
Leddy JJ, Baker JG, Merchant A, et al. Brain or strain? Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury. Clin J Sport Med. 2015 May;25(3):237-42. doi: 10.1097/JSM.0000000000000128. https://www.ncbi.nlm.nih.gov/pubmed/25051194
Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015 Jul;43(3):274-84. doi: 10.1080/00913847.2015.1064301. Epub 2015 Jul 3. https://www.ncbi.nlm.nih.gov/pubmed/26138797
Tiwari D, Goldberg A, Yorke A, et al. Characterization of cervical spine impairments in children and adolescents post-concussion. Int J Sports Phys Ther. 2019 Apr;14(2):282-295. https://www.ncbi.nlm.nih.gov/pubmed/30997280.
Zumsteg D, Wennberg R, Gütling E, Hess K. Whiplash and concussion: similar acute changes in middle-latency SEPs. Can J Neurol Sci. 2006 Nov;33(4):379-86. https://www.ncbi.nlm.nih.gov/pubmed/17168163
Belson K. The Concussion Crisis in Australian Rules Football. New York Times. 26 Sept 2019. Accessed 27 Jan 2020. https://www.nytimes.com/2019/09/26/sports/afl-football-concussions.html
Bogage J. Female soccer players suffer more concussions than males, study finds
Sydney Morning Herald. 28 Mar 2017. Accessed 27 Jan 2010. http://www.smh.com.au/sport/soccer/female-soccer-players-suffer-more-concussions-than-males-study-finds-20170328-gv7z2g.html
Came M. Head injuries should always be linked to the neck. CBC Sports. 31 Jan 2012. Accessed 27 Jan 2020. https://www.cbc.ca/sports/hockey/nhl/head-injuries-should-always-be-linked-to-neck-1.1137439
Carter L. NRL players' brains shown to be more damaged than brains of non-players, says neuroscientist. ABC News. 21 Mar 2017. Accessed 27 Jan 2020. http://www.abc.net.au/news/2017-03-20/nrl-players-brains-more-damaged-than-non-players:-study/8369226
Gleeson M. Brisbane Lions defender Justin Clarke retires at 22 from concussion. The Age. 31 Mar 2016. Accessed 27 Jan 2020. http://www.theage.com.au/afl/afl-news/afl-2016-brisbane-lions-defender-justin-clarke-retires-at-22-from-concussion-20160330-gnuju1.html
Wiederer D. After significant breakthrough, ex-Bear Jim McMahon finds agony lessening. Chicago Trubune. 27 Jan 2016. Accessed 27 Jan 2020. http://www.chicagotribune.com/sports/football/bears/ct-jim-mcmahon-85-bears-film-spt-0128-20160127-story.html
Chiropractic - Brain & Neck
Daligadu J, Haavik H., Yielder PC, et al. Alterations in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. Manipulative Physiol Therap. 36(8); 2013:527-537. https://www.ncbi.nlm.nih.gov/pubmed/24035521
Gouttebarge V, Aoki H, Lambert M et al. A history of concussions is associated with symptoms of common mental disorders in former male professional athletes across a range of sports. Phys Sportsmed. 2017 Sep 13:1-7. doi: 10.1080/00913847.2017.1376572. https://www.ncbi.nlm.nih.gov/pubmed/28870119
Haavik-Taylor H and Murphy B. The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: a crossover study. J Manipulative Physiol Therap. 33(4);2010:261-272. https://www.ncbi.nlm.nih.gov/pubmed/20534312
Haavik H and Murphy B. The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control. J Electromyography Kinesiology, 22(5);2012:768-776. https://www.ncbi.nlm.nih.gov/pubmed/17137836
Lelic D, Niazi IK, Holt K, et al. Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study. Neural Plast. 2016;2016:3704964. doi:10.1155/2016/3704964. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800094/
Ogura T, Tashiro M, Masud M, et al. Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain. Altern Ther Health Med. 2011 Nov-Dec;17(6):12-7. https://www.ncbi.nlm.nih.gov/pubmed/22314714
Rosa S, Baird JW. The craniocervical junction: observations regarding the relationship between misalignment, obstruction of cerebrospinal fluid flow, cerebellar tonsillar ectopia, and image-guided correction. Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015, pp 48-66 (DOI:10.1159/000365470).
Rosa S, Baird JW, Harshfield D, Chehrenama M. Craniocervical Junction Syndrome: Anatomy of the Craniocervical and Atlantoaxial Junctions and the Effect of Misalignment on Cerebrospinal Fluid Flow, Hydrocephalus Bora Gürer, IntechOpen, DOI: 10.5772/intechopen.72890. A
Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015. DOI:10.1159/000365463.
Wong JJ, Shearer HM, Mior S, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. Spine J. 2016 Dec;16(12):1598-1630. doi: 10.1016/j.spinee.2015.08.024. Epub 2015 Dec 17. https://www.ncbi.nlm.nih.gov/pubmed/26707074