Chiropractor’s Role in
Learn what tools, resources, and methodologies a chiropractor may use for concussion assessment and management.
This guide is based on the scope of doctors of chiropractic in the U.S. The extent to which chiropractors can be involved in concussion management differs by state. Always check your state’s scope of practice to confirm what roles and responsibilities you may have within the concussion care team.
Benefits of chiropractors in concussion care
1. Immediate care - chiropractors can be on the sidelines to make removal from activity decisions and refer for further evaluation
2. Differential diagnosis - chiropractors can determine which symptoms are related to concussion and which are related to another condition such as a whiplash associated disorder.
3. Concussion rehab - Chiropractors may be involved in many areas of concussion rehab including neuromusculoskeletal rehab, cervical rehab, sport-specific rehab, vestibular therapy, and vision therapy.
The Chiropractor’s Scope of Practice
for Concussion Care
In the past, concussion management was mainly limited to neuropsychologists. More recently, a multidisciplinary approach has been recommended which includes collaboration between different specialties for more comprehensive concussion treatment.
As a doctor of chiropractic, you may or may not be able to assess and manage concussions in your state. However, your role will still include triaging patients to rule out complicating factors and determining if there is involvement of the cervical spine. Chiropractors are allowed to be primary care providers and portal of entry clinicians for patients in all 50 states. However, only about 50% of the states include a scope of practice allowing a doctor of chiropractic to return an athlete back to their activity. No matter your scope of practice, it’s important to work effectively with a variety of providers when managing patients with concussion.
Sideline Assessment of Concussion
Chiropractors may be on the sidelines of sports games and practices to triage, make removal from activity decisions, and refer for further assessment.
It’s important to consider that you may not have the resources to do a comprehensive assessment on the sidelines. Rather, you may administer modified cognitive, balance, ocular-motor, and cervical assessments as well as observe concussion signs and ask about symptoms.
One of the chiropractor tools you may use when assessing concussion is ImPACT Quick Test - a brief, neurocognitive test battery that can be administered in 5-minutes on the sidelines or point of care to assist with removal from activity decisions. ImPACT Quick Test also includes the ability to administer and record the Vestibular Ocular Motor Screening (VOMS) and Balance Error Scoring System (BESS) tests. Any athlete who manifests signs or symptoms consistent with concussion, or shows impairment in any of the areas assessed, should be removed from play for further evaluation.
Concussion Evaluation and Differential Diagnosis
Concussion symptoms may overlap with those of other conditions, making a differential diagnosis extremely difficult on the sidelines without a thorough assessment. Symptoms may be related to the cervical spine, vestibulocochlear injury, ocular dysfunction, or temporal mandibular dysfunction.
At a minimum, your comprehensive concussion evaluation should consist of:
- Physical examination
- Symptom check
VOMS can be very useful when trying to differentially diagnose between concussion and a whiplash associated disorder.
VOMS consists of:
- Smooth pursuits
- Horizontal and vertical saccades
- Near point convergence (NPC)
- Horizontal VOR
- Vertical VOR
- Visual Motion Sensitivity
Conducting an in-depth vestibulocochlear and ocular examination will help differentially diagnose a patient. This may include:
- Otoscopic / ophthalmic exam
- Dix-Hallpike test
- Semicircular canal defect
- Targeted vision testing
If the patient experiences jaw discomfort, ear pain, or headaches, you should conduct an in-depth temporomandibular joint assessment. During which you will be looking for jaw deviations and/or malocclusion.
Chiropractors may use ImPACT for patients ages 12-80 (ImPACT Pediatric for patients 5-11) to help determine the cause of some of the signs and symptoms the patient is experiencing, as well as use it to monitor progress throughout return to academics and sport. ImPACT consists of 8 neurocognitive test batteries that measure visual and verbal memory, reaction time, and processing speed. It also includes a 21 item concussion symptom scale that you may use to cater your exam and make sure you address any symptoms the patient is reporting. After administration, a detailed clinical report is automatically generated that you can use to help guide rehab plans.
Chiropractor Concussion Treatment and Rehabilitation
In addition to the sideline and clinical assessment, chiropractors may also be involved in multiple areas of concussion rehab. These may include:
- Neuromusculoskeletal rehab: manual procedures including soft tissue modalities or joint manipulative therapies
- Cervical rehab: deep neck flexor endurance testing and proprioceptive testing
- Sport-specific rehab: agility drills and strength training
- Vestibular therapy: VOMS, Epley’s Maneuver, “BBQ” Roll
- Vision therapy: eye exams and determining if there’s blurred vision
While chiropractors may be involved in many areas of concussion rehab, it’s important to recognize when something is beyond the scope of your expertise and refer out to a specialist. Make sure you have a good referral network in place that you can utilize if a patient is not making progress.
Reimbursement for Chiropractic Concussion Care
As a doctor of chiropractic, you may be able to get reimbursed for a variety of techniques and modalities used for examining concussion patients.
Commonly used CPT codes for chiropractic concussion services
99212-99214: E/M established patient
98940-98943: Chiropractic manipulative treatment (CMT)
97140: Manual therapy
97112: Neuromuscular re-examination
97110: Therapeutic exercise
97530: Therapeutic activities
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