Empowering Women in Chiropractic – Concussion in Kids – Dr. Monika Buerger

Hello everybody and welcome to an incredible ChiroSecure Look to the Children show. I’m your host, Dr. Monika Buerger, and I want to thank ChiroSecure for always giving us this incredible opportunity to share so much wisdom with the chiropractic world and offers this platform to help us help more children. I am beyond stoked about our guest today. I have such incredible respect for this gentleman. I got to hear him speak a little over a year ago at an autism convention and we’ve known each other in the past, but Dr. Jon Chung is with us today. Hey, doc.

Hi. Thanks for having me on, Monika.

Oh, hey, I am so honored to have you here. I really, really love and admire your brilliance. Dr. Chung practices in Wellington, Florida, correct?

Yes. That is correct. We’re in Wellington, which is a suburb of West Palm.

You’re a writer, a lecturer in the chiropractic paradigm, upper cervical specialist. And I think the reason we kind of connected so well is one, our love for the vestibular system. So we’re both vestibular junkies. You’re kind of what I refer to as one of the experts in the concussion world and also tying concussion, vestibular work, and dysautonomia, all kind of into one paradigm. So thank you and congratulations on your new little fiddle fart.

Thank you so much.

You just became dad for the second time, right? Another little girl.

I did, I did. We’re thrilled to have some happy, healthy babies back in the household and yeah, mom’s working hard and I’m just doing the easy stuff now.

And you have a couple of websites for those out there in Facebook land to be aware of is protecttheneck.com, correct?

Correct. That’s for my technical writing, for clinicians, practitioners, doctors, and so forth.

And so, protecttheneck.com. You guys get on it. He really has incredible, incredible information. And then your office website is Chiropractic Keystone?

Yes, that is correct.

Okay. And you have … is it on the protecttheneck.com, is that where you have a handout to offer or tell us a little bit about that.

Yeah, so protecttheneck.com is a resource for doctors and clinicians to read a little bit more about the literature when traumatic head injuries happen to people, what can we do from a doctor standpoint to better understand what’s happening neurologically and what can we do best to help a lot of these patients, whether using some of the research that we know, whether it’s in physical therapy, chiropractic, and other modalities. So I tried to develop something where people can easily absorb some of the information. We translate it for people so they can use it in their office as soon as possible.

Awesome. And is that where the toolkit that you have to offer is on there?

Yes. So the head injury toolkit is a seminar that I put on and you can find out information about that seminar through protecttheneck.com.

Oh, fabulous. Oh, awesome. Exciting, exciting. And I should say that Dr. Jon has a background with extensive postgraduate work with the Carrick Institute and with the ICPA. So he’s definitely been in the trenches in the academic arena, as well as the practice arena, and that’s why we wanted to grab him and have him on today for you all. So let’s chat a little bit. You cool beans with throwing some stuff around?

Absolutely. Especially with someone as bright as you, I’m more than happy to.

I bow to you, man. I really was excited to have you hang out with us today. So we know that the rates of head trauma, concussion, they’re on the upswing and it’s a little bit different in the pediatric paradigm, being able to decipher some of the potential consequences of concussion or head injuries. And I understand that, from the literature, we know that when one sustains a whiplash along with a concussion, that kind of throws some other things into the rehab mixer, to the time sequence, et cetera, of healing. What can you tell us on that?

So there was a study that was published in 2018 out of this Canadian concussion center that looked at the outcomes for patients that had suffered a concussion alone, versus a concussion with some documentable form of neck injury. So what they found was in these patients, when patients had a concussion plus a neck injury, they were at much higher likelihood of having a delayed or worse recovery, which means that if a child with just a concussion by itself, we know that on average that they’re going to get better within about 16 to 18 days without any treatments at all. But these kids that will get neck injuries plus concussion, will actually get close to the 30 days if they make a full recovery.

And there’s a high percentage of these kids that don’t make a full recovery and will end up being diagnosed with post concussion syndrome or some type of persistent post-concussion type disorder. So that just adds to this building body of evidence that if you have a cervical spine injury with a concussion, that your chances of getting better unless you get good care for your neck are going to be a lot worse.

And for us, this is gold you guys out there, because we do need to be aware that whiplash injuries will magnify that concussion injury, but whiplash injuries can also mimic the same signs and symptoms, right, as a concussion or TBI?

That’s absolutely true and a lot of us, even if you don’t think that you see a lot of concussion patients in your office, there’s a lot of people in your office that have been in car accidents and some of these people that have had car accidents probably had some minor forms of concussion or brain injury, but they might not have even known that they suffered that, because these symptoms of concussion and whiplash do overlap quite a bit. There was an interesting study by John Leddy, who is out of the University of Buffalo where he took a bunch of patients from his clinic and he separated the groups into patients that had a whiplash mechanism, versus patients that had more of a concussion mechanism, and he gave those symptoms to doctors and he said, “Can you tell the difference between those that had a concussion versus those that had whiplash?”

And people couldn’t really tell the difference, because most people think, all right, if you have a concussion, you’re probably more likely to have cognitive symptoms. But we know that people who have neck injuries, they’re going to have cognitive symptoms, too. So you can’t tell just from symptoms alone whether someone has had a concussion or had a whiplash, you have to really dig deep and look into their history and look at their exam findings.

Yeah, absolutely. And for chiropractors, I mean that for us is imperative. We need to know this, that when people … even the little fiddle farts, if they sustain a whiplash type injury off the monkey bars on the playground or fall off the changing table or whatever, I think we need to be aware that this can set up the same sequelae as a concussion.

For sure. And plus, we’re chiropractors. We work on necks every single day. We should be seen as the experts of the neck because there’s no one that’s better trained in the biomechanics of the cervical spine. We know the soft tissues and the nervous tissue of the cervical spine in and out. We are well equipped to be able to handle these types of scenarios and what better intervention is it for someone than to get a correction to the neck through really specific chiropractic care?

Absolutely. And like you said, we should be on the forefront of this. Excuse me. And the upper cervical spine, in particular, I mean that is a very important area when it comes to the almighty proprioceptive and vestibular input. And I think in chiropractic, we talk a lot about proprioception, but I’ve always kind of had a love affair with the vestibular system as you do, because it’s such a profound sensory system and really regulates all the incoming sensory input, rate, timing, and so forth. Tell the world a little bit about the importance of proper vestibular function.

Yeah, so the vestibular system, and I know we talked about this the last time we were together, is just this magical thing that integrates with so many different parts of the brain, right? And we’re seeing that the vestibular system in people who have vestibular loss, that they have documented cognitive deficiencies, compared to normal controls. And we know that the vestibular system has really robust autonomic contributions, too. And I would almost venture to say that when we are adjusting people through the upper cervical spine, it’s through those cervical sensory contributions to the vestibular nuclei in the brainstem, that is probably giving us some of the most robust autonomic consequences when we’re adjusting people.

And just having that sensory integration between the proprioceptive sensors of our cervical spine with good, healthy vestibular function, I think time and time again, when I’m measuring something like heart rate variability to measure the autonomics of my patients, we see these changes happen so, so fast and it just lends credence that we can’t just break people down into these isolated pieces because the brain is such an integrated thing in and of itself, that whenever we hit these areas that have such high integration, that we’re going to have wide-ranging effects on the body. And especially when it comes to concussion and whiplash, we know that there’s dysautonomia and concussion, and we know that patients with concussion are at a higher likelihood to have things like postural orthostatic tachycardia syndrome, so you might have POTS and have a higher likelihood to have orthostatic hypotension and syncope. So the evidence is there that the autonomic nervous system is affected. It’s just now we’ve got to put our money where our mouth is, and showing that we’re affecting these things in meaningful ways.

Absolutely, absolutely. And that vestibular system, I mean there’s a lot of evidence it’s involved anxiety, regulating anxiety because it has that connection into that limbic system, the limbic structures are from the upper cervical spine. It has a direct connection into the limbic structures, which is huge, right?

Yeah.

And if we’re stuck in limbic lock and load mode, what does that look like? Anxiety.

Yeah. And when we see some of our patients that have … We think of vestibulized dizziness, even though it’s so much more than dizziness, but our dizzy patients are the most anxious people that we have. And as soon as you start to get their vestibular system calmed down, you could see that they become a different human being, just from having that vestibular contribution becoming more normal again.

Absolutely. And scoliosis, I mean there’s studies even looking at asthma, ADD, all these postural disorders that are associated with poor vestibular function, are associated with a plethora of labels that we see in common, everyday life now. So when you are looking at a little fiddle fart, the pediatric patient, are there certain red flags or pearls you look at that might be different than the adult patient?

When I’m looking at a pediatric patient, your exam findings become even more important because concussion is a clinical diagnosis for the most part. It’s like going back to that previous study that we talked about, you can’t really tell if someone has a concussion just by their symptoms alone, you have to assess their entire sensory system to make sure that there’s no abnormalities there. So one of the things that are going to pop up, especially if a kid has gone through their normal developmental progressions, you’re going to see some primitive reflex issues start to pop up again. One of the things that is kind of the gold standard for when someone has a concussion on the field, is that you’re going to see them get into that fencer response whenever they start to lose consciousness. And that’s one of the things that’ll pop up and you’ll see that becomes an issue when you look at things like the asymmetric tonic neck reflex and the tonic labyrinthine reflex start to show up again.

You’re going to see some Moro issues start to come up when it comes to that. And then some patients with a severe enough concussion, you’re going to see some abnormalities with their vestibular ocular reflex, too. So, those are some of the bigger things that I would be looking for, especially in that pediatric population, because balance is a useful tool and eye movements are useful tool, but they’re not as reliable when you’re dealing with that pediatric patient, because their motor control, in itself, isn’t that great until they get into closer to their teenage years.

Right, right, right. And that’s because we don’t have full function of that frontal lobe yet until [inaudible 00:14:43].

Exactly.

So that’s why the motor control isn’t necessarily there. So on the little fiddle farts, we might also see, excuse me, some behavioral difficulties start to pop up or more defiant behavior. They don’t like to be in a sensory stimulating environment. They might be more clingy. We might even see digestive issues, right?

Yeah, for sure. And especially if you correspond some of these findings, whether you have kids that have high visual sensitivity issues, so if they’re starting to become very light and sound sensitive, that’s another big cue for you to look into. And then when you’re having this overwhelming sensory stimuli coming in, and of course you’re going to act out and you’re going to do things that aren’t part of your normal behavioral patterns, but we also know that concussions will also affect clarity of vision, too. So if you have a kid that’s normally been a really good student, and all of a sudden they’re starting to slip behind, then it might not be a cognitive issue, in itself. It might be because concussion has effected their vision and they’re sitting towards the back of the classroom and all of a sudden, because of their head injury, they can’t see the board quite as well or they’re not reading quite as well.

So when it comes to concussion, having a team with you, so you have someone that understands vision therapies, they could do vision therapy for that child or teaming up with other members of the concussion team is really helpful and making sure that, hey, this kid that you think is just having cognitive issues, it might not be their cortical regions of the brain that’s responsible. It could be these other sensory areas that people just aren’t looking hard enough at. And that’s why people that are trained in the ICPA and understand this type of stuff, are really well equipped to help with the pediatric concussion.

Right. Yeah, and we do, we need to look at … So one of the things we want to take away with this is, you docs out there listening, these what we call primitive reflexes, is what Dr. Jon was talking about, can re-emerge in a time of a trauma. So we look at that Moro, the startle reflex. And you talked about the fencer pose, the ATNR, so we really want to get you thinking about those are some exams that we can do to see if those reflexes are not active following a whiplash or a concussion injury. So do you do those in most of your patients, doc?

I don’t do them in most of my patients, but when someone is having some of the clear signs from their history and other exam findings are kind of pointing me in that direction, then I will definitely take a look at a lot of those findings. In the pediatric population, then that’s something that I’ll jump to straight away, because I know that’s one of the areas that will point me in the right direction pretty quickly.

Then if you had to pick three pearls to give the docs out there, when you have a patient comes in and let’s kind of stick to that pediatric population, and you are suspecting they might have a concussion injury or whiplash injury, what would be three pearls you would say, “Docs, I want you to look at, boom?”

Perfect. So first and foremost is, “Hey, make sure that that patient is safe, because there’s a difference between mild traumatic brain injury, which is a concussion, versus the more moderate and severe traumatic brain injuries.” So one of the first things you just want to rule out is just look at their pupils and see if there’s any anisocoria, making sure that their pupil sizes aren’t terribly asimilar and just make sure that that kid doesn’t have a bleed on the brain. So that’s the first and foremost part, because there’s a lot of docs that are out there, that you guys become that patient’s primary care doctor, right? So if you’re going to be that person’s primary care doctor, then you have to make sure you do your due diligence and make sure that that patient is safe. And if you see any of these red flag signs like anisocoria, the patient has headache that is continually escalating, then just get that person out, get them to the hospital get them a CT scan, make sure that there’s no brain bleeds going on, and just get that taken care of.

The second aspect is once you know that that patient is in the clear, one of the things that I would go to, is those initial primitive reflex responses, especially the Moro’s, if you know that that patient has a really high sensory sensitivity. We talked about the vestibular system, so taking a look at that vestibulo-ocular reflex, because just sometimes training that kid’s VOR might be good enough for them to really start getting better really quickly. And that asymmetric tonic neck reflex is one of the ones that also jumps up really quickly, as a place where you can intervene really, really fast and get that patient [inaudible 00:19:34] better.

And the last thing is, when it comes to actually adjusting the spine of a patient that has had a concussion or whiplash, there’s patients that do great with more heavy-handed adjustments, but then when some other patients have some of these higher sensitivity issues, it’s probably a good idea to start more low force and then work your way back up. So let’s just say that you are a full spine practitioner, you’re more of a hands-on adjuster, you know, it’s probably not bad to just take some sustained contact type style of adjustments if you don’t have something like an activator and pulse device. So treat it like you would adjust an infant and just hold a static contact right on their upper cervical spine and then watch how their autonomics change when you’re just holding that contact on there, as opposed to actually applying a thrust.

Because from my bias, we do NUCCA, so most of our adjustments feel like just a static contact on the person’s neck, anyway, and you can see magic happen really fast, because you can always add more force if you need to, but it’s very hard to take that away, if that extra force just overstimulated that person’s brain. And it’s not to say that you injured that patient, but that person’s brain just might not have been ready for that adjustment at that moment in time, so you start slow and work your way up towards doing something that that patient can tolerate. And that would be my biggest takeaways for the pediatric population.

That’s great. And that those are really important pearls, you guys out there, because an adjustment is a huge metabolic blast to the brain. And so after these injuries, we’ve got this inflammatory load and there’s a lot more hypersensitivity to input. So low, slow, and safe is kind of a good motto. So, rule out any bleeds, and I know this might be a little controversial in some states. Do you ever check the ears for any blood in the canals?

I don’t. I don’t look inside the years, but I’ll definitely do a surface check. I’ll make sure that there’s no clear fluids coming out of the nose or the ears, just to rule out any cerebrospinal fluid problems that might be leaking out. And if there’s any obvious abrasions and stuff like that, then I’ll get that checked out further. Fortunately, knock on wood, I haven’t run into any of these situations where I’ve had to refer for that scenario, but I’m well-prepared to make that referral when I need to.

Yeah, unfortunately I’ve had to do that out here in Idaho. You know, it’s a big winter ski environment and I’ve had some really traumatic brain injuries, was actually sad. They went to the ER, they got dismissed and they had a number of concerning symptoms. They ended up in my office and they’ve had hemorrhages and skull fractures and it can be quite the scary scenario. So let’s talk a little bit. So we got three great pearls there. Rule out bleeds. Look at pupil size and dilation. You’ll see these kids come in oftentimes, just those pupils are huge and they’re on that sympathetic dominant state. Go low, slow, and safe. You’ve got to check the vestibular system, guys because vestibular and visual are going to be huge, and the primitive reflexes that Dr. Jon talked about. Can you touch on what you’re seeing in regards to association with dysautonomia?

Yeah, so that’s one of the cool things that has come out in the concussion literature probably in the last 10 years or so, is that they’re finding that a lot of patients who have suffered concussion, especially that have had persistent symptoms that are going beyond 30 days. A lot of them have POTS, syncope, or orthostatic hypotension. And one of the things that Dr. Leddy has been talking about at the University of Buffalo is that a lot of people with these metabolic injuries to the brain, is that their brain is not prepared to take on this increased metabolic capacity. So you can actually make a case that an acute concussion in those days right after an acute concussion, that that brain is in a state of dysautonomia, because it can’t handle the load that the body is placing on it. And doing something like sub-symptom threshold exercise, is a way where you can help that patient start to progress out of that dysautonomia in those early phases of concussion.

And the reason that this is a cool thing for us, is because you know we love talking about the brain-gut axis, we love talking about the vagus nerve, and all of that really comes into play with this, too, because someone that has a traumatic brain injury, their gut lining is also going to be dysregulated as well. So one of the places where you can adjust the person from a long-term perspective, is start to fix their gut after they’ve had a concussion, so that that gut-brain axis is intact and the gut issue doesn’t also reinforce a bad blood brain barrier. The other things that we could start to look at, is just really start testing autonomics really closely. I measure HRV in all my concussion patients. I’m looking at pupil sizes and pupil reactivity in all my patients, and not only is this a way for you to show the patient, “Hey, look your kid’s autonomic nervous system is working better.” It also tells you how effective the things that you’re doing for that patient, is working for them.

So if you see that that person’s HRV starts to go up, as you start to take care of them, you know that your adjustments or your therapies are probably in the right line, along with the patient getting better physically. And then if you start to see that it’s tanking, then you might say, “All right, you know what? We probably overdid it too much on this session. Next time you come in, we’re probably a dial it down and take it a little bit slower.” Maybe what we use on those lower force contacts or you just modify whatever you need to do in order to make sure that their autonomic system can tolerate the things that you’re doing to them.

That’s a great point. That’s a great point, because they will go into overload a lot quicker. So as you’re working on them, if you see the heart rate variability go up, you know that they can adapt to that. Their nervous system can make room to adapt to that. But like Dr. Jon said, if you see it tank, you know you’re putting them over that threshold and you don’t want to throw them, because then they’re going to end up in that sympathetic shift again and [inaudible 00:25:58] more pro-inflammatory state, which contradicts what we’re trying to do to get the inflammation off the system.

And even if you want, you can just get a pulse ox and just put them [inaudible 00:26:07] and do some of your rehab with them or do some of your adjustments with them and see if the pulse ox is staying steady. If you see it tank, then you’re like, “All right, you know, we probably did too much.” If you see it’s holding steady, then it’s a sign that you’re doing well. So, use tools that cost nothing.

Yeah. You can get them on Amazon for a couple bucks. It’s not that much, you guys out there. It’s a very easy monitoring tool to use.

Absolutely.

Especially, we’ve got to remember the pediatric population, those little fiddle farts, they don’t know how to express themselves well. Our adults can say, “I’m starting to feel a little dizzy or I’m starting to get a headache or get overwhelmed, where in a pediatric population, they can act out. But I think one thing we also need to be savvy on is looking, especially on vestibular overload, they might turn pale, might start to flush or perspire. They might get hiccups. I find with the pediatric kiddos, sometimes they’ll start getting hiccups-

That’s an interesting one.

Yeah, or start sighing or yawning a lot. That means that you’re pushing that vestibular system, so, you need to get it back down.

Yeah, for sure. Yeah, and just look at their eyes, too. If you see that their eyes are starting to kind of glaze over or you’re seeing them starting to go upwards on the patient, then yeah, back off a little bit.

Yeah. I say when they start looking like a drunken sailor, you know, that glazed look. You’re like, “Ah, that’s it.” Sometimes these little five-year-olds walk and they’re starting to go and they look like you’re getting them drunk and you’re like, “I swear I’m not giving them alcohol.” They’re just [inaudible 00:27:45]. But this is such incredible information. I think it’s so huge for us on many realms because A, we are the spine experts, right? And we are the [inaudible 00:27:54] in that cervical spine and thank you for bringing up the gut-brain axis, because the research out there does show that after a head injury, it does start the gut dysbiosis and it changes those tight junctions. So it has an effect on zonulin, right, on the tight junctions.

And so it’s incredibly important that I think if you’re not comfortable doing it in your office, any gut work, work with somebody, another chiro in your community that’s like, hey, I like to do the nutritional component, or an MD or something. But you supporting the gut. What other, just as a wrap up, are there other key nutritional anti-inflammatories that you like to use, to start getting some of the inflammatory load down, because we need to get omegas on, we need to get the fats on board.

For sure.

What else are some of your go-to’s?

So during the acute phase, I actually let the inflammatory phase just kind of run its course because they show that the inflammatory phase and the acute phase is really important for tissue healing and tissue responses in the early phase. But once people get beyond 10 to 14 days, then I’ll start to look at some of the boswellia, I’ll start to look at some of the turmeric and boswellia complexes, the omega threes. The omega threes, there’s some tentative evidence that suggests that omega threes can be a prophylactic for football players. They’ve shown some studies that one of the markers of traumatic brain injury in football players, even before they had a concussion, if you’d take DHA, that those biomarkers actually start to go down a little bit. So it might be something that it can help prevent some of the long-term consequences of hitting your head repeatedly.

So that’s one that I look at. Ketogenic diet is showing a little bit of promise in the handful of anecdotal reports. So ketosis for patients with some long-term consequences of traumatic brain injuries, one of the places I would start to look at as well. And you know, compliance is always the toughest part with that, especially if you’re dealing with the pediatric population, but that’s another tool in your tool belt, where having the patient generally go into ketosis and starting to use some of the things that help drive ketosis, might be one of those things that can help the brain recover and reduce that inflammatory load long-term.

The other thing I just want to throw out there is, I know the sphenoid is very much affected. So if any of you guys do cranial work, the sphenoid, because they see that pituitary stock can jar in that sella turcica, so we can also see some hormonal dysregulation down the road.

Yes, for sure.

Yeah. So this is great, great stuff, you guys out there listening in. I want to pick your brain real quick about in 2018 when the FDA approved the blood test, looking at glial proteins and ubiquinol proteins, do you refer for that very much?

I don’t. So the main thing behind that blood test, is to decide that if they need to do a CT scan or not because, basically, that blood test isn’t really to diagnose concussion, it’s to help separate does this person have a likelihood of a brain bleed versus do they not? And the problem with that test as of now, is that the results can take a little bit of time and if that person is having a brain bleed, then that’s not necessarily something that you want to worry about, anyway. So the testing of it is still a work in progress to try to figure that out. But it’s probably something that’s hopefully down the line and will save people from needing some of these heavy dose CT scans and you could bypass it a little bit by using the blood tests. But, as of now, there’s not really a biomarker to say, hey, this person has a concussion versus they don’t.

Awesome, awesome stuff. Again, thank you so much for taking … I know you’ve got a busy, crazy schedule and you’ve got now that new little beautiful little fiddle fart, and you made time in your schedule to hang out with us and give this incredible information. So if they want to find out about your course, tell them to go where again?

So you could go find out about my course at protecttheneck.com. You can also sign up for an email newsletter where I pump out different emails about different head injury cases and I break down some of the research behind head injuries and the cervical spine and you can take a look at some of the stuff there. And then I’ll announce the date for our next head injury toolkit seminar, sometime in the next month or so, so be on the lookout for that. And then if you ever want to chat with me on social media, I’m pretty active on Instagram and Twitter. You can follow me at Dr. Jonathan Chung and I’m pretty responsive to that or you can find on Facebook, too.

Yeah, and he always posts some great research and we like to play back and forth with that research so he’s the man to go to. So, hey doc, thanks again, I appreciate it. And all of you guys out there listening in, thanks so much for joining us. And again, ChiroSecure, thank you for giving us this platform and giving us this ability to get this incredibly important information out to our colleagues and to the general public, because we need to be out there in full force, changing the tide, spreading our message, and giving hope to more and more families and children for generations to come. And we’ll see you next month for an incredible guest, Dr. [inaudible 00:33:19] Slack is going to join me as my guest and-

Oh, nice.

I know. Yes, the first Thursday of the month is the incredible Erik Kowalke, that gives you tons of pearls and tips to get out there and be the ultimate in your communities. And so till next month, you guys all have an incredible month and keep changing lives.

Thank you.

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