Acupuncture for Recovery from Pediatric Sport-Related Concussion

Abstract

Background:

Sport-related concussion is a major concern for young athletes because a growing number of children participate in sport-related activities. Postconcussive symptoms can lead to physical, academic, and social impairment. There is no definitive treatment for sport-related postconcussive symptoms, and most available pharmacologic therapies have potential side-effects.

Cases:

The aim of this case report is to describe the use of acupuncture in the management of sport-related postconcussive symptoms in 3 pediatric patients. All 3 patients presented with chronic postconcussive symptoms that did not improve with conventional treatments alone. A retrospective chart review was performed from 2012 to 2015 on the 3 patients who received acupuncture in a tertiary pediatric pain clinic for postconcussive symptoms. Demographics and results from the Numerical Rating Scale, a postconcussive symptoms questionnaire, and the Brief Pain Inventory were included in the review.

Results:

All 3 patients experienced satisfactory symptomatic reduction following acupuncture treatment.

Conclusions:

Acupuncture with conventional medication appeared to reduce the postconcussive symptoms in the 3 patients.

Introduction

Sport-related concussion, a type of mild traumatic brain injury (TBI),¹ is a serious national public health issue. Concussions are common in youth contact sports, such as ice hockey² and football,³ and represent nearly 15% of all sport-related injuries among high-school athletes.⁴ These injuries can have catastrophic outcomes, causing ∼500,000 emergency department visits from children every year⁵ and even causing death.⁶ Sport-related concussive injuries are receiving an increasing amount of attention in the media and are a growing concern for children, families, teachers, coaches, and healthcare providers. As children are encouraged to participate in sports and exercise to combat the rising threat of obesity in our largely sedentary modern society, they are also increasing the risks of concussion and other sport-related injuries. Although a tremendous amount of research and much advancement have focused on athletic concussion in the adult population, there is less known about this injury in the pediatric population.⁷

Concussion is a brain injury resulting from impact to the head and biomechanical forces that disturb normal brain function.⁸ The International Consensus Conference on Concussion in Sport has compiled a list of several possible characteristics of concussion, including rapid-onset short-lived impairment of neurologic function, neuropathologic changes, and a range of clinical symptoms that may resolve or be prolonged.⁸ Postconcussive symptoms include headache, dizziness, difficulty with concentration and mental tasks, impaired memory, fatigue, insomnia, and irritability. Patients may also have decreased tolerance to stress, emotional excitement, or alcohol.⁹ Loss of consciousness is not required for a diagnosis of concussion, as loss of consciousness occurs in <10% of concussions¹⁰ and is not a reliable predictor of concussion severity.¹¹ The most commonly reported symptom of concussion is headache.^10,12–14 The headaches can be persistent and severe; can worsen with physical and cognitive exertion; and can interfere with daily life activities and social interaction. Most children with concussion heal rapidly within days to weeks.⁴ However, many of these children have prolonged symptoms that are often difficult to treat.

Acupuncture is part of a 2000-year-old history of traditional Chinese medical practice. Research on acupuncture has allowed for its integration into conventional medicine areas, such as anesthesia and pain management.¹⁵ Linde et al. concluded that acupuncture should be considered as a treatment option for patients who have headaches and who are interested in exploring acupuncture's benefit. Compared to conventional prophylactic therapies for migraine headaches, acupuncture is just as—or even more—effective and has fewer side-effects.¹⁶ Acupuncture also can be a valuable nonpharmacologic tool for treating patients with frequent episodic or chronic tension-type headaches.¹⁷ Many patients suffering from headache after concussion seek relief through over-the-counter medications, which do not provide pain relief for the majority of these patients.¹⁸ Headache is one of the most common postconcussive symptoms. Several studies have shown that acupuncture provides benefit for adults with TBI and concussion,^19,20 but there is limited information on the pediatric population. This case report aims to describe the integration of acupuncture for treating headaches and other symptoms following pediatric sport-related concussion.

Cases and Results

Materials and Methods

A retrospective review of 3 patient cases was performed wherein their demographics were recorded as well as their results from the Numerical Rating Scale (NRS), a Brief Pain Inventory (BPI), and a postconcussive symptoms questionnaire.

Patients were referred from a pediatric sports-medicine clinic after comprehensive evaluation by sports-medicine specialists. Pediatric anesthesiologists and pain specialists trained with at least 10 years of experience in acupuncture medicine administered the acupuncture treatment at a tertiary pediatric-pain clinic. Written acupuncture treatment consent was obtained prior to the treatment. An administrative associate collected the data from the NRS, the BPI, and a postconcussive symptoms questionnaire. Patients were recommended for 5–6 weekly acupuncture sessions. Additional sessions could be scheduled if the patients wanted more acupuncture treatment. In addition to the acupuncture treatment, all 3 patients continued to receive conventional medical therapies.

The acupuncture treatment protocol was based on Traditional Chinese Medicine (TCM). Disposable sterile SEIRIN® acupuncture needles (Shizuoka-shi, Shizuoka, Japan) with tube size No. 02 × 30 mm were used. The depth of the needle insertion was 5–10 mm. The needle was manually manipulated until De Qi was achieved. Acupuncture needles were left in place for 15 minutes. At the same time, low-frequency 2-Hz electrostimulation using ITO Physiotherapy and Rehabilitation IC-1107+ (Toyotama-Minami, Nerima-ku, Tokyo, Japan) was applied at ST 36. The acupuncture needles were removed with no apparent complications. Cupping, using valve cups, and gua sha were applied at the Back Shu points. There were no adverse events.

All 3 pediatric patients presented with chronic postconcussive symptoms that did not improve with conventional treatments alone. Following treatment with acupuncture, the patients had decreases in headache pain scores and cognitive, emotional, and physical improvements. The patients returned to their physical, social, and school activities. After acupuncture treatment, the average headache pain scores decreased from 7 to 0 out of 10 for Case I; from 6 to 3 out of 10 for Case II; and from 7 to 2 out of 10 for Case III (Table 1). The mean decrease in average headache pain score for the 3 patients was 5.0 ± 1.2 (mean ± standard error of the mean).

Table 1.

Changes in NRS Pain Score

	NRS Pain Score
Case	Baseline	Post-treatment	Change
I	7	0	7
II	6	3	3
III	7	2	5

NRS, Numerical Rating Scale.

Case I

An 8-year-old boy, who was an active ice hockey player, was referred for evaluation and treatment following his first lifetime concussion. He sustained a head injury at hockey practice, during which he fell, hit his head on the ice, slid into the boards, and then hit the top of his head. He did not lose consciousness but developed significant persistent headaches. The headaches were generalized throughout his head and worsened with lights, noise, schoolwork, computers, reading, watching television, walking, and exercise. His pain score was 7 out of 10. In addition to daily headaches, the patient reported dizziness and fatigue. He was unable to read because of his headache and dizziness. He went to bed 1–2 hours earlier than usual and was sleeping longer than usual, getting nearly 12 hours of sleep per day. He had no history of snoring or sleep disturbances and had no changes in appetite. He could not climb stairs because he felt unsteady while walking and had difficulty moving from a supine to a standing position or from a sitting to standing position.

Upon examination, it was noted that this patient had an unsteady gait. He was unable to close his eyes and bring his arm up into a steady position. He had abnormal proprioceptive sensations and a positive Romberg sign. Magnetic resonance imaging (MRI) of this patient's brain revealed a 2-mm area of signal abnormality in the left thalamus; however, this was an incidental finding, and the abnormality was stable.

He received physical therapy. His medications included acetaminophen, ibuprofen, and amitriptyline (20 mg per day). Initially, he was not able to attend school or participate in any physical activities. He was eventually able to attend school part-time but still was unable to participate in any sport-related activities.

Pediatric concussion specialists did a full evaluation of this patient and referred him 1 month after his concussion for acupuncture treatment. The primary acupuncture points used for treatment of his postconcussive symptoms included the following bilateral points: LI 4; ST 36; LR 3; TE 5; and Ashi points. Immediately after the first acupuncture session, he felt significant relief. At the second session, he reported that his average headache pain decreased from 7 out of 10 to 3 out of 10. At the third visit, he noted complete resolution of mood disturbances, and his pain score decreased further to 2 out of 10. At the fourth visit, he reported that he had returned to normal daily activities, including going to school, and his pain score was decreased to 1 out of 10. He started to taper off amitriptyline. At the sixth treatment, many of his physical symptoms—including blurry vision, dizziness, double vision, fatigue, headache, light sensitivity, nausea, and noise sensitivity—were reduced. He had reduced cognitive and emotional symptoms, such that he no longer had poor concentration or took longer time to think, and he felt less depressed.

Overall, this patient's average headache pain score decreased from his initial score of 7 out of 10 to 0 out of 10 over the 6 treatment sessions. His neurologic examination results returned to normal. He reported that he felt he was doing very well with the acupuncture treatment, his family was very pleased with his progress, and he no longer used any medication.

Case II

A 15-year-old female field hockey and lacrosse player presented to the clinic 1 month after her second lifetime concussion. Her first concussion had occurred 2 years prior after she had been hit in the head with the ball while playing basketball. She recovered from her first concussion within 2 weeks. This second concussion occurred when she was elbowed in the face during a field hockey game. The patient had a nasal injury with swelling, although she did not develop any specific symptoms at that time. She woke up the next day with a headache. This was localized to her forehead and sometimes at other spots around her head; at other times, she felt sharp pain at particular points along her head. She had headaches every day throughout the day and rated her pain score as 5–6 out of 10 on the NRS. Her headaches started in the early morning and worsened with schoolwork and throughout the day. She felt better with rest and on the weekends, but her headache never completely resolved.

This patient felt fatigued, had mild sensitivity to light, and suffered from dizziness. Whenever she closed her eyes, she felt a spinning sensation. She had issues with eye tracking and when riding in a car. She had sleep disturbances, including difficulty falling asleep. When undergoing Balance Error Scoring System (BESS) testing, she immediately fell over, made multiple errors in the test, and was unable to complete it. Her cognitive symptoms included poor concentration and caused her to require extra accommodations at school, such as reduction of computer time and extra time to complete her work. She had a history of anxiety, and, after her concussion, she continued to have moderate feelings of anxiety or nervousness.

Her brain MRI revealed no abnormalities or clear etiology for her ongoing headaches. She took acetaminophen every day, ibuprofen only for severe headaches, and amitriptyline (20 mg) every day, but these medications provided minimal improvement. This patient did not participate in any physical activities. She received physical therapy and vestibular therapy but did not notice any significant improvement.

This patient was referred for acupuncture treatment 1 month after her second lifetime concussion. The primary acupuncture points used for treatment of her postconcussive symptoms included bilaterally: LI 4; ST 36; LR 3; TE 5; SP 6; Yin-Tang; and Ashi points. After each acupuncture session, she felt headache reduction or even resolution. At the second session, her average pain score was 4 out of 10. At the fourth session, she reported that she would wake up in the morning without a headache. At the sixth session, the patient reported reductions of physical symptoms, including less fatigue and sensitivity to light; however, she continued to experience dizziness. Emotional symptoms, such as frustration, were also reduced. Her pain decreased from her initial pretreatment score of 6 out of 10 to 3 out of 10. Her mood improved and returned to normal by the sixth treatment session. This patient noticed improved functional levels in daily life activities, including schoolwork, and she reported that she felt that the acupuncture was beneficial for her symptom management. By the end of the 6 acupuncture sessions, she was able to reduce her amitriptyline dose to 10 mg per day.

Case III

An 18-year-old female soccer player sustained her first lifetime concussion when she was kicked in the back of her head during an indoor soccer game. After this incident, she immediately developed a headache. This patient had a previous history of headaches for the past 2 years; these headaches were localized over her forehead, behind her eyes, and in the occipital region. The headaches occurred a few times per week and would last from 1 to 3 hours. Her new postconcussive headaches occurred in the same location, but they were more painful and persistent. During the inciting injury at her soccer game, she did not lose consciousness but felt dizzy, fatigued, and was light-sensitive. She denied having any nausea or vomiting, and she sat out the rest of the first half of the game but continued to play in the second half. As she continued playing, her symptoms worsened.

The next day, she continued to note persistent headache, fatigue, dizziness, photophobia, and phonophobia. The following day, while she was riding an all-terrain vehicle, the vehicle rolled over, she hit her chest, and she suffered from rib pain afterward. Although she did not hit her head in this accident, her headache symptoms worsened. She rated her headache pain as 5–7 out of 10 all day, every day. Her pain was reduced with sleep, although she reported waking up with continued headaches that were still rated 5–7 out of 10. Her headaches worsened whenever she stared at a computer or television screen.

The patient took a few days off school initially and then returned for partial days with frequent breaks throughout the day. At school, she required more time to complete her work and was falling behind in her studies. She had cognitive symptoms, such as poor concentration and taking longer to think. Her emotional symptoms included frustration and irritability. She could no longer play soccer; had vestibular, vision, and sleep disturbances; and experienced low energy. She was seen by an ophthalmologist for trouble with visual tracking, but her examination results were normal with 20/20 vision.

For her previous chronic headaches, she had tried several different medications, including amitriptyline, nortriptyline, topiramate, and Magnesium l-Threonate, without any benefit. For the new headache resulting from her concussion, she took ibuprofen as needed ∼2 times per week but experienced minimal relief. She had also started physical therapy twice per week, which helped relieve her neck tension.

The patient was referred for acupuncture treatment 1.5 months after her new concussion. She had tried almost every available therapy, and nothing had worked. She received 14 weekly acupuncture treatment sessions. The primary acupuncture points used to treat her postconcussive symptoms included the following bilateral points: LI 4; ST 36; SP 6; LR 3; TE 23; GV 20; Yin-Tang; TE 5; LI 11; ST 7; BL 4; BL 6; TE 9; GB 21; GB 20; and Ashi points.

At the first session, the patient reported an average headache pain score of 7 out 10. At the second session, she no longer complained of irritability, and her average headache pain score was 6 out of 10. Immediately after the second acupuncture treatment, the patient noted that she had no headache at all. She resumed full days of school and still took a few breaks during the day but was taking far fewer breaks. She was able to do some homework and could handle one or two assignments per day. Because she had accumulated significant make-up work, she felt stress. At the fourth session, her double vision and fatigue had resolved. At the fifth session, she no longer had dizziness or noise sensitivity. At the sixth session, her blurry vision, light sensitivity, and frustration were gone, and she no longer had these issues in subsequent visits. At this time, her average headache pain score was 4 out of 10. At the seventh session, she no longer complained of forgetfulness and was able to tolerate screens and light.

At this time, she was graduating from high school. She awaited her return to soccer eagerly and expressed her hope to play on her college soccer team. Over subsequent acupuncture treatments, she continued to have low-grade headaches that gradually decreased in frequency. Eventually, she was cleared for all school and sports activities. Her headache pain score was 3 out of 10 at the twelfth session. She continued to have satisfactory results, and, at her final session, her pain score was 2 out of 10. Overall, she felt that receiving acupuncture on a consistent basis was tremendously helpful for alleviating her postconcussive symptoms.

Discussion

Pediatric patients with mild TBI or concussion are an especially important subset of patients to study, as this young population is particularly susceptible to brain damage.²¹ Having just one concussion makes an athlete three times more likely to sustain a second incident,¹⁰ and children with histories of prior concussions have longer durations of symptoms.²² In children, symptoms following a concussion can impair brain functioning and have profound and long-lasting effects in multiple avenues of their lives. The symptoms disrupt learning and academic abilities; children who have not yet recovered from postconcussive symptoms experience more severe impedance with academics and more academic difficulty than children who have recovered.²³ Neurocognitive impairment can persist even when an athlete no longer reports symptoms from a sport-related concussion.²⁴ Emotional symptoms from pediatric sport-related concussion can engender suicidal thoughts, exacerbate preexisting psychiatric disorders, and contribute to the development of novel psychiatric disorders in children.²⁵ Thus, proper management and adequate treatment of postconcussive symptoms are crucial for minimizing long-term health risks and optimizing future health for such a patient.

Treatment of pediatric postconcussive symptoms requires a multidisciplinary approach. Nonpharmacologic treatments include rest, physical therapy, cognitive–behavioral therapy, and meditation, all of which have limited evidence for effectiveness in managing postconcussive symptoms.²⁶ There are very limited studies on the efficacy of any pharmacologic treatments for pediatric postconcussive symptoms,^27,28 and many such pharmaceuticals produce adverse side-effects.

Acupuncture has been found to provide benefit for TBIs and concussions in several studies in the adult population. Some studies that included children enrolled mostly adult patients and aggregated pediatric and adult data, so the effects of acupuncture solely on pediatric patients could not be ascertained.^29,30 Research on acupuncture treatment in 90 cases of brain concussion sequelae resulted in cure with no relapse for nearly 20% of patients and improvement in nearly 40% of the patients.²⁹ In a study of acupuncture therapy for 12 cases of cranial trauma, including 1 case of concussion, all patients had reductions in symptoms, including recovery of consciousness, speech, and bodily functions.³⁰ In the same study, one third of the patients had full recovery from sequelae of cerebral concussion or acute cerebral contusion and laceration and became completely independent following the acupuncture treatment.³⁰

A case report on a 22-year-old man with severe TBI from a snowboarding incident noted that, after acupuncture treatment over a 4-year duration, the patient was able to regain motor function, speech, and vision.²⁰ Furthermore, a retrospective cohort study showed that adult patients with TBI who had acupuncture treatment had a decreased number of emergency-room admissions and hospitalizations in their first year post injury, compared to similar patients who did not receive acupuncture treatment, thereby providing further evidence of the benefits of acupuncture treatment in patients with TBIs.¹⁹ Thus, the literature on acupuncture and head injuries suggests that acupuncture can be helpful for patient recovery.

The TCM perspective provides many potential explanations—through theories of energy flow in the body—for how acupuncture can alleviate postconcussive symptoms. Acupuncture is intended to correct imbalances in Qi of the body. In TCM, postconcussive symptoms result from various possible imbalances in Qi. Possible causes for the clinical pattern of postconcussive symptoms include hyperactivity of Liver Yang, Kidney Essence Deficiency, Qi and Blood Deficiency, Phlegm Turbidity Obstructing the Middle, and Blood Stagnation.^31,32 Hyperactivity of Liver Yang produces headache, dizziness, frustration, short-temper, insomnia, and/or flank pain.³² Symptoms of Kidney Essence Deficiency include headache and emptiness, lightheadedness, lumbago, fatigue, and insomnia.³² Qi and Blood Deficiency engender light headache, frequent tiredness, palpitations, and/or poor appetite.³² Phlegm Turbidity Obstructing the Middle can cause chest fullness, nausea, vomiting, increased sputum, and headache associated with unsteadiness.³² A history of direct head trauma can increase risk of Blood Stagnation, which can lead to prolonged headaches that do not respond to treatment, localized pain that does not change location, and stabbing pain.³² By restoring balance in the body, acupuncture can be useful for facilitating recovery from postconcussive symptoms.

The rationale for the acupuncture point selection for the patients in the current case series was adapted from Sun as follows.³³ LI 4, the Source point of the Large Intestine channel, was chosen because this point regulates the Qi circulation and relieves pain. ST 36, the Sea point of the Stomach channel, activates the Stomach and tonifies the Qi and the Blood. LR 3 is a Source point that promotes Liver Qi circulation and regulates the function of the Liver channel. TE 5, the connecting point of the Triple Energizer Channel, regulates Qi circulation and eases headache symptoms. SP 6 promotes the circulation of Qi and eliminates Damp. Yin-Tang and GV 20 calm the Mind and regulate the circulation of Qi. LI 11 is the Sea point of the Large Intestine and relieves headaches. ST 7 dispels Heat, harmonizes the collateral of the Stomach channel, and eases pain. GB 20 and GB 21 clear Heat and relieve the spasm and tension in the Gall Bladder channel. Ashi points promote circulation of Qi.³³

The current case series had limitations. Postconcussive symptoms are quite complex, so there is no single TCM diagnosis that fits every patient and, thus, no standard combination of points for every individual. All of the patients also received conventional Western therapy. As this was a retrospective chart review, long-term follow-up of the patients was not included in the study, and there was no option to assign patients randomly to an acupuncture treatment group or to a control group. Therefore, it was difficult to determine whether patient improvements were the result of acupuncture treatment alone or the result of the natural progression of postconcussive symptoms.

Conclusions

Three pediatric patients, ages 8–18, who received acupuncture treatment for headache and other symptoms caused by sport-related concussion reported improvements. Previously published evidence on adult patients suggests that acupuncture is beneficial for aiding recovery from TBI. The current case series indicate that pediatric athletes recovering from postconcussive symptoms may experience therapeutic benefit from integrating acupuncture with conventional management of pediatric sport-related concussion. Further randomized controlled trials are necessary to examine the role of acupuncture in pediatric sport-related postconcussive symptoms.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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