The following scenario exists only in my imagination. While these specific patients are unlikely to appear in any of our offices, their clinical presentations are plausible. I invite you to assess the implications of the following thought experiment.
Jesse James and his brother Frank are partners in various illegal business ventures. Both came under your care for back and neck pain a few weeks ago. (They pay cash! No insurance paperwork!) Both suffered concussions during a violent episode (the details of which have not been revealed to you for some reason) approximately seven months ago. They both recovered from all symptoms in a week or two without intervention. During their most recent visits, in addition to neck and back pain, they have both been complaining of fatigue.
They both go to the same primary care physician, who offered no specific diagnosis for the fatigue, but suggested they undertake a less stressful and tiring method of making a living.
You ask Jesse if he has noticed a reduced sex drive recently. After calling you a number of unflattering names, he angrily denies this symptom, and asks you if you have any other stupid questions.
You reply, "Yes, have you noticed any changes in your appetite and food choices?" Jesse calms down and considers this thoughtfully. "As a matter of fact," he replies, "I can't seem to put enough salt on my food these days."
Frank answers no to both of the questions you asked Jesse. You go on to ask whether or not he has been feeling unusually hot or cold lately. Frank replies: "As a matter of fact, I seem to want a sweater or a jacket when everyone else in my gang (oops, I meant company, not gang) seems to be comfortable."
What's Going on Here?
Post-concussion chronicity has many manifestations. Emerging research indicates depressed pituitary function can emerge months or years after a concussion. In effect, concussion can function as a pituitary dimmer switch. Because the pituitary influences many other endocrine glands, the clinical picture of hypopituitarism can include symptoms related to low levels of human growth hormone, antidiuretic hormone, thyroid hormones, adrenal hormones, the estrogens or the androgens.1-5
If Jesse James had answered yes to the libido question, it would have suggested low androgen levels secondary to reduced pituitary secretion of luteinizing hormone (LH). His report of salt craving suggests low levels of aldosterone due to hypoadrenia. The sensitivity to cold suffered by his brother Frank suggests hypothyroidism.
Can Chiropractic Help?
I have not found any published reports on chiropractic amelioration of post-concussive hypopituitarism. This is not surprising, as awareness of the concussion-pituitary connection has only recently emerged within the bioclinical community. However, there are several factors that make a positive chiropractic contribution plausible. To illuminate a few examples:
- The sympathetic innervation to the cranial vasculature, including the blood supply to the pituitary, originates with the first five thoracic spinal nerves, with postsynaptic axons emerging from the superior cervical sympathetic ganglion. Therefore, correction of upper cervical through upper thoracic subluxations may be helpful.
- The narrow stalk of hypothalamic tissue that connects the brain to the pituitary (the hypothalamic infundibulum) must pass through a covering of dura mater to reach the gland. (This dural covering is called the sellar diaphragm.) Cranial, upper cervical, sacral and coccygeal adjustments may normalize dural mechanics, thereby reducing mechanical stress on the pituitary.
- Researchers have noted elevated levels of anti-pituitary and anti-hypothalamic antibodies in patients with post-concussive hypopituitarism.5 This suggests an autoimmune aspect to this disorder. Case reports of chiropractic amelioration of disorders with robust autoimmune components such as myasthenia gravis, psoriasis and multiple sclerosis constitute a small, but growing body of evidence consistent with immunological normalization under chiropractic care.6-11
In addition to the chiropractic adjustment, good care for Frank and Jesse James should take into consideration possible co-management with a medical endocrinologist, patient education on the effect of certain prescription and non-prescription drugs, and nutritional considerations.
Editor's Note: Access Dr. Masarsky's previous three articles, which also address concussion, via the Previous Articles section of his DC columnist page. He also offers a seminar for chiropractic associations on concussion as it relates to the vertebral subluxation complex.
References
- Foley CM, Wang DH. Central diabetes insipidus following a sports-related concussion. Sports Health, 2012;4(2):139-141. Full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC3435907/
- Ives JC, Alderman M, Stred SE. Hypopituitarism after multiple concussions: a retrospective case study in an adolescent male. J Athletic Training, 2007;42(3):431-439. Full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC1978466/
- Wilkinson CW, Pagulayan KF, Petrie EC, et al. High prevalence of chronic pituitary and target-organ abnormalities after blast-related mild traumatic brain injury. Front Neurol, 2012;3:11. Full text: www.ncbi.nlm.nih.gov/pmc/articles/PMC3273706/
- Dubourg J, Messerer M. Sports-related chronic head trauma as a cause of pituitary dysfunction. Neurosurg Focus, 2011;31(5):E2.
- Tanriverdi R, De Bellis A, Battaglia M, et al. Investigation of antihypothalamus and antipituitary antibodies in amateur boxers: is chronic repetitive head trauma-induced pituitary dysfunction associated with autoimmunity? Eur J Endocrinol, 2010;162:861-867.
- Araghi HJ. Juvenile myasthenia gravis: a case study in chiropractic management. Proc Int Conference on Pediatrics & Chiro (ICA), 1993:122-131.
- Alcantara J, Steiner DM, Plaugher G, Alcantara J. Chiropractic management of a patient with myasthenia gravis and vertebral subluxations. JMPT, 1999;22:333-340.
- Elster EL. Upper cervical chiropractic management of a multiple sclerosis patient: a case report. J Vertebral Subluxation Research, 2001;4(2):22-30.
- Elster EL. Eighty-one patients with multiple sclerosis and Parkinson's disease undergoing upper cervical chiropractic care to correct vertebral subluxation: a retrospective analysis. JVSR, 2004:1-9.
- Killinger LZ, Azad A. Multiple sclerosis patients under chiropractic care: a retrospective study. Palmer J Research, 1997;2:96-100.
- Behrendt M. Reduction of psoriasis in a patient under network spinal analysis care: a case report. JVSR, 1998;2(4):196-200.
Click here for previous articles by Charles Masarsky, DC, FICC.