Monograph 14 ~ INJURIES TO THE EYE AND EAR
 
   
Monograph 14

Injuries to the Eye and Ear


By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Copied with permission from  ACAPress


Injuries of the Eye and to Vision
   Injuries of the Lids and Conjunctiva
   Orbital-Bridge Lacerations
   Injury of the Eyeball
   Traumatic Cataract and Complications
   Contact Lenses in the Unconscious Victim
   Corneal Trauma
   Foreign Bodies
   Eye Injuries Produced by Indirect Trauma
   Retinal Injury
Injuries of the Ear and to Hearing
   Cauliflower Ear
   External Ear Disorders Associated with Water
   Miscellaneous Disorders of the External Ear
   Trauma-Related Middle Ear Disorders
   Trauma-Related Inner Ear Disorders

References and Bibliography


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INJURIES OF THE EYE AND TO VISION

Good vision is vital in sports and most occupations, although the blind have accomplished remarkable tasks. Good vision is necessary to follow a monitor screen, read a dial, observe a moving object, etc, and perceive subtle movements of a sports opponent. In athletics, good vision is equally a safeguard from injury in anticipating a defensive move in contact sports. Badminton and racketball, especially, have a high incidence of eye injuries, usually occurring in inexperienced or nearsighted players not wearing safety glasses.

The clinical picture may be one of commotio retinae, corneal abrasion, hematoma and laceration of the lid, hyphema, traumatic mydriasis, and vitreous and subconjunctival hemorrhage. Eye injuries also have a high incidence in basketball, especially where jumps under the backboard place the eye in jeopardy of an opponent's fingers or elbow, or even of the ball.

Some cases have been reported of explosive ocular injuries as the result of curious children cutting into a liquid-center golf ball (2000-2400 psi) containing suspensions of metal. Concussion to an eye frequently results in anterior and/or posterior chamber hemorrhages. These may be noticed on gross inspection, but any complaint of blurred vision requires careful ophthalmoscopy. Slow bleeding may require several hours to obscure vision. Except for the most minor eye or visual injuries, ophthalmologic consultation should be sought.


Injuries of the Lids and Conjunctiva

Inspect lids for cuts, edema, and skin changes. Note position of the lid relative to the anterior orbit and record degree of ptosis. Evaluate degree of exophthalmos or enophthalmos and the distance between orbits. Inspect for conjunctival edema, pallor, foreign bodies, petechiae, and vascular injection both on the anterior eyeball and posterior lid surfaces. Note any conjunctival congestion, bogginess and episcleritis.

Abrasions and Lacerations.   Conjunctival abrasions usually result from dirt or an opponent's fingers. A severe concussion to the orbital area usually results in injury and edema to the affected lid. Swelling may be so severe that the lid cannot be opened by either the patient or doctor. If this occurs, the patient must be referred to an ophthalmologist without further evaluation. Hematomas of the lid always require the exclusion of an associated orbital fracture. Proptosis after injury may be associated with retrobulbar hemorrhage.

Traumatic splits in the lid may expose deep tissues. These require immediate cleaning, covering with a sterile pad, and referral for suturing. Linear splits in the lid or a torn tear duct usually require the attention of a plastic surgeon because they take special surgical experience to avoid trouble for many years. If a vertical split through the circular lid muscles and the palpebral cartilage is not repaired expertly, a troublesome V-notch lid scar can result.

Subconjunctival Hemorrhage.   When the eye is struck with a fist, elbow, knee, ball, puck, or any blunt object larger than the eyeball itself, the result is usually swelling, eyelid ecchymoses, and bright-red subconjunctival hemorrhage. Other causes include harsh rubbing with a finger or nicking the conjunctiva with a sharp object. There is usually no visual disturbance or eye pain. Although frightening in appearance, the patient should be reassured that subconjunctival hemorrhage is not serious and will disappear in 10-15 days. As with any subcutaneous bleeding, cold packs should be applied initially, followed by warm compresses in the late stage. Specific medications are not required according to Grant/Cinotti and Williams/Sperryn.


Orbital-Bridge Lacerations

One of the most common facial injuries in sports is that of laceration in the bony-prominent orbital area. The typical face mask protects other areas quite well. Injuries in the supraorbital areas are often deeper than first thought, frequently exposing the bony ridge. During cleaning the wound, never shave an eyebrow for in about 25% of cases it does not grow back or grows back most scantily. Proper suturing often requires a plastic surgeon, as the scar increases vulnerability and each additional scar encourages the accumulation of dense scar tissue (eg, boxer's brow).


Injury of the Eyeball

Severe eye trauma or disease deserves ophthalmologic consultation. It is not unusual to have rupture of the eyeball just outside the corneoscleral margin where the sclera is thinnest. A rupture here is often associated with subconjunctival dislocation of the lens. Hemorrhage is a frequent complication. Mild injuries may produce traumatic keratitis, and severe injuries may cause rupture of the cornea. Rupture of the sphincter of the iris is also common and diagnosed by first finding that the iris is dilated and then by detecting a slight notch in the pupillary margin. Temporary dilation of the pupil may result from sphincter stretching.

Sometimes the iris is torn from its attachment to the ciliary body, producing iridodialysis. Detachment of the ciliary body may occur, thus deepening the anterior chamber at the point of separation. Paresis of accommodation, sometimes observed after injury, may show improvement when acute symptoms subside. The lens is frequently partly dislocated due to partial rupture of the suspensory ligament. Evulsion of the optic nerve may also occur. A well-defined hole may be seen occupying the position of the nerve, corresponding in size to that of the disc.

Prolapse of the vitreous may occur into the anterior chamber, usually producing a shallow anterior chamber in this area. The lens may be dislocated into the anterior chamber, with resulting secondary glaucoma requiring extraction. A traumatic cataract may also result that requires surgical intervention. Rupture of the choroid is not uncommon and usually appears as a crescentic lesion between the optic nerve and the macula. Glaucoma frequently follows eyeball contusion and is one of the most serious complications. It may occur at the time of injury or later. Traumatic enophthalmos appears as a lifeless eyeball in its sunken orbit. The motility of the eye is sometimes seriously reduced. Sympathetic ophthalmia is a rare complication of eyeball contusion.

The retina may be ruptured or detached with or without tear. Commotio retinae may follow injury, resulting in edema of the retina that appears gray and cloudy while the macular region assumes a dark red color in comparison with surrounding retina. In traumatic retrobulbar neuritis, the optic nerve suffers a low-grade traumatic retrobulbar inflammation that may be so slight as to be noted only by careful study of the blind spot (which may be enlarged).


Traumatic Cataract and Complications

Traumatic cataract usually results from a rupture or disturbance of the capsule or lens from any injury allowing the aqueous or vitreous fluid to come into contact with lens fibers. The result is a partial or complete loss of transparency of the crystalline lens or of its capsule.

Traumatic cataracts are usually caused by penetrating foreign bodies, but a blunt blow on the orbit or even to the side of the head may cause cataract. Soon after capsular laceration, the lens fibers near the tear begin to swell and cloud. Later, the lens substance oozes into the anterior chamber and appears as gray fluffy-appearing masses which are dissolved and eventually absorbed on coming in contact with the aqueous. In time, the major portion of the lens substance may be absorbed and the pupil again becomes almost black. In most cases, however, the capsule scars and closes, stopping the process of absorption before liquefaction is fully accomplished.

Many cases pursue their course with few signs of inflammation, but a successful termination is often prevented by the development of an iritis caused either by direct injury or by pressure of loose or swollen lens matter. Septic matter may also be introduced into the eye either at the time of injury or later, which gives rise to an iridocyclitis, a panophthalmitis, and even an orbital inflammation. If not prevented, a secondary glaucoma may supervene.


Contact Lenses in the Unconscious Victim

Contact lenses offer a special hazard with the unconscious or injured person. Here, a warning bracelet or identification card helps to alert first-aid attendants of the presence of the lenses. When possible, ask the injured to remove the contacts, as an awkward search by another party may do more harm than good. For the unconscious victim who is unable to remove the lenses himself, the eye should be examined with a small flashlight. By focusing the beam of light from the side, the edge of the lens will often become visible. Most disengaged contact lenses will be found under the upper eyelid. The doctor places the tip of a finger on the athlete's lower eyelid, pulls down and laterally, then pushes the upper lid against the top of the lens. The lens should eject; if not, a small suction cup can be used for assistance.


Corneal Trauma

Sun or Snow Blindness.   Ultraviolet injury is often seen in prolonged skiing, yachting, welding, and outside work when glasses with filtering lenses do not prevent sustained reflection of the sun's rays from snow, water. or metal. Considerable ultraviolet exposure results in small multiple corneal epithelial erosions.

Concussion.   Concussion injuries (eg, a ball) may result in hyphema with hemorrhage between the cornea and iris from damage to the small vessels of the iris. It should always be considered serious. Symptomatology includes blurred vision, aching eye pain, severe eye redness with intense dilatation of the pericorneal vessels, and photophobia. In a short time, blood settles below from gravity to form a "fluid level." There is danger of secondary hemorrhage into the anterior chamber that may be more dangerous than the initial hyphema. If secondary hemorrhage does not occur, absorption usually takes place in a week.

Hyphema and Hematic Corneal Infiltration.   After eye trauma, the patient may complain of eye pain, fuzzy vision, and present red or black blood over all or just the inferior aspect of the iris or pupil. Referral should be made to an ophthalmologist who usually suggests hospitalization, sedation, and careful observation for several days until the hemorrhage clears. Prior to referral, an eye pad should be applied over the closed lid. Cases of hematic discoid infiltration of the cornea are nearly always of traumatic origin. Contusions of the anterior segment of the eye or penetrating wounds may be followed by a disturbing picture of "blood stain". After 10 or more days, it may simulate an anterior dislocation of the lens. The cornea slowly recovers its transparency in 3-24 months.

Abrasion.   Protective reflexes tend to prevent extensive corneal abrasions, but even minor lesions are quite painful, result in blurred vision, photophobia, excessive lacrimation, and usually require some hospitalization. They are commonly the result of scratches from a fingernail, ball, piece of equipment, or contact in sports and always present a threat of possible visual impairment. A topical dye is required for positive diagnosis. Uncomplicated cases heal in 4-6 days with only first-aid treatment. The clinical picture is one of an extremely red eye, pain, photophobia, and excessive lacrimation. First aid consists of an eye ointment, a firm pad over the closed lid, and cool applications.

Traumatic and Striate Keratitis.   Injuries to the cornea may establish a general inflammation of the membrane, but more frequently they cause loss of substance of the cornea and thus produce corneal ulcers. These ulcers heal quickly if small and not affected. They present little pain and leave only a temporary opacity proportionate to their extent. If they are extensive, even if superficial like a severe abrasion, they may be extremely painful if the corneal epithelium is removed. Once infected, they exhibit characteristics of a suppurating ulcer. An injury causing bending of the cornea may show a number of fine gray streaks (striate keratitis), more or less perpendicular to the corneal injury, noticed from a few hours to a week or more after the trauma.

Laceration.   Lacerations of the eyeball from sharp or pointed objects result in eye pain and visual impairment. On examination, the cornea will appear cut, present an irregular corneal reflex, possibly exhibit a tear-shaped pupil with a small ebony tip at the apex of the tear, or the iris may exhibit a hole from perforation. A cold pack should be applied immediately, followed by a protective shield, a loose patch, and referral to an eye surgeon.


Foreign Bodies

Foreign bodies within the eye are especially common under windy and/or dusty conditions. Foreign bodies are frequently imbedded in the cornea because it occupies nearly two-thirds of the space between the opened eyelids and a much larger proportion of that space when the eyes are partly closed as during squinting in bright sunlight or when the entrance of a foreign body is anticipated. The tissue of the cornea tends to retain particles that may penetrate it, but the conjunctiva and subconjunctival tissues are so loose that imbedded particles easily expel spontaneously.

Once a foreign body becomes imbedded in the cornea, it causes irritation and usually a suppurative inflammation by which it becomes loosened and easily drops out or is wiped away by the lids. If, however, it lies at the bottom of a considerable loss of substance, it may lie there for some time, although quite detached from corneal tissue. Under these circumstances, it becomes a source of painful irritation causing chronic eye muscle weakness, blurred vision, photophobia, excessive lacrimation, conjunctival redness, and the development of vessels in the adjoining pericorneal space. These vessels press against the seat of the foreign body and give an appearance of a chronic phlyctenular ulcer or superficial vascular keratitis.

Management.   Most superficial unembedded debris can be washed out with clean water, a weak saline solution, or a commercial eye wash (eg, Cramer's). For this purpose, a bulb lavage is a helpful tool in the emergency kit. If gentle irrigation is not adequate, a light patch should be applied and immediate referral to an ophthalmologist should be made.


Eye Injuries Produced by Indirect Trauma

Papilledema.   Papilledema following skull fracture, especially a depressed fracture, is sometimes seen, but swelling of the disc and hemorrhages are rare. Vision is usually not affected, and visual fields are typically normal. The papilledema usually disappears in 1-3 weeks after intracranial pressure is reduced.

Occipital Injuries.   Complete blindness may be a temporary result in occipital injuries because of physical shock affecting the neurons correlated with the damaged cortical neurons. There is usually complete restoration of function of all but the definitely destroyed neurons. Vision may be permanently lost if hemorrhage involves the visual centers. Fracture through the optic canals may result from cranial trauma without fracture of other bones of the skull. Blindness of one eye or both may follow even if the nerves preserve their normal appearance for a period after the accident.


Retinal Injury

Concussion injuries of the eye may result in retinal hemorrhages, retinal tears and disinsertions, choroid ruptures, and optic nerve avulsion (rare).

Retinal Hemorrhage and Choroidal Ruptures.   Retinal edema and bleeding usually occur in the macula or temporal area. Resolution usually occurs in a few weeks without radical treatment. A choroidal rupture exhibits as a whitish circumscribed area near the disc in ophthalmoscopy because the herniation allows underlying sclera to be viewed. Strenuous physical activity must be restricted for 2-5 weeks.

Retinal Dialysis and Detachment.   While disinsertion of the retina likely occurs at the time of concussion, retinal detachment may not occur for weeks or even months after the time of injury. Initially, the area of retinal dialysis will appear red, well defined, and near the periphery of the retina, usually on the lateral aspect. Early diagnosis of retinal dialysis may save the patient's vision if cryotherapy or photocoagulation can be effectively applied. In the later stage, the detached retina will present a gray appearance with dark vessels and require surgical intervention. Once retinal detachment has been corrected, further contact sports are ill-advised as recurrence is quite frequent.



     INJURIES OF THE EAR AND TO HEARING

Most sports and many occupations and recreational activities have their share of injuries to the external ear. Even in mandatory-helmet sports, lacerations and abrasions are seen. These may be due to an opponent's fingernail or a player bending the ear during the placement of a helmet. This latter injury may not be uncomfortable at first, but after hours of practice, the folded ear may swell and bleed at the crease, producing intense pain and many months of sensitivity.

Cauliflower Ear

While cauliflower ear has in past years been commonly associated with boxing, its incidence is much higher in wrestling. The condition itself is the result of untreated or poorly treated hematoma. The clinical picture progresses from (1) injury to the ear causing persistent, throbbing pain that lasts long after the causative event, (2) possible fibrocartilage fracture, (3) swelling, local heat, tenderness, followed by the development of a hematoma after several hours, initially between cartilage and overlying skin, visible to the naked eye, (4) tissue hardening and the development of early fibrous tissue in about 14 days, and (5) the resulting keloid mass, development of new cartilage, and permanent deformity of the external ear characterized by skin wrinkling, thickening, and contraction at the site of injury.

Professional Care.   First-aid consists of ice packs and pressure bandages during the healing stage. Hirata condemns straightforward incision, although a common practice, as it opens the area to secondary infection, chondritis, and perichondritis due to the relative avascularity of the cartilage. Referral for aspiration, several drainings if need be, is preferred. Following aspiration, some authorities recommend irrigating the aspirated area with a solution of hyaluronidase to reduce swelling and edema of injured tissues. Several trainers have found that hyaluronidase is more effective if "driven in" with iontophoresis or phonophoresis.

After aspiration, or even if aspiration is not necessary, a pad of folded gauze about 2-inches thick, covered with collodion, should be applied to the bruised ear and supported by an ace bandage. Before the pressure pad is applied, a loose plug of cotton should be inserted within the middle and exterior thirds of the external canal. The pressure pad should remain in place for 3-5 days in which time daily monitoring is made to assure the swelling is subsiding. Prevention lies essentially in the use of proper head gear, but care must be taken that the ear cap is properly fitted or this in itself creates a hazard.


External Ear Disorders Associated with Water

Otitis Externa.   External otitis (swimmer's ear) is commonly seen in competitive surface swimmers. The cause is a breakdown of the normal cerumen barrier due to constant exposure to warm water. Itching and discharge are the first symptoms. Infection in the skin of the external auditory canal quickly leads to inflammation, erythemia, edema (which hides the drum), acute tenderness, and a mild cellulitis that matures rapidly to a firm furuncle that is extremely painful and tender, usually requiring antibiotics and sedation. Each attack destroys some cerumen glands, which encourages further attacks.

A chronic mild itching encourages "ear picking" which tends to spread the infection. Diffuse otitis externa is typically a bacteria, fungi, or allergic disorder. Pool work must be restricted until healing is complete. Many otolaryngologists recommend careful monitoring of the pool chlorine content and the instilling in each ear of half-strength Burrow's solution after each pool session to prevent infection. Others suggest a commercial antifungal preparation or a solution of 90% isopropyl alcohol and 10% vinegar or 5% glacial acetic acid for irrigation.

External Barotrauma.   During a diving descent below 30 feet when the ear is protected by ear plugs or a hood, a negative pressure develops that causes the drum to bulge outward, usually without discomfort or rupture. Capillaries within the external canal may break to form small blisters in the skin of the exterior canal to present a roughened surface. People so afflicted should be advised to avoid scuba diving. If diving is continued, some help can be obtained by avoiding ear plugs or cutting a hole in the hood to allow water to enter the exterior ear.

Exostoses.   Exostoses are another affliction often seen in swimmers, especially cold water swimmers, which often predispose to otitis externa. The superior aspect of the canal just lateral to the pars flaccida of the drum is a favorite site of these benign bony tumors of the exterior canal. They are neither the cause nor the effect of the otitis directly. They are usually asymptomatic and rarely cause complete canal blockage, but they do encourage otitis externa because they interfere with cerumen passage and inhibit water within the ear to drain outward. Ear plugs may help in prevention and avoid continued growth, but surgical removal may be necessary.


Miscellaneous Disorders of the External Ear

Insects in the Ear.   An uncommon but frightening experience is an insect buzzing within an ear. Treatment can be provided by placing the patient in the side position with the affected ear up and syringing or pouring warm vegetable oil or water into the external auditory meatus. This will usually float out the insect.

Lacerations.   In any case of laceration of the pinna, secondary infection is always a danger due to the poor resistance of the relatively avascular cartilage exposed. Appropriate care must be made to avoid permanent and ugly scarring.

Canal Collapse.   Due to relaxation of soft-tissue support, the medial end of the condral cartilage may drop forward to narrow the lateral end of the external canal. The resulting slit can easily be opened with a speculum, but normal cerumen passage is inhibited, leading to infection and possible otitis externa.


Trauma-Related Middle Ear Disorders

Hearing depends upon the integrity of the external canal, the drum, the air chamber of the middle ear, the windows, the mobile chain of ossicles, the auditory nerve, and the perceptive higher centers in the brain. Any abnormality of one or more of these factors can impair hearing. Treatment of most all middle-ear disorders consists of keeping the ear dry (difficult with swimmers and divers), using preventive irrigation, using an appropriate therapy to decongest the tissues, managing any infection present by appropriate means, and seeking otologic consultation when necessary.

Middle-Ear Barotrauma.   In rapid pressure changes such as in diving or an airplane descent, the drum herniates inwardly if the eustachian tube does not afford pressure equalization. The negative pressure within the middle ear causes slight hemorrhages and extracts fluids from adjacent tissues. A weakened drum may rupture in a deep descent, resulting in severe vertigo as water enters the middle chamber. Prevention is made by avoiding clogged ears or nasal congestion prior to descent. When on the surface, a diver may help unblock an eustachian tube by laterally flexing the neck away from the affected side and pulling the pinna or skin of the neck up and down on the affected side.

Alternobaric Vertigo.   Alternobaric vertigo sometimes occurs during a rapid diving ascent where eustachian tube blockage causes middle-ear pressure buildup. In severe cases, the drum may rupture. The associated rotary vertigo, vertical nystagmus, and severe disorientation may produce panic. An experienced diver will usually recognize the early signs of dizziness and slow his ascent accordingly.

Drum Perforation.   In addition to the barotraumatic forces described above, a concussive blow on the ear can result in traumatic perforation of the drum and possible ossicle damage. Special audiometric tests are usually required to determine the exact degree of resulting deafness. Slightly perforated drums usually heal spontaneously if kept dry. There is slight scar development. During healing, care must be taken while blowing the nose. Flying and deep diving should be avoided.

Ruptured Round-Window Membrane.   An aqueduct connects the cochlea and the subarachnoid space. In some people, this aqueduct is large enough to allow a free flow of cerebrospinal fluid within the scala tympani. As the aqueduct's opening is near the round-window membrane that separates the inner and middle ear, a forceful Valsalva maneuver or an attempt at autoinflation (causing transient increase in blood and cerebrospinal pressure) can transmit cerebrospinal fluid pressure to an extent to rupture the round window membrane. Once this occurs, fluid escape causes the hair cells to malfunction, the ear feels full or "dead," a loud tinnitus is perceived, deafness (unnoticed when under water) occurs especially with high tones, and vertigo and nausea usually manifest and are associated with spontaneous nystagmus and a staggering gait. During diagnosis, differentiation must be made from Meniere's disease or a viral infection of the middle ear.

Otitis Media.   Common earache is rarely trauma oriented; it is usually secondary to pharyngitis. Otitis media is the result of the normally air-filled middle ear chamber with an intact drum becoming filled with fluid because of impaired eustachian tube function. This is usually the result of an inflammation spreading from a sore throat via the eustachian tube. A feeling of fullness in the ear progresses to pain and a degree of deafness. As pressure builds within the chamber, the drum appears thick and red (blood) or yellow (pus) prior to possible rupture.

The common cause in swimmers is poor technique; ie, not expelling air when the nose is under water. Ocean, lake, or pool water irritates the nasal mucosa, resulting in nasal congestion and infection. For the same reason, scuba divers should never let water enter the mask. An ear where fluid leakage is seen should never be plugged, just lightly covered with a sterile pad.


Trauma-Related Inner Ear Disorders

Inner-ear disorders are characterized by vertigo, tinnitus, and hearing loss. Acute viral labyrinthitis is usually secondary from a cold or gastrointestinal infection, not trauma. Hearing loss is rarely associated, but vertigo is usually severe. It is usually self-limiting in 1-3 weeks.

Referred Earache.   A common cause of earache is often not within the ear itself but from the adjacent temporomandibular joint, especially in gum-chewers and brace-wearers having subclinical arthralgia of this joint. Chronic tonsil, pharynx, or larynx inflammations are also common causes of referred pain to the ear. Other causes include cervical subluxation, sternomastoid and masseter trigger points, dental problems, and an abnormally long styloid process.

Inner-Ear Barotrauma.   Injury to the inner ear is usually of an intrinsic nature as it is well protected by surrounding bone. Impairment is usually the result of abnormal pressure changes or fistulae.

Meniere's Syndrome.   The syndrome features endolymphatic hydrops from pressure changes in inner-ear fluids. Symptoms include paroxysmal dizziness, tinnitus, and a degree of deafness. The latter two may originate unilaterally and progress to both ears. It is often secondary to a number of metabolic disorders, but a common cause (primary or secondary) often overlooked is a cervical or upper thoracic subluxation. Differentiation must be made from CNS vertigo and benign paroxysmal postural vertigo.



REFERENCES AND BIBLIOGRAPHY:

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Grant WF, Cinotti AA: Eye Problems. Sports Medicine for the Athletic Female (edited by C.E. Haycock). Oradell, New Jersey, Medical Economics Company, 1980.

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Rutledge BJ: Injuries to the Cranial and Central Nervous System During Athletics. In O'Donoghue DH: Treatment of Injuries to Athletes, ed 4. Philadelphia, W.B. Saunders, 1984, pp 94-104.

Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 2. Baltimore, Williams & Wilkins, 1986.

Schafer RC: Chiropractic Physical and Spinal Diagnosis. Oklahoma City, Associated Chiropractic Academic Press, 1980.

Schafer RC: Physical Diagnosis. Arlington, Virginia, American Chiropractic Association, 1988.

Solheim RN: Cerebral Contusion Syndrome with Post-Traumatic Headaches. ACA Journal of Chiropractic, November 1965.

Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore, Williams & Wilkins, 1976.

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