PCS Eligibility Criteria- Feasibility Trial

The effects of chiropractic manual adjustments on nervous system function in individuals with post concussion syndrome

Eligibility Questionnaire
Eligibility Status

EligibleIneligibleOther
Contact Status (eligible only)

EnrolledDeclinedNo ResponseDropoutOther
Reason for declining

LocationScheduleCompensationPersonal circumstanceFacebook ad location errorNone givenOther
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you at least 18 years old?*

YesNo
Were you diagnosed with post concussion syndrome by a physician?*

YesNo

Please answer each question in the table below.*

	Yes	No
Have you ever hit your head or been hit in the head?
Were you ever seen in the emergency room, hospital, or by a doctor because of an injury to your head?
Did you ever lose consciousness or experience a period of being dazed and confused because of an injury to your head?
Do you experience at least 3 of these problems in your daily life since you hit your head? Headaches Dizziness Anxiety Depression Difficulty concentrating Difficulty remembering Difficulty reading, writing, calculating Poor problem solving Difficulty performing your job/school work Change in relationships with others Poor judgment (being fired from job, arrests, fights)
Have you ever had any major sicknesses that could have caused these problems (brain tumor, meningitis, West Nile virus, stroke, seizures)?

Check the boxes next to each symptom you continue to experience at least 3 months after your heady injury.*

	Check
Headache
Dizziness
Insomnia
Fatigue
Difficulty concentrating
Memory difficulty
Irritability
Intolerance to stress, emotions, or alcohol
I do not experience any of these symptoms at least 3 months after my head injury

Look at the pain scale below. What is your typical pain level on a daily basis?*

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain Possible
Are you able to understand and communicate in English?*

YesNo
Are you able to make informed decisions without assistance?*

YesNo
You will be asked to wear a cap made of a net with multiple small sensors. It will be wet with a saline solution and snug on the head. Can you wear that for 40 minutes?*

YesNo
Can you sit quietly for at least 15 minutes?*

YesNo
Are you capable of walking on a treadmill at a comfortable pace for 10 consecutive minutes?*

YesNo
Are you capable of moving from lying on a table face-up to a standing position then back to lying down face-up quickly and safely?*

YesNo
Are you able to wear multiple electrodes placed on your chest, back, and fingers?*

YesNo
Are you able to wear multiple sensors placed on your head, back, pelvis, hands, arms, and legs?*

YesNo
Have you had a chiropractic adjustment within the last 3 months?

YesNo
Have you had a chiropractic adjustment within the last month?*

YesNo
Have you received any interventions such as osteopathic spinal manipulation, physical therapy rehabilitation or manipulation, massage, body movement therapy, or acupuncture within the last 3 months?

YesNo
Have you received any interventions such as osteopathic spinal manipulation, physical therapy rehabilitation or manipulation, massage, body movement therapy, or acupuncture within the last month?*

YesNo
Are you able to provide the name and contact information of a medical care provider (ex primary doctor, therapist, or neurologist) you have received care from recently or in the past?

YesNo
Have you been diagnosed with a serious mental disorder such as schizophrenia or bipolar disorder?*

YesNo
Do you have malignant hypertension (a condition where your blood pressure rises suddenly and quickly)?*

YesNo
Do you have a known condition such as postural orthostatic tachycardia syndrome (POTS) that causes syncope or fainting with postural changes?*

YesNo
Do you have any implanted devices such as a pacemaker?*

YesNo
Do you have a physical disability that affects the way you walk?*

YesNo
Have you had any surgeries or injury to the musculoskeletal structures or skull in the past 3 months?*

YesNo
Do you have a prosthetic for any of your arms or legs?*

YesNo
Do you have a hearing impairment or require a hearing aid?*

YesNo
Do you have a history of stroke?*

YesNo
Are you on any short-acting benzodiazepines including midazolam and triazolam?*

YesNo
Are you involved with any current litigation related to a physical, health-related injury?*

YesNo
Do you have untreated diagnosed osteoporosis or articular instability, such as atlanto-axial instability?*

YesNo
Are you currently pregnant?*

YesNo

What times are you typically available for appointments?*

	Available hours (i.e., "10am-12pm")
Mondays (10am-2pm)
Tuesdays (10am-4pm)
Thursdays (10am-4pm)
Fridays (10am-2pm)
Saturdays (9am-4pm)

How did you hear about this study?
How did you hear about this study?

FacebookInstagramClinicalTrials.govCCR WebsiteLife University CampusMidtown Lab (1 Baltimore Pl NW, Atlanta)E-mail outreachMonday Research KickstartWord of mouthOther
If you have any questions, please reach out to the Center for Chiropractic Research at research.studies@life.edu.
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The effects of chiropractic manual adjustments on nervous system function in individuals with post concussion syndrome