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Cervical spine management in Sport-related concussion

Shuhei Suzuki DPT, ATC, OCS, FAAOMPT

Disclosure:

• Nothing to disclose

Objectives:

• Be able to identify the signs and symptoms related to cervical

spine involvement in athletes with concussion.

• Be able to identify cervical spine injury requiring a direct

referral to physician following a head injury.

• Demonstrate understanding of current evidence behind

cervical spine assessment and treatment strategies.

Cervical Spine… Does it matter?

https://www.youtube.com/watch?v=Sno_0Jd8GuA

Do we use our neck? Concussion vs. Whiplash-associated disorder:

• Concussion: (McCory, et al

2017)

– Sport related concussion is a

traumatic brain injury

induced by biomechanical

forces.

– It is caused either by a direct

blow to the head, face, neck

or elsewhere on the body

with an impulsive force

transmitted to the head.

• Whiplash-associated

disorder: (Elliott, et al

2009)

– Injury that involves “an

acceleration-deceleration

mechanism of energy

transferred to the neck”.

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Prevalence:

• Retrospective analysis (Ellis et al 2018)

– 80/266 – 32.5% (age: 6-19 y/o) with Cervical Spine Dysfunction

– Gender difference: female vs male = 42.5% vs. 24.1%

Concussion + CSD Concussion with NO

CSD

P value

# achieved clinical

recovery

59 (73.75%) 139 (83.73%) 0.64

Days until clinical

recovery (median)

28.5 (18-36.75) 17 (12-25) < 0.0001

# delayed clinical

recovery

29 (51.79%) 27 (19.42%) < 0.0001

Anatomy Review:

Interaction of multiple

systems:

• Cervical

• Vestibular

• Visual

Elliott et al. 2009

Marshall et al 2015

Symptoms following sports-related concussion:

1. Headache (71%)

2. Feeling slowed down (58%)

3. Difficulty concentrating (57%)

4. Dizziness (55%)

5. Fogginess (53%)

6. Fatigue (50%)

7. Visual blurring / double vision

(49%)

8. Light sensitivity (47%)

9. Memory dysfunction (43%)

10. Balance problems (43%)

http://www.upmc.com/Services/sports-

medicine/services/concussion/about-

concussions/Pages/symptoms.aspx

Lovell, Collins et al. 2004

Neck pain!?!?

Classification of clinical presentations:

Concussion Clinical

Trajectories (Fu et al)Evidence- based classification

system (Ellis et al)

APTA: Clinical Practice Guideline: (2017)

• Impairment / Function-based Diagnosis:

– Neck pain with mobility deficits

– Neck pain with headache (Cervicogenic headache)

– Neck pain with movement coordination impairments (WAD /

cervicogenic dizziness)

– Neck pain with radiating pain (radicular)

Neck pain with mobility deficits:

Symptoms:

• Segmental palpation

• Manual spinal examination

• Extension – rotation test

– Neg seg palpation: - LR:

0.08 (95% CI: 0.03 – 0.24)

– All tests Pos: + LR: 4.94 (95%

CI: 2.8 – 8.2)

• Central and/or unilateral neck pain

• Limitation in neck motion that consistently reproduces symptoms

• Associated (referred) shoulder girdle or upper extremity pain may be present

Physical findings: (Schneider et al)

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Cervicogenic Headache:

– Symptomatic pattern which

included:

• Unilateral dominant headache

• Without side shift

• Associated with ipsilateral

neck / shoulder / arm pain

• Pain that begins in the neck

• Headache aggravated by neck

movement / neck posture.

Headache:

• Jull et al 2007

– N=73 (with single headache classification)

• Migraine: 22, Tension-type: 33, Cervicogenic: 18

Symptomatic joint dysfunction

ROM

Strength

SCM Activation Level

• Jull et al 2007

– N= 108 headache group, 57 for control

with no headache

• 77 with 2 headache types, 27 with 3 headache

types

Symptomatic joint dysfunction

ROM

SCM Activation Level

Cervicogenic Dizziness:

• Differential diagnosis:

– Vertebral Artery

– Vestibular-related:

• BPPV

• Peripymph Fistula

• Peripheral vestibular

• Central vestibular

– Psychological (anxiety /

stress / depression)

• “Dizziness and disequilibrium due to changes in cervical spine position”

• Presence of imbalance, unsteadiness, disorientation, neck pain, limited c-spine ROM and may be accompanied by a headache.

Wrisley et al / Riley et al

1. Red flag screen

2. Vestibular screen

+

interventions

3. C-spine exam

+

interventions

Diagnosis:

Specific Tests:

• Cervical Neck Torsion Test (L’Heureux-Lebeau et al)

– Sn = 72%, Sp = 92%

• Smooth Pursuit Neck Torsion Test

• Cervical Joint Position Error Test: (Treleaven et al)

– 92% had >4.5 deg error in at least one position (L/Heureux-Lebeau et al)

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Treatment:

• Strengthening:

– Reduced peak linear and angular velocity with greater isometric neck

strength

– 8-week cervical resistance training: (Mansell et al),

• Improvement in strength / girth

• No change in head-neck segment dynamic stabilization

– Neck Strength as risk factor: (Collins et al)

• Reduced neck circumference, smaller mean neck to head circumference ratio

and weak mean overall neck strength associated with concussion.

Gender:

• Biomechanical soccer study:

– Tierney et al, 2005, 2008

• 50% less isometric neck flexor strength in female

• 53% less isometric neck extensor strength in female

• 10-44% greater linear head acceleration in female

– Caccese: 2016

• Statistically significant gender difference in peak linear and rotational head

acceleration

• No significant difference across age

Treatment:

• Manual Therapy:

– Cervicogenic headache / dizziness:

• SNAGs (susatained natural apophyseal glides) / Maitland mobilization

targeting upper cervical spine effective (Reid, et al) (Blanpied et al)

– Mechanical neck pain:

• Cervical mobilization + thoracic manipulation more effective than c-spine

mobilization alone (Masaracchio, et al)

• Pragmatically cervical / thoracic mobilization and manipulation effective

(Griswold, et al)

• Manual therapy + stabilization exercise > stabilization exercise alone for

mechanical neck pain (Celenay, et al)

Treatment:

• Proprioception

– Both proprioception exercise and deep neck flexor training were

effective in improving joint position sense. (Jull et al) (Treleaven, et

al)

– Examples: (Treleaven, et al)

• Static vs dynamic balance with cervical movement

• Gaze stability exercises

• Cervical kinesthetic sense exercise

Treatment:

Cervicovestibular rehabilitation:

(Schneider et al)

• Randomized controlled trial

• 31 subjects with persistent symptoms (greater than 10 days) of dizziness, neck pain and/or headache. (median: 15 y/o)

• Intervention: cervical spine physiotherapy / vestibular rehabilitation for 8 weeks.

Multidisciplinary Approach:

• It’s a TEAM WORK!!!Physician

ATC

Coach / Parents

PTSchool

administrator

Optometrist

Neuropsychologist

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References:

• Reid, S A., Rivett, D A, Katekar, M. G., & Callister, R. Comparison of Mulligan sustained natural apophyseal glides and Maitland mobilizations for treatment of cervicogenic dizziness: A randomized controlled trial. Physical Therapy. 2014; 94: 466-476.

• Reid, S.A., Rivett, D.A., Katekar, M.G., & Callister, R.Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy. 2008; 13: 357-366.

• Treleaven, J. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. J OrthopSports Phys Ther 2017; 47(7): 492-502.

• Reiley, A.S., Vickory, F.M., Funderburg, S.E., Cesario R.A., & Clendaniel, R.A. How to diagnose cervicogenic dizziness. Archives of Physiotherapy. 2017; 7:12.

• Caccese, J.B. Head accelerations across collegiate, high school and youth female and male soccer players. Br J Sports Med. 2018; 52: 98-99.

• Tierney, R.T., Higgins, M., Caswell, S.v., Brady, J., McHardy, K., Driban, J.B., & Darvish, K. Sex differences in head acceleration during heading while wearing soccer headgear. Journal of Athletic Training. 2008; 43 (6): 578-584.

• Tierney, R.T., Sitler, M.R., Swanik, C.B., Swanik, K.A., Higgins, M., & Torn, J. Gender differences in head-neck segment dynamic stabilization during head acceleration. Med. Sci. Sports Exerc. 2005; 37 (2) 272-279.

• Collins, C.L., Fletcher, E.N., Fields, S.K., Kluchurosky, L., Rohrkemper, M.K., Comstock, R.D., & Cantu, R.C. Neck Strength: A protective factor reducing risk for concussion in high school sports. J Primary Prevent. 2014. DOI 10.1007/s10935-014-0355-2.

• Mansellm J., Tierney, R.T., Sitler, M.R., Swanik, K.A., & Stearne, D. Resistance training and head-neck segment dynamic stabilization in male and female collegiate soccer players. Journal of Athletic Training. 2005; 40(4): 310-319.

• Eckner, J.T., Oh, Y.K., Joshi, M.S., Richardson, J.K., & Ashton-Miller, J.A. Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads. 2014; 42(3): 566-576.

References:

• Collins, M.W., Kontos, A.P., Reynolds, E., Murawski, C.D., & Fu, F.H. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2013. DOI 10.1007/s00167-013-2791-6.

• Kennedy E., Quinn, D., Tumilty, S., & Chapple, C.M. Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskeletal Science and Practice. 2017;29: 91-98.

• Schneider, K.J., Meeuwisse, W.H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports Med. 2014; 48: 1294-1298.

• Jull, G., Amiri, M., Bullock-Saxton, J., Darnell, R., & Lander, C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches. Cephalalgia. 2007; 27: 793-802.

• Jull, G., Amiri, M., Bullock-Saxton, J., Darnell, R., & Lander, C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 2: Subjects with concurrent headache types. Cephalalgia. 2007; 27: 891-898.

• Marshall, C.M., Vernon, H., Leddy, J.J., & Baldwin, B.A. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed, 2015. 1-11.

• Ellis, M.J., McDonald, P.J/, Olson, A., Koenig, J., & Russell, K. Cervical spine dysfunction following pediatric sports-related head trauma. J Head Trauma Rehabil. 2018. DOI: 10.1097/HTR.0000000000000411.

• Ellis, M.J., Leddy, J.J., & Willer, B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment. Brain Inj. 2015; 29(2): 238-248.

• McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699

• Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. Published online September 04, 2018. doi:10.1001/jamapediatrics.2018.2853

• Elliott, J.M., Noteboom, J.T., Flynn, T.W., & Sterling, M. Characterization of acute and chronic whiplash-associated disorders. J OrthopSports Phys Ther 2009; 39 (5): 312-323.

• Wrisley DM, Sparto PJ, Whitney SL et al. Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther 2000; 30:755-66.

• L’Heureux-Lebeau, B, Godbout A, Berbiche D & Saliba I. Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness. Otology & Neurotology 2014; 35: 1858-1865.