concussion: cervical and neuromuscular deficits · 2019-08-30 · and concussion/post-concussion...

Concussion: cervical and neuromuscular deficits

JON MINOR, MD

SPARCC, CO-MEDICAL DIRECTOR

Objectives At the conclusion of this talk, attendees should feel more capable of:

1. Recognizing the similarities in symptoms of cervical injury and concussion/post-concussion syndrome.

2. Identifying students, athletes or patients who may benefit from therapeutic intervention of the head, neck and/or upper back.

3. Counseling and prevention of delayed lower extremity injury following concussion injury.

Concussion: Background

•Incidence: 300K-3.8M annual athletic concussions (estimated) Marar M et al 2012; Yard EE et al 2009; Halstead ME et al 2010

• 50% of concussions in kids 11-15 are not sports-related

Concussion: Mechanism of Injury

4

Concussion: Mechanism of Injury Biomechanics: ”spinning of the brain”

Rotational acceleration ◦Early 1900’s slaughterhouses (free to move, accelerate)

◦Ommaya and Genarelli 1974 (experiment: proving rotational vs. linear acceleration)


Acceleration and rapid deceleration via rotation or angular velocity force to head and brain (spinning the brain)

Is it really Concussion?

Depression

Anxiety

Thyroid disorder

Parathyroid d/o

Sleep disorder: sleep apnea, bruxism, leg d/o

ADD/ADHD

Sinus infection

URI

Dehydration

Migraines

Brain tumor

Labyrinthitis

Vestibular dysfunction

Chiari malformation

Cervicogenic headaches

PCS

Visual dysfunction

If it’s not concussion (or PCS), what else can it be?

Concussion Symptom Interplay

Concussion vs Cervical Injury

Headache

Dizziness

Tinnitus

Irritability

Sleep disturbances

Blurred vision

Neck Stiffness

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Concussion Cervical Injury


Balance disturbances

Depression

Cognitive deficits

Memory deficits

Attention deficits

Decreased cervical ROM

Decreased isometric neck strength

X

X

X

X

X

X

X

X

X

X

X

Concussion Cervical Injury


Concussion:

Complex pathophysiologic process induced by biomechanical forces affecting the brain

Cervical Injury:

Persistent impairments caused by dysfunction of the somatosensory system of the cervical spine ◦ Likely caused by the strain placed on soft tissues of the neck

◦ Strain disrupts afferent pathways that relay information from the neck to brain

Cervical Injury: Mechanism

4 Phases of neck injury:

1. Initial position

2. Retraction

3. Extension

4. Rebound

Initial neck position

Force



1. Initial position

2. Retraction

3. Extension

4. Rebound

Retraction

Force

Initial compression force



1. Initial position

2. Retraction

3. Extension

4. Rebound

Extension



1. Initial position

2. Retraction

3. Extension

4. Rebound

Rebound Result: myofascial strains

Cervical Injury: Pathways

Journal of Athletic Training, 2016; 51 (12): 1037-1044

Three checks and balances systems for redundancy: 1. Ocular system 2. Central/vestibular system 3. Neck proprioception and somatization (pain/sensation)

Cervical Injury: structures

Facet joint involvement associated with cervical symptoms in mTBI:

C1-C2, C2- C3, C0-C1, and C3-C4

Note: C2 nerve root arises from C1-C2; forms the Greater Occipital Nerve

Evaluating & Treating Cervical Injury

Case Example:

• 16 y/o female (MVA, soccer collision, slip and fall- could be anything)

• 6 weeks since injury, and NOT FEELING LIKE SHE’S IMPROVING

• Significant headaches (light and sound sensitive, exercise and cognitively induced), nausea & dizziness, “moody”

• In school for 2 hours per day, not tolerating well

• Working with PT

• Scheduled for neuro-optometry evaluation in 6 weeks

Cervical Injury: Differentiation Tests

1. Joint-reposition error test (JPET) ◦ Test ability to reposition after passive

flexion, extension and rotation


Assesses for spindle damage in muscles: treat with neck proprioception


2. Smooth-pursuit neck-torsion test (SPNTT) ◦ Testing for cervicogenic causes of

dizziness


Assesses for afferent disturbance in the neck: treat with manual therapy & gaze stabilization

@ 45o


3. Head-neck differentiation test (HNDT) ◦ Testing for cervicocollic reflex, cerebellar function


If symptoms (dizziness/balance) treat with head & neck differentiation training


4. Cervical flexion-rotation test (CFRT) ◦ Tests for afferent proprioception

disturbance in the neck


If dizziness treat with manual therapy

Cervical Injury: Headache Patterns


Cervical Injury: Additional Intervention

Injection Therapy

1. Greater occipital nerve trigger point injection ◦ Cortisone

◦ Anesthetic agent only

◦ Prolotherapy (dextrose & anesthetic agent)

Cervical Injury: Additional Treatment

Injection Therapy

2. Levator Scapula & trapezius trigger point injection ◦ Cortisone




Injection Therapy

3. Subscapular bursa trigger point injection ◦ Cortisone




Injection Therapy

4. Facet joint injection ◦ Cortisone



◦ PRP


Non-invasive Therapy

1. Physical therapy ◦ Soft tissue & joint mobilization, dry

needling, strengthening, proprioception

2. Osteopathic Manual Manipulation ◦ Sub-occipital release & other treatments

3. Acupuncture/acupressure

4. Massage therapy

5. Cranio-sacral manipulation

Recent Summary: 2017 PhD dissertation defense at U of Pittsburgh

Amy Aggelou (Micky Collins team)

PhD, LAT, ATC

Director and Instructor, Athletic Training Education Program

4047 Forbes Tower

Pittsburgh, PA 15260

[email protected]

Study Design:

Injury Surveillance at U of Pitt from 2007/2008 – 2016/2017 athletic seasons


Amy Aggelou, PhD, LAT, ATC

Findings:

62% of concussed athletes sustained LE injury within 180 days (vs 26% of non-concussed controls)

Risk of subsequent LE injury 7.37 times higher for concussed athlete within 180 days (vs controls)

Risk of subsequent LE injury 7 times higher for concussed athlete within 180 days, when having a LE injury within 90 days prior to concussion


Amy Aggelou, PhD, LAT, ATC

Location of LE injuries after concussion

Findings:

1. Knee (35%) and Ankle (33%) were most common joints injured after concussion

2. Foot comprised 12% of injuries after concussion

3. Lateral ankle sprains were most common specific injury (25.5%)

Lower Extremity MSK Injuries: Timeline of injury

Lynall et al. Acute Lower Extremity Injury Rates Increase following Concussion in College Athletes. Medicine and science in sports and exercise. 2015.

Findings:

1. Significantly increased risk of LE injury at 180 and 365 days after concussion

2. No increased risk of LE injury at 90 days after concussion

Lower Extremity MSK Injuries: Timeline of injury

Consider:

Ongoing proprioception, balance, agility, hips & core strengthening for months after recovering from concussion

Summary

1. Concussions will occur

2. Consider cervical origin of prolonged concussion symptoms, and treat accordingly

3. Recovered individuals are at increased risk of lower extremity injury for up to 1 year following concussion

4. Provide a plan to prevent future concussion and lower extremity injury with ongoing dynamic exercise program

Thank you!

Questions?

concussion: cervical and neuromuscular deficits · 2019-08-30 · and concussion/post-concussion...

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