concussion: cervical and neuromuscular deficits · 2019-08-30 · and concussion/post-concussion...
TRANSCRIPT
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Concussion: cervical and neuromuscular deficits
JON MINOR, MD
SPARCC, CO-MEDICAL DIRECTOR
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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.
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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
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Concussion: Mechanism of Injury
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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)
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Concussion: Mechanism of Injury
Acceleration and rapid deceleration via rotation or angular velocity force to head and brain (spinning the brain)
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Concussion: Mechanism of Injury
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Concussion: Mechanism of Injury
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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?
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Concussion Symptom Interplay
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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
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Concussion vs 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
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Concussion vs 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
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Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Initial neck position
Force
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Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Retraction
Force
Initial compression force
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Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Extension
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Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Rebound Result: myofascial strains
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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)
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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
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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
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Cervical Injury: Differentiation Tests
1. Joint-reposition error test (JPET) ◦ Test ability to reposition after passive
flexion, extension and rotation
Journal of Athletic Training, 2016; 51 (12): 1037-1044
Assesses for spindle damage in muscles: treat with neck proprioception
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Cervical Injury: Differentiation Tests
2. Smooth-pursuit neck-torsion test (SPNTT) ◦ Testing for cervicogenic causes of
dizziness
Journal of Athletic Training, 2016; 51 (12): 1037-1044
Assesses for afferent disturbance in the neck: treat with manual therapy & gaze stabilization
@ 45o
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Cervical Injury: Differentiation Tests
3. Head-neck differentiation test (HNDT) ◦ Testing for cervicocollic reflex, cerebellar function
Journal of Athletic Training, 2016; 51 (12): 1037-1044
If symptoms (dizziness/balance) treat with head & neck differentiation training
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Cervical Injury: Differentiation Tests
4. Cervical flexion-rotation test (CFRT) ◦ Tests for afferent proprioception
disturbance in the neck
Journal of Athletic Training, 2016; 51 (12): 1037-1044
If dizziness treat with manual therapy
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Cervical Injury: Headache Patterns
Journal of Athletic Training, 2016; 51 (12): 1037-1044
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Cervical Injury: Additional Intervention
Injection Therapy
1. Greater occipital nerve trigger point injection ◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose & anesthetic agent)
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Cervical Injury: Additional Treatment
Injection Therapy
2. Levator Scapula & trapezius trigger point injection ◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose & anesthetic agent)
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Cervical Injury: Additional Treatment
Injection Therapy
3. Subscapular bursa trigger point injection ◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose & anesthetic agent)
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Cervical Injury: Additional Treatment
Injection Therapy
4. Facet joint injection ◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose & anesthetic agent)
◦ PRP
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Cervical Injury: Additional Treatment
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
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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
Study Design:
Injury Surveillance at U of Pitt from 2007/2008 – 2016/2017 athletic seasons
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Recent Summary: 2017 PhD dissertation defense at U of Pittsburgh
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
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Recent Summary: 2017 PhD dissertation defense at U of Pittsburgh
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%)
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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
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Lower Extremity MSK Injuries: Timeline of injury
Consider:
Ongoing proprioception, balance, agility, hips & core strengthening for months after recovering from concussion
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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
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Thank you!
Questions?