10/19/2018. Disclosure: Objectives: Cervical Spine Does it matter? Concussion vs. Whiplash-associated disorder: Nothing to disclose

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1 Disclosure: Nothing to disclose Cervical spine management in Sport-related concussion Shuhei Suzuki DPT, ATC, OCS, FAAOMPT Objectives: Cervical Spine Does it matter? 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. 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. 1

2 Prevalence: Retrospective analysis (Ellis et al 2018) 80/ %(age: 6-19 y/o) with Cervical Spine Dysfunction Gender difference: female vs male = 42.5% vs. 24.1% # achieved clinical recovery Days until clinical recovery (median) # delayed clinical recovery Concussion + CSD Concussion with NO CSD P value 59 (73.75%) 139 (83.73%) ( ) 17 (12-25) < (51.79%) 27 (19.42%) < Anatomy Review: Interaction of multiple systems: Cervical Vestibular Visual Elliott et al Marshall et al 2015 Symptoms following sports-related concussion: Classification of clinical presentations: Neck pain!?!? Lovell, Collins et al 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%) Concussion Clinical Trajectories (Fu et al) Evidence-based classification system (Ellis et al) APTA: Clinical Practice Guideline: (2017) Neck pain with mobility deficits: 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) Symptoms: 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) Segmental palpation Manual spinal examination Extension rotation test Neg segpalpation: -LR: 0.08 (95% CI: ) All tests Pos: + LR: 4.94 (95% CI: ) 2

3 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. ROM Headache: Jull et al 2007 N=73 (with single headache classification) Migraine: 22, Tension-type: 33, Cervicogenic: 18 Symptomatic joint dysfunction Strength SCM Activation Level Cervicogenic Dizziness: Jull et al 2007 N= 108 headache group, 57 for control with no headache 77 with 2 headache types, 27 with 3 headache types ROM Symptomatic joint dysfunction SCM Activation Level 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. Diagnosis: 1. Red flag screen 2. Vestibular screen + interventions 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 degerror in at least one position (L/Heureux-Lebeau et al) 3. C-spine exam + interventions Wrisleyet al / Riley et al 3

4 Gender: 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. Biomechanical soccer study: Tierney et al, 2005, % 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 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) 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 Multidisciplinary Approach: Cervicovestibular rehabilitation: (Schneider et al) It s a TEAM WORK!!! Physician 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. Neuropsychologist Optometrist ATC Coach / Parents School administrator PT 4

5 References: 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: 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: Treleaven, J. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. J Orthop Sports Phys Ther 2017; 47(7): 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: 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): 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) 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 DOI /s 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): 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): 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 SurgSports Traumatol Arthrosc DOI /s 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: Schneider, K.J., Meeuwisse, W.H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. Cervicovestibular rehabilitation in sportrelated concussion: a randomized controlled trial. Br J Sports Med. 2014; 48: 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: 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: Marshall, C.M., Vernon, H., Leddy, J.J., & Baldwin, B.A. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed, 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 DOI: /HTR 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): McCroryP,MeeuwisseW,DvorakJ, et al Consensus statement on concussion in sport the 5 th international conference on concussion in sport held in Berlin, October 2016 Br J Sports MedPublished Online First: 26 April doi: /bjsports Lumba-Brown A, YeatesKO, 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, doi: /jamapediatrics Elliott, J.M., Noteboom, J.T., Flynn, T.W., & Sterling, M. Characterization of acute and chronic whiplash-associated disorders. J Orthop Sports Phys Ther 2009; 39 (5): Wrisley DM, Sparto PJ, Whitney SL et al. Cervicogenic dizziness: a review of diagnosis and treatment. J OrthopSports Phys Ther2000; 30: L Heureux-Lebeau, B, Godbout A, BerbicheD & Saliba I. Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness. Otology & Neurotology 2014; 35: