PCS –V 3 –CERVICAL SPINE · STT(ART, Vibration, ACU) Left SCM,Left superior oblique, Right...

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PCS – VISIT 3B – CERVICAL SPINEEvidence-Based Concussion Care

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Complete Concussion Management Inc. © 2019. All rights reserved

PCS Management Algorithm

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Cervical Spine Assessment• Goal – recreate headache, recreate dizziness, look for

dysfunctional patterns that may be causing symptoms• Treatment tends to be impairment based• Physical Exam:– ROM– Orthopedic/Special tests

• Rule out red-flags – arterial dissection, fracture, s/c injury, etc.• Proprioception & dizziness

– Manual palpation** • Really have to dig in and sometimes stay there until headache comes on

(referral patterns – should have an idea of where to check based on location of headache)

• Can elicit dizziness in some cases

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Ruling out RED-FLAGS

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Cervicogenic Vertigo• Cervicogenic dysfunction directly overlaps with PCS• History– Vertiginous feeling w/ certain head movements– Dizzy with motion or with driving – Overlap with visual motion

sensitivity• PCS patients generally don’t have a true vertigo – the room does not spin &

they do not have nystagmus– “Just feel off” – like they have to hold on to something when looking up, yet when they

lay supine they have no issue– Often find it difficult to explain the feeling – cervicogenic!

– Reid et al., 2017 (Dizziness Handicap Inventory - cervicogenicdizziness vs. general dizziness)• Cervicogenic vertigo were more likely to report that their symptoms increased

with looking up and reporting that quick movements of their head increased their symptoms vs. other forms of dizziness

• They were also more likely to report that they were NOT afraid to leave the house because of their dizziness (very functional form of vertigo)

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Sensorimotor Impairment• 3 Pillars of Sensorimotor Control:– Proprioception– Oculomotor Control– Postural Stability

• Not a true vertigo – room not spinning– Subtle sense of unsteadiness, dizziness, lightheadedness, “Feeling

off”– Vision-related symptoms (Treleaven & Takasaki, 2014):

• Need to concentrate harder to read*• Visual fatigue*• Sensitivity to light*• Blurred vision

– Double vision is NOT related to neck dysfunction• Words moving on the page• Difficulty judging distances

* = most common – 50% of people with neck pain/dysfunction

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Sensorimotor Impairment• Tremendous neurological connections between:– Cervical muscle spindles & eyes (Cervico-ocular reflex – COR)– Vestibular apparatus & eyes (Vestibulo-ocular reflex – VOR)– FASTEST reflexes in the body

• Tells our eyes to move at exactly the same rate as the neck movement when turning our heads – finely tuned

• If one of these mechanisms is off – you will feel off• Muscle Spindles are very sensitive to changes:– High density in small intrinsic neck muscles – Injection of anaesthetic = postural control probs & ataxia– Vibration = postural control probs– Neck fatigue = postural control probs (be wary of BOTOX)

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Proprioception• Assessment:

– Cervical Joint Position Error Test (JPET)• Tests the ability to relocate the head to a starting (neutral) position with the

eyes closed• Laser helmet – patient seated 1 meter (3.3 feet) away from target, points laser

at bullseye of target, then closes eyes and turns all the way to the left and comes back to neutral – once they feel that they are in position, they open their eyes and you take a measurement – Take a mean of 6 trials– <5cm of error = no impairment– >6.5 cm of error = impaired– Between 5 & 6.5 cm = borderline– Test is valid and reliable (Stanton et al., 2016; de Vries et al., 2015)– Able to accurately discriminate between those with neck pain & whiplash vs. those

without • Repeat with extension, flexion, and right rotation • Error increases naturally with age

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Cervical Joint Position Error Test

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Oculomotor Control • Smooth Pursuits– Object moving side to side 30 degrees from midline in

each direction– No neck problems = normal smooth motion – Neck Problems = saccades (may also cause headache,

dizziness, increased neck pain)– Abnormal smooth pursuits

• https://www.youtube.com/watch?v=gqCgzSSwPLk– Test in Neutral but also with neck torsion

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Smooth Pursuit Neck Torsion Test• Treleaven et al recommended adding the Smooth

Pursuit Neck Torsion Test (SPNTT) to the JPET for diagnosing cervical injury. – Sitting or standing– Eliminates input from vestibular system (head still)– Actively rotate neck 45O to one side and perform a

smooth-pursuit eye-tracking test• Spindles stretched on one side of the neck = increased spindle

output• If position is abnormal = ↑ saccades, ↓ smooth pursuits

– Neck torsion reduced smooth pursuit among patients with vertigo due to whiplash-associated disorders but did not reduce it among healthy controls or patients with central or peripheral vertigo (Tjell & Rosenhall, 1998)

• Sensitivity = 90%• Specificity = 91%

– Tjell & Rosenhall 1998

Cheever et al., 2016

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Influence of neck torsion on near point convergence (NPC) in subjects with idiopathic neck pain (INP)• People with neck pain experience sensorimotor and oculomotor deficits &

dizziness thought to be due to abnormal cervical afferent input.• Study:

– 42 subjects (21 with INP, 21 controls with no neck pain in past 6 mo)– Looked at NPC in 3 conditions for all:

• Neutral (straight on)• Neck in 45o torsion to right• Neck in 45o torsion to left

– Average of 3 trials was taken for each position• Results:

– No significant differences between groups in neutral (control=8.4cm, INP=8.7cm)– In torsion, INP group had much higher NPC differences (but not significant)– Significant difference between groups in the Torsion Differences (amount of difference

between neutral and torsion)• Example: Neutral = 8.4cm, torsion = 8.6cm, torsion difference = 0.2cm

Demonstrates the influence of the neck on visual function – how many cervicogenicpatients are undergoing vision therapy as a stand-alone? Need the comprehensive approach!!

Giffard, et al., 2017

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SPNT

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Postural Stability• Increased postural sway in those with whiplash >

idiopathic neck pain > normal (Field et al., 2008)– Static - 74% of whiplash patients with dizziness unable to

stand in tandem with their eyes closed for 30 seconds• Greater deficits with neck torsion (Stokell et al., 2011) – BESS-H

• Gait in neck pain/whiplash:– ↓ step width, length & speed (Uthaikhup et al., 2013)–Walking with head-turns

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BESS-H• BESS-H (just eye movement) – progression:

– Head progression - Head neutral, rotated left, rotated right, looking down, looking up (includes C-spine activation)

– Balance progression – 2-foot stance, tandem, 1-foot, BOSU ball (only increase balance progression when patient feels comfortable with all head positions)

• Large BESS-H (full head movement) – Large H-pattern incorporating head movement

• Can use a stick to accentuate neck movement– Standing, tandem stance, single foot, walking forwards, walking

backwards, sport specific activities (ladder drills, stick handling, etc.)– Head motion progression:

• Slow à Medium à Fast• Only increase speed when comfortable with all stages at slower speeds

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Walking with Head-Turns– Need 10-15m of open space (hallway)– Patient walks 2-3 steps and then turns their head right

for 2-3 steps, then back to straight for 2-3 steps, then right again for 2-3 steps

– Ask them if that makes them feel dizzy or off – if so, make note

– Repeat for looking up, looking down, and looking left

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BESS-H & Walking with Head-Turns

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Cervicogenic Vertigo • Other Tests– Rotatory Chair Test

• Hold pts head while they rotate their body side to side – this isolates cervical joint proprioceptors – dizzy feeling here is positive for cervicogenic vertigo

• Non-specific for affected muscles and joints– Cervical flexion rotation test

• Patient supine – flex cervical spine fully, then rotate side to side slowly to not elicit vestibular stimulation

– Stimulation of ipsilateral SCM– VOR (VOMS)

• Can be C-spine related!

Cheever et al., 2016

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Manual Therapy for DizzinessDizzy with TreatmentLeft Head Turns (or left Smooth-pursuit neck torsion test)

STT (ART, Vibration, ACU) Left SCM**, Left superior oblique**, Right inferior oblique**, bilateral Deep Neck Flexors, right splenius capitus, possibly scalenes, the restSMT to all affected c-spine, t-spine, and costovertebral jointsRehab – walking with head-turns (bilateral), Figure 8 walking, BESS-H, Brandt-Daroff, Cervical joint repositioning, tossing ball over head side to side

Right Head Turns (or right SPNT test)

STT (ART, Vibration, ACU) Right SCM**, Right superior oblique**, left inferior oblique**, bilateral Deep Neck Flexors, left splenius cap, possibly scalenes, the restSMT to all affected c-spine, t-spine, and costovertebral jointsRehab – Same as above

Looking up STT (ART, Vibration, ACU) Bilateral Deep Neck Flexors**, bilateral SCM, rectus capitus, possibly scalenes, the restSMT to all affected jointsRehab – same as above

Looking down STT (ART, Vibration, ACU) Bilateral rectus capitus**, bilateral SCM**, semispinalis cap, upper traps, scalenes, Deep neck flexors, the restSMT of all affected jointsRehab – walking while looking down, stepping over objects, and same as above

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Yaseen et al., 2018

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Acupuncture• Increasing evidence for post-concussive headaches• Also some evidence for improved cognition (Zeng et al., 2017)• Evidence as well for diagnosing & treating cervicogenic dizziness

– Aydin et al., 2018 – 55 women – RCT (dry-needling + exercise or just exercise alone) – dry needling + exercise superior (SCM & trapezius mm)• Exercise was 5x/week (20 mins) for 4 weeks• Dry needling was 2x/week for 4 weeks (needles left in for up to 20 minutes)

– Xie et al., 2018 – 80 patients – microneedling plus manipulation vs. manipulation only in patients with dizziness for at least 2 months• Treatment was 5x/week for 2 weeks • Significant improvement for both groups at 2 weeks and 6 months after last

treatment (87.5% complete cure rate a 6 months in combined treatment group vs. only 42.5% in manipulation only group)

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Acupuncture for improvement of cognitive function after concussion – an RCT• 72 patients with cognitive impairment following a mTBI• Randomized 36 patients to receive acupuncture and 36 to be controls

– Both groups: oral citicoline sodium tablets (0.4g, 3x/day)– Acupuncture group – received electro-acupuncture every second day (200-300

pulses/min (i.e., 4-6 hz))– Treatment protocol for both groups was 30 days

• Results:– There was significant improvement in both groups on MoCA from pre- to post-

treatment period (p<0.01)– There was a significantly greater improvement in the acupuncture group over the

control group (p<0.05)• Conclusion:

– Acupuncture treatment can significantly improve cognitive function in mTBIpatients over medical treatment alone

Zeng et al., 2017

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Zeng et al., 2017Acupuncture for improvement of cognitive function after concussion – an RCT

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The use of dry needling as a diagnostic tool and clinical treatment for cervicogenic dizziness Pathophysiology of cervicogenic dizziness-Sub occipitals have an active role on positioning our head on the neck, however Obliquus Capitus Inferior (OCI) is a predominant proprioceptor of the upper cervical spine, due to high muscle spindle density. Altered OCI activity following injury lead to increased neck rotatory muscle activation with changes in eye position, resulting in experiencing ocular coordination difficulties and dizziness. Case series on dry needling as a test and treatment for cervicogenic dizziness• 3 patients (age 36, 74 and 89) with chief complaint of dizziness (red flags ruled out). • All patients described their dizziness as sensation of light-headed with certain head movements but not the same as

those described in BBPV, as well changes in body position (transitioning movements ie. supine to sitting, sit to stand) all provoked dizziness.

Dry needling procedure • Patients were placed in prone or side lying position and Obliquus Capitus Inferior was identified via its proximal and

distal attachments onto the spinous process of C2 and TVP of ipsilateral C1. • The needle was inserted midway between C1 and C2, two fingerbreadths laterally, with anteromedial 45 degree

caudad angulation until a bony end feel of the lamina of vertebral arch of C2 was achieved. • Needles were left in for 10 minutes. Results • Dry needling of the OCI produced sensation of dizziness. • Two patients had complete resolution of dizziness immediately following treatment or at follow-up two days later. • All had significant reduction or complete resolution of chief complaint at 6 month follow-up

Escaloni, et al., 2018

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The use of dry needling as a diagnostic tool and clinical treatment for cervicogenic dizziness

Obliquus capitusinferior needle placement

Escaloni, et al., 2018

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Headaches - Cervical Referral Patterns• Sclerotogenous referrals to the head from C/S– Muscles

• Splenius Capitis• Suboccipitals• SCM• Traps• Longus Colli• Semispinalis capitis• Occipitalis, Frontalis, Temporalis, Masseter

– Facet Joints • Especially upper cervical spine

– Ligaments (many)

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Splenius Capitis

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Suboccipitals

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SCM

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Trapezius

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Semispinalis Capitis

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Occipitalis

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Longus Colli

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Cervical Spine Facets

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Cervical Spine Assessment - Manual

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Dr. Cam’s Manual Therapy For Headaches• Goal – postural function vs. going right after pain causing

areas– STT (ART, ACU, Graston)

• Pec minor, Subscapularis, Upper traps• SCM**, Deep Neck Flexors• Suboccipitals**, splenius cap• As needed: semispinalis cap, scalenes, levator, rhomboids,

– SMT• Cervical spine restrictions – especially upper cervical spine• Costovertebral joints• Thoracic Spine• CT junction as needed

– Rehab• Postural rehab and scapular stabilization

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Manual Therapy of the Cervical Spine

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Rehab • Impairment-based – Mild reproduction of symptoms is imperative for

improvement!– Walking with head turns

• Can also evolve into fixating gaze on a single spot as they walk by– Cervical joint position training

• Pattern tracing with laser with varying degrees of neck rotation (ex. figure 8’s)• Using a mirror

– BESS-H– Visual tracking – thumb, target sheet– Gaze stabilizations – VOR

• For all the above play with speed, range of rotations, and positions (sitting/standing/tandem/walking, etc)

• Deep Neck Flexor Endurance Training• Other:

– Desensitization/Habituation – Visual Motion Sensitivity (crowds, cars, etc)

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PCS –V 3 –CERVICAL SPINE · STT(ART, Vibration, ACU) Left SCM**,Left superior oblique**, Right...

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PCS –V 3 –CERVICAL SPINE · STT(ART, Vibration, ACU) Left SCM,Left superior oblique, Right...