1. Concussion: Manual Therapy to Optimize Environment for Healing Jessica Paparella, DPT

2. CASE STUDY #2 IE: 2/2/12
Pt is 33 y.o. professional hockey player who suffered a concussion on 12/30/11
Mechanism of injury: getting hit in back of helmet with puck during practice
c/c: right side HA, right neck pain, mm spasm, dizziness, sensitivity to light/noise, irritability, and inability to complete exertion testing (ie: bike)
PMH: right orbital fx 11/10, hip labral repair 1/10, 2-3 dx concussions
ROS:
Head: chronic/recurring right HA
Neck: right pain/tightness in UT, ↑neck flexion and extension, radiating pain up back of neck
Neurological: dizziness
Physical Findings:
Pain: 3/10 activity dependent
(-) ligaments stress tests
+lateral head deviation right /holding pattern
+tightness/hypertonicity right anterior/middle scalene, UT/levator, sub-occipital mm
+OA dysfunction
+AA dysfunction
+FRS mid-low c/s
**pressure point right orbital region 40 secx3 relieved symptoms
5 weeks post concussion

3. 2/6/12
Pt enters therapy with “minor soreness after manual tx.”
Denies symptoms, except HA
↓ mm tightness
Riding BIKE today without increased symptoms
c/c: right HA and pain above right eye
2/7/12
Pt enters therapy with “continued decrease in muscle tightness and HA” with 1/10 pain
RETURN to GAME 2/26

4. CASE STUDY #1 IE: 3/6/12
Pt is 27 y.o. professional hockey player who suffered a concussion on 12/20/11
c/c: HA, tightness(L>R),limited mobility of neck.
ROS:
Head: chronic/recurring HA
Neck: pain/tightness in UT, ↑neck flexion and extension
Neurological: +radic left UE
Physical Findings:
Pain: 3-5/10 activity dependent
(-) ligaments stress tests
+OA dysfunction
+ERS mid-low c/s
+left elevated first rib
Hypomobility C3-6
7 weeks post sx

5. RETURN to TEAM and GAME (3/17/12)…which was a WIN
3/7/12
Pt enters therapy feeling “better after manual tx last session.” pt points to proximal attachment of SCM as source of discomfort
↓ neck pain
Denies HA
3/8/12
Pt enters therapy “continuing to feel better after manual therapy; neck feels looser’ and no longer needs mm relaxor during day”
3/9/12
Pt enters therapy stating “neck feels looser and increased c/s mobility”
c/c: UE mm tightness; spasm and anterior c/s mm ache
1/10 pain
RETURN to TEAM and GAME (3/17/12)…which was a WIN

6. THE BRAIN
Highly sensitive to hypoxic states: the brain does NOT store energy so it relies on a continuous blood flow for oxygen and glucose to live/function

7. CERVICAL SPINE ANATOMY
Roles of cranial cervical structures:
Provide strong support of skull
Protect neural components and vascular structures
Provide muscular attachments
Allow flexibility/ROM of the C/S
Shock absorber and “vault” to protect the brain
Passage of neurovascular structures
This area is susceptible to acute dynamic/motion disorders (ie concussion) as well as static/postural disorders (FHP)
(Ellis, FFCFMT 2003)

8. CERVICAL SPINE: LIGAMENTS→ → ↓ →

9. CERVICAL SPINE: MUSCLES→

10. CERVICAL SPINE: NEUROANATOMY AND VASCULARIZATION
Significant blood/venous supply
2 Carotid arteries/2 vertebral arteries supply most
of the brain
Vertero-basilar system
RED FLAGS: distress, diplopia, dilatation, dizziness, dysarthria, drop attacks, distal parasthesias
(Ellis, FFCFMT 2003)

11. POSTCONCUSSIVE PATHOLOGY
Impactdepoliarizationrelease excitatory amino acid (glutamate)increased extracellular K+ (spreading depression is when LOC occurs)
Effort to restore homeostasis: hyperglycolisis for ATP- CA2+ influxaxonal swelling decreased CBF

12. Can manual therapy optimize an environment for healing?
CLINICAL QUESTION
Can manual therapy optimize an environment for healing?

13. EVIDENCE BASED MEDICINE
Soft tissue mobilization and sub-occipital trigger point release
Dysfunctions can be reduced thus returning the body to a system of balance and efficient function through the appropriate application of techniques of STM and functional mobilization (IPA 2010) * * * *

14. EVIDENCE BASED MEDICINE
Muscle Energy Technique (MET)
“MET is a manual medicine procedure that has been described as a gentle form of manipulative therapy effective for treating movement restrictions of both the spine and extremities”
Spinal joint dysfunction: local tenderness, tissue texture change, asymmetry, limitation of segmental motion and altered end-feel
(J. Osteopathic Med, 2003)

15. EVIDENCE BASED MEDICINE
Exercise
Light exercise of affected mm to increase mm blood flow and enhance healing (Tiidus, JOSPT 1997)

16. DOES THIS OPTIMIZE AN ENVIRONMENT FOR HEALING??
Sub-occipital release  normalize cerebral blood flow
Soft tissue mobilization  normalizing muscle tone
C/S MET  To normalize anatomical alignment
Ther-ex  to increase blood flow and normalize muscle imbalances
DOES THIS OPTIMIZE AN ENVIRONMENT FOR HEALING??

17. CASE STUDY #3 SCAT 2 Athlete Name: Matt Sport: Varsity Football
Injury Date: 9/30/12
Assessment Date:10/2/12
Test Classification: Baseline Post-Injury
Examiner: Jessica Tau, ATC

18. Pre-Treatment #1
Post-Treatment #1

19. Pre-Treatment #1
Post-Treatment #1 10 5

20. Post-Treatment #1
Post-Treatment #2

21. Post-Treatment #1
Post-Treatment #2 5 4

22. REFERENCES
American Academy of Manual Medicine. Suboccipital Muscle Group
Brain Trauma Research Center. Sports-Related Concussions: Background and Significance
Ellis, Jeffery. Cervical Thoracic Integration. IPA Continuing Education 2003.
Fink, Dustin. Concussion Blog. January 2011.
Giza, et al. The Neurometabolic Cascade of Concussion. Journal of Athletic Training 2001; 36(3)
Grady, Matthew. Concussion in the Adolescent Athlete. Current Problems in Adolescent Health Care 2010; 40:
Institute of Physical Art. Functional Orthopedics I
Institute of Physical Art. Proprioceptive Neuromuscular Re-education
Johnson, Gregory. Soft Tissue Mobilization. IPA Continuing Education;
McKee, et al. TDP-43 Proteinopathy and Motor Neuron Disease in Chronic Traumatic Encephalopathy. Journal of Neuropathology Experimental Neurology 2010; 69(9)
Moser, et al. Neuropsychological Evaluation in the diagnosis and management of sports related concussion. National Acadamy of Neuropsychology 2007;
Signoretti, et al. The Pathology of Concussion. American Academy of Physical Medicine and Rehabilitation 2011;
Tiidus, Peter. Manual Massage and Recovery of Muscle Function Following Exercise; a literature review. Journal of Orthopedic and Sports Physical Therapy 1997; 25(2)
Toledo, et al. The young brain and concussion; Imaging as a biomarker for diagnosis and prognosis. Neuroscience and Biobehavioral Reviews 2012;
USA today online. Concussion Statistics. October 11, 2012.