Mild TBI & Neck Pain SG

SCM, scalenes, upper trapezius, cervical erector spinae, levator scapulae

Global muscles of cervical spine:

Longus colli, rectus capitis anterior/lateralis, longus capitis, multifidi

Deep segmental stabilizers of the spine:

- Origin: External occipital protuberance, nuchal ligament

- Insertion: Lateral 1/3 of clavicle

- Action: Upward rotation, retraction, and elevation of scapula.

- Innervation: CN XI (C3-C4 sensory)

Upper Trapezius

- Origin: Manubrium, clavicle

- Insertion: Mastoid process

- Action:

- Bilateral: Extends head, flexes neck, raises thorax

- Unilateral: Ipsilateral lateral flexion and contralateral rotation

- Innervation: CN XI (C2-3 sensory)

Sternocleidomastoid (SCM)

- Origin: Transverse processes of C1-C4

- Insertion: Superior angle of scapula

- Action: Elevates, downwardly rotates, retraction of scapula

- Innervation: Dorsal scapular nerve (C4, C5), Anterior rami (C3,C4)

- Circulatory: Dorsal scapular artery

Levator Scapula

- Origin:

- Anterior: Transverse processes C3-6

- Middle: Transverse process of C2-7

- Posterior: Transverse process of C4-6

- Insertion:

- Anterior and middle: 1st rib

- Posterior: 2nd rib

- Action:

- All: Flexes, laterally flexes neck, rotates neck opposite, elevates 1st rib

- Innervation:

- Anterior: Ventral rami C4-6

- Middle: Ventral rami C3-8

- Posterior: Ventral rami C6-8

- Circulatory: Branches of subclavian artery

Scalenes

1. Longus colli

2. Longus capitis

3. Rectus capitis anterior

4. Rectus capitis lateralis

What are the anterior prevertebral muscles?

- Origin: Transverse processes C3-C5; Bodies of C5-T3

- Insertion: Anterior tubercle of atlas (C1), anterior vertebral bodies of C1-3, transverse processes of C3-C6

- Action:

- Bilateral: Flexes neck

- Unilateral: Contralateral rotation

- Innervation: Ventral Rami of cervical spinal nerves

Longus colli

- Origin: Transverse processes of C3-C6

- Insertion: Inferior surface occipital bone

- Action: Flexes neck

- Innervation: Ventral Rami of cervical spinal nerves

Longus capitis

- Origin: Anterior, lateral mass of atlas (C1)

- Insertion: Base of occipital bone anterior to foramen magnum

- Action: Flexes head, stabilizes A-O joint

- Innervation: Ventral Rami of cervical spinal nerves

Rectus capitis anterior

- Origin: Transverse process of atlas

- Insertion: Jugular process of the occipital bone

- Action: Lateral flexes head

- Innervation: Branches of loop between C1-C2

Rectus capitis lateralis

1. Rectus capitus posterior major

2. Rectus capitus posterior minor

3. Inferior oblique of the head

4. Superior oblique of the head

What are the suboccipital muscles?

- Origin: C2 spinous process

- Insertion: Inferior nuchal line

- Action:

- Unilateral: ipsilateral rotation of head

- Bilateral: Extends head at AO joint

- Innervation: Suboccipital N (C1)

Rectus capitus posterior major

- Origin: C1 posterior tubercle

- Insertion: Inferior nuchal line

- Action:

- Unilateral: ipsilateral rotation of head

- Bilateral: Extends head at AO joint

- Innervation: Suboccipital N (C1)

Rectus capitus posterior minor

- Origin: C2 spinous process

- Insertion: C1 transverse process

- Action: Ipsilateral rotates head

- Innervation: Suboccipital N (C1)

Inferior oblique of the head

- Origin: C1 transverse process

- Insertion: Occipital bone (B/w superior and inferior nuchal lines)

- Action: Extends, lateral flexes head

- Innervation: Suboccipital N (C1)

Superior oblique of the head

7

How many cervical vertebrae are there?

8; above except C8 exits between C7-T1

How many cervical spinal nerves?

Exit above or below same named vertebra? Except?

Atlanto-occipital

_________ joints: Condylar synovial joint that permits flexion and extension of the cranium. This motion is often noted when nodding the head to say "Yes"

Atlanto-axial

________ joints: Plane synovial joints that permit flexion, extension, lateral flexion, and rotation of the spin. The majority of rotation of the skull on the spinal column occurs here.

Intervertebral

________ joints: Formed by the superior and inferior surfaces of the vertebral bodies and the associated disk.

Zygapophyseal

________ joints: Formed by the right and left superior articular facets of one vertebra and the right and left inferior articular facets of an adjacent superior vertebra.

Intervertebral discs

________: Formed by a dense layer of collagen fibers and fibrocartilage called the annulus fibrosus as well as a flexible inner layer called the nucleus pulposus.

Posterior and superior

Cervical superior articular facets face?

1. Capsular pattern restriction: Lateral flexion and rotation equally limited, then extension

2. Loose pack (Facet): Midway between flexion and extension

3. Closed pack (Facet): Extension

Cervical capsular pattern/closed pack/loose pack:

1. Flexion/extension

2. Side bending

3. Rotation

4. Anterior/posterior shear

5. Lateral shift

6. Compression/distraction

Six degrees of motion of the spine:

Upper cervical extension with lower cervical flexion

Protraction of c-spine:

Upper cervical flexion with lower cervical extension

Retraction of c-spine:

Alar ligament

______ ligament: From dens (C2) to occipital condyle; limit axial rotation of head and atlas relative to the dens.

Transverse ligament

______ ligament: Between the lateral masses of C1 and functions to provide posterior support to the dens (forming a collar with the anterior arch of C1)

Posterior longitudinal ligament

_________ ligament: Limits flexion, reinforces posterior disc.

Anterior longitudinal ligament

_________ ligament: Limits extension of the spine and reinforces the anterior portion of the intervertebral disks and vertebrae.

1. Passive (bones/ligaments resist motion)

2. Active (muscles respond dynamically)

3. Neural control (nervous system coordinates muscle activation)

Spinal stability is supported by three subsystems:

A. Anterior cerebral artery

B. Internal carotid artery

C. Posterior communicating artery

D. Posterior cerebral artery

E. Vertebral artery

F. Basilar artery

G. Arterial circle

H. Middle cerebral artery

I. Anterior communicating artery

Circle of Willis

1. Roots (C5-T1)

2. Trunks (superior, middle, inferior)

3. Divisions (anterior, posterior)

4. Cords (lateral, medial, posterior)

5. Branches (Musculocutaneous, axillary, median, radial, ulnar)

Brachial plexus

1. Dorsal scapular (rhomboids, levator scapulae)

2. Long thoracic (Serratus anterior)

Brachial plexus: Nerves/muscles from the rami of the plexus

1. Nerve to subclavius (subclavius)

2. Suprascapular (infraspinatus/supraspinatus)

Brachial plexus: From the trunks of the plexus

1. Lateral pectoral (pectoralis major - clavicular head)

2. Musculocutaneous (coracobrachialis, biceps brachii, brachialis)

3. Lateral root of the median (flexor muscle in forearm, except flexor carpi ulnaris, and five muscles in the hand)

Brachial plexus: From the lateral cord of the plexus

1. Medial pectoral (pectoralis major, pectoralis minor)

2. Ulnar (flexor carpi ulnaris, flexor digitorum profundus, most small muscles of hand)

3. Medial root of the media (flexor muscles in the forearm, except flexor carpi ulnaris, and five muscles of the hand)

Brachial plexus: From the medial cord of the plexus

1. Upper subscapular (subscapularis)

2. Thoracodorsal (latissimus dorsi)

3.Lower subscapular (subscapularis, teres major)

4. Axillary (deltoid, teres minor)

5. Radial (brachioradialis, triceps, supinator, wrist extensors, anconeus)

Brachial plexus: From the posterior cord of the plexus

"Oh Oh Oh to touch and feel very good velvet, ah heaven"

"Some say marry money but my brother say big brains matter most"

CN mnemonics

Olfactory

CN I: ________

Classification: Sensory

Function: Smell

Test: Identify familiar odors

Optic

CN II: ________

Classification: Sensory

Function: Sight

Test: Test visual fields

Oculomotor

CN III: ________

Classification: Motor

Function: Eye Movement: Look R, L, up, down, and parasympathetic motor

Test: Upward, downward, and medial gaze/reaction to light - smooth pursuit

Trochlear

CN IV: ________

Classification: Motor

Function: Eye muscle: Superior oblique

Test: Downward and inward gaze

Trigeminal

CN V: ________

Classification: Both

Function: Face sensation and mastication

Test: Face sensation. corneal reflex, clench teeth

Abducens

CN VII: ________

Classification: motor

Function: Eye muscle: lateral rectus muscle

Test: Lateral gaze

Facial

CN VII: ________

Classification: Both

Function: Taste (anterior tongue), facial expression muscles, and parasympathetic motor

Test: Closes eye, smile, puff cheeks, familiar tastes

Vestibulocochlear

CN VIII: ________

Classification: Sensory

Function: Hearing and balance

Test: Hearing test/eyes closed

Glossopharyngeal

CN IX: ________

Classification: Both

Function: Taste and parasympathetic motor

Test: Gag reflex/ability to swallow

Vagus

CN X: ________

Classification: Both

Function: Taste, fore/midgut sensory and parasympathetic motor

Test: Gag reflex, ability to swallow, say "Ahhh"

Accesory

CN XI: ________

Classification: Motor

Function: Trapezius & SCM

Test: Resisted shoulder shrug

Hypoglossal

CN XII: ________

Classification: Motor

Function: Muscle of tongue

Test: Tongue protrusion (if inured, tongue deviates toward injured side)

1. C5, C6 Musculocutaneous

2. C5, C6 Radial

3. C6, C7 Radial

Match the following:

1. Biceps

2. Brachioradialis

3. Triceps

C6, C7 Radial

C5, C6 Musculocutaneous

C5, C6 Radial

Meninges

____________: Consist of three layers of connective tissue covering the brain and spinal cord. They provide protection from contusion and infection. There are blood vessels and cerebrospinal fluid within them.

Dura mater, arachnoid mater, pia mater

Put in order from superficial to deep:

- Pia mater

- Dura mater

- Arachnoid mater

Blood-brain barrier

___________: Consists of the meninges, protective glial cells, and capillary beds of the brain. It is responsible for exchange of nutrients between the CNS and the vascular system. Provides protection for the CNS by restricting certain molecules from crossing the barrier while others are able to do freely.

Cerebral spinal fluid

_________: Clear, fluid-like substance that cushions the brain and spinal cord from injury and provides shock absorption, circulates nutrients and chemicals filtered from the blood, and removes waste products.

Causes structural and biochemical changes:

- Stretching of axons

- Damage to cell membranes

- Dysregulated ion flow

- Increased glutamate release

This disrupts normal neurological function and produce concussion symptoms

What is occurring physiologically during a concussion?

1. CNS/brain

2. Vestibular system

3. Oculomotor/visual

4. Cervical musculoskeletal system

5. Autonomic/exertional system

6. Cognitive/emotional systems

What tissues or body systems are involved in a concussion?

- Blunt force or jolt to the head or neck

- Direct blow to the head, face, neck

- Force elsewhere on the body transmitted to the head

- Common mechanisms: falls (main), sports collision, and blast injuries

- Causes brain to rapidly twist or bounce inside of skull

What causes a concussion?

- Symptoms may occur immediately

- LOC may occur but is not required

- PTA/altered mental status may occur (Antero/retrograde)

- Recovery can occur as quickly as 7-10 days

- >14 days = protracted recovery

- Some develop persistent symptoms lasting months or longer

- Progress from relative rest for the first 24-48 hours and gradually return to daily activity/exercise based on symptoms

What causes a concussion to progress/resolve?

1. Cognitive/fatigue: Fogginess, concentration/memory problems fatigue

2. Vestibular: Dizziness, nausea, imbalance, motion sensitivity

3. Ocular: Blurred/double vision, difficulty focusing/reading

4. Migraine/headache: Headache, nausea, light/noise sensitivity

5. Anxiety/mood: Anxiety, depression, irritability, emotional changes

6. Motor/balance: Impaired balance, coordination, dual-tasking

7. Autonomic/exertional: Symptoms w/ PA and heart rate

8. Cervical: Neck pain, decreased ROM, cervicogenic

9. Sleep: difficulty sleeping or altered pattern

What impairments develop because of a concussion?

Anyone sustaining sufficient head/body trauma

Common populations:

- Athletes

- Military personnel

- Individuals who fall

Who develops a concussion?

1. Sports participation

2. Previous concussion

3. Female sex - risk factor

4. Concussion risk is greater during games

4. Collision/contact exposure

5. Military personnel

What characteristics or demographics are common in concussions?

1. Risk factors

- Previous concussion

- Sports

- Female sex

2. Medical history

- Cognitive/fatigue: Prior cognitive deficits or sleep disturbance

- Vestibular: History of motion sickness

- Ocular: Oculomotor impairment (strabismus)

- Migraine: Personal or family history

- Anxiety/mood: Hx of mental health disorder

3. Lifestyle/environmental

- Sports, continuing to participate after injury

- High physical/cognitive demands

- Poor sleep

- Visually stimulating environment

What are the predisposing risk factors for concussions?

Typical MOI:

- Direct blow to head, face, or neck

- Jolt/impulsive force transmission to head

- Fall (main cause)

Common patient history:

- Headache, dizziness, feeling dazed/foggy, confusion, balance problems, nausea, visual disturbance, difficulty concentrating/remembering, LOC may or may not occur, PTA may occur

MOI of concussions

Chief complaint: Reports of headache, dizziness, fogginess/fatigue, difficulty concentrating, balance problems, visual problems, neck pain, nausea, light/noise sensitivity.

Subjective findings during concussion: Chief complaints

- Symptoms vary between patients

- May have a few symptoms at rest but symptoms appear with activity

- Symptoms can increase with physical, visual, vestibular, or cognitive demands

- May become more symptomatic with dynamic movement and crowded environments

Subjective findings during concussion: Symptom behavior

Aggravating:

- Exercise/PA

- Head movement

- Reading/screens

- Bright lights/noise

- Busy/crowded environments

- Cognitive activity

- School/work

- Poor sleep

Easing:

- Relative rest

- Decreasing provocative stimulation/activity

- Pacing activities

(24-48 hours of relative rest followed by gradual return to daily activity)

Subjective findings during concussion: Aggravating and easing factors

School/work, reading/computer use, exercise/sports, walking/balance, driving, community activity, dual-tasking, return to previous PA

Subjective findings during concussion: Functional limitations

- What happened? MOI

- Did you lose consciousness? Length?

- Any post-traumatic amnesia?

- What symptoms occurred immediately after?

- Previous concussion?

- History of headaches/migraines?

- mental health or sleep history?

Subjective findings during concussion: Questions to ask

May observe:

- Appears dazed, foggy, or slowed

- Gait/balance difficulty

- Difficulty concentrating or following commands

- Symptoms may increase as examination becomes more provocative

- Normal at rest, but increase symptoms with activity

Objectives findings during concussion: Observation

May have decreased or painful cervical ROM with C-spine involvement

Objectives findings during concussion: ROM findings

With cervical involvement, may have:

- Decreased strength

- Decreased endurance

- Pain with resisted testing

Objectives findings during concussion: Strength

Testing may be normal but screen:

- Cranial nerves

- Sensation/motor function

- UMN

- Cognition/mental status

911 or seek ED if: One pupil larger than other, drowsiness or difficulty waking up, unrelenting or worsening headache, loss of sensation or strength on one side of body, slurred speech, nausea with vomiting, seizures, LOC, unusual behavior/agitated.

Objectives findings during concussion: Neurological

May demonstrate:

- Increased postural sway

- Increased balance errors

- Impaired static/dynamic balance

- Difficulty with gait

- Difficulty with dual-tasking/multitasking

Balance outcome measures include: BESS, SOT, HiMAT, DGI, FGA, and BEST

Objectives findings during concussion: Balance/Postural impairments

May have difficulty with:

- Exercise/sports

- School/work

- Reading/computer use

- Busy/crowded environments

- Busy/crowded environments

- Head movements

- Dual-task

- Return to PA

Objectives findings during concussion: Functional limitations

1. Prognosis

- Generally favorable

- Varies depending on symptom severity/systems involved

2. Typical recovery timeline

- Recovery can occur as quick as 7-10 days, protracted recovery is >14 days

- Some experience symptoms for months or longer

3. Factors with delayed healing

- Immediate LOC

- Post-traumatic amnesia

- Continuing sport after injury

- Prolonged headache

- Fatigue/fogginess/memory problems

- >3 initial symptoms

- Visual memory/processing speed deficits

- Premorbid headaches

- Previous concussion

- Worsening symptoms after injury

- Emotional symptoms on day of injury

- Female sex

Clinical Course - Concussion

1. Activity/work/school:

- Gradually increase physical and cognitive activity

- Use pacing strategies and accommodations as needed

- Progress based on symptom response and irritability

2. Exercise:

- Begin symptom-guided aerobic exercise when appropriate

3. Sport

- Team based decision

- Must be symptoms free at rest and tests including (VOMS, BCTT, phased return to sport, IMPAACT, practice, school demands)

- Impact test is compatible to baseline score

- If protracted recovery, consider ramp up period due to deconditioning

Return to activity/work/sport expectations: Concussion

1. Manual therapy to C-spine/T-spine

2. ROM exercises/ SNAGs

3. Strengthening - i.e., DNF, endurance training

4. Re-integrate cervico-ocular reflex with joint position error training (move head on stationary body, move body on stationary head position)

Recommended interventions: Cervical

1. Treat what you see

2. Recall treatments for saccades, smooth pursuit, convergence, etc.

Refer to vision specialist when necessary:

- Neuro-opthalmologist

- Neurobehavioral optometrist

Recommended interventions: Oculomotor

1. BPPV (Canalith repositioning)

2. Motion sensitivity (desensitization techniques)

3. VOR (vestibular rehab program)

4. Need to integrate into functional activities/sports specific activities

Recommended interventions: Vestibular

How: Stroke lateral plantar foot from heel toward forefoot

Normal response: Toes flex/down

Abnormal: Great toes extend with fanning of other toes

Interpretation: Positive = possible UMN/CNS pathology

Examination techniques concussion: UMN Babinski

How: Flick distal phalanx of middle finger

Normal: No thumb/index flexion

Abnormal: Thumb/index flexion

Interpretation: Positive = possible UMN/CNS pathology

Examination techniques concussion: UMN Hoffmann's

How: Rapidly dorsiflex ankle and maintain stretch

Normal: No sustained rhythmic contractions

Abnormal: Sustained/repetitive beats

Interpretation: Positive = Suggest UMN involvement

Examination techniques concussion: UMN Clonus

How: Tap brachioradialis tendon

Normal: Brachioradialis contraction/elbow flexion

Abnormal: Reduced response with finger flexion

Interpretation: Positive = cervical spine cord/UMN involvement

Examination techniques concussion: UMN Inverted supinator sign

1. Any high-risk factors?

- Age >=65

- Dangerous mechanism

- Paresthesia in extremities

2. Is there a low-risk factor allowing safe ROM testing?

- Simple rear-end MVC

- Able to assume sitting position in ER

- Ambulatory at any time

- Delayed onset neck pain

- No midline cervical tenderness

3. Can patient actively rotate neck 45 left and right?

- Yes - radiography not indicated

- No - radiography indicated

Examination techniques concussion: Canadian C-spine rules

How: Patient keeps head still and follows target with eyes

Normal: Smooth tracking

Abnormal: jerky/poor tracking or symptom provocation

Interpretation: Oculomotor involvement

Examination techniques concussion: Smooth pursuit

How: Patient rapidly looks between two targets horizontal and then vertical

Normal: Quick, accurate eye movements w/o symptoms

Abnormal: Poor accuracy/slowed movements or symptoms

Interpretation: Oculomotor involvement

Examination techniques concussion: Horizontal & vertical saccades

How: Slowly move target toward patient's nose and measure

Normal:

Examination techniques concussion: Convergence

How: Patient looks at stationary target while moving head horizontal and vertical (180 bpm)

Normal: Maintains fixation w/o symptoms

Abnormal: Difficulty maintaining target or symptom provocation

Interpretation: Vestibular/VOR impairment

Examination techniques concussion: Horizontal and vertical VOR

How: Patient focuses on thumb while rotating head, trunk, and arms together

Normal: Minimal/no symptoms

Abnormal: Increased dizziness, headache, nausea, or fogginess

Interpretation: Suggests visual-motion/vestibular sensitivity

Examination techniques concussion: Visual motion sensitivity

How: Stabilize C2 and move the head/atlas into side bend

Normal: Firm restriction

Abnormal: Excessive movement compared with opposite side or soft end-feel

Interpretation: Alar ligament instability

Examination techniques concussion: Alar ligament test

How: Patient seated with slight cervical flexion. Stabilize C2 and apply a posterior force through forehead

Normal: No excessive translation, clunk, or symptom change

Abnormal: Excessive movement, clunk, reduction of neurological symptoms

Interpretation: Transverse ligament/atlantoaxial instability

Examination techniques concussion: Sharp-Purser test

Symptoms: Noncontinuous, unilateral neck pain W/O side shift and associated headache (referred). Headache is precipitated by or aggravated by neck movements or sustained positions/postures.

Demographic: Mean age 42.9

Impairments: Positive CFRT, headache produced with provocation of upper cervical segments, limited cervical ROM, restricted upper cervical segmental mobility, strength, endurance, and coordination deficits of neck and scapulothoracic muscles.

Cause: Impairments in C-spine (upper), stemming from trigeminocervical nucleus

Neck pain with headaches: Symptoms, demographic, and impairments

- Female: male - 50/50

- Unilateral without side shift

- Occipital to frontoparietal and orbital

- Chronic, episodic

- Moderate-severe

- 1 hour to weeks

- Non-throbbing, and non lancinating, pain usually starts in the neck

- Triggers, neck movement, and postures, limited ROM, pressure over C0-3

Cluster: Decreased AROM of cervical extension, palpably painful somewhere from OA to C3/4 joint dysfunction, deep cervical flexor strength impairments w/ CCFT

Differential diagnosis of headaches: Cervicogenic headaches

- Female: male - 75:25

- 60% unilateral with side shift

- Frontal, periorbital, temporal

- 1-4 per month

- Moderate/severe

- 4-72 hours

- Throbbing, pulsating

- Triggers, multiple, neck movement not typical

- Associated symptoms nausea, vomiting, visual changes, phonophobia, photophobia

Differential diagnosis of headaches: Migraine

- Female: male 60:40

- Diffuse bilateral

- 1-30 per month

- Mild/moderate

- Days to weeks

- Dull

- Multiple triggers, neck movement not typical

- Associated symptoms, occasionally decreased appetite, phonophobia, photophobia

Differential diagnosis of headaches: Tension-type headache

Symptoms: Unilateral neck pain, neck stiffness, onset of symptoms often linked to a recent unguarded/awkward movement, may report recurrent bouts of pain, associated UE pain may be present.

Demographic: Spondylosis related to increased age/OA (typically 40-50)

Impairments: Limited c-spine AROM, neck pain at end AROM & PROM, hypomobile segmental mobility of C-spine/thoracic, cervical and scapulothoracic strength deficits.

Neck pain with mobility deficits (Cervicalgia, pain in thoracic spine, spondylosis): Symptoms, demographic, and impairments