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

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

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

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

  2. CASE STUDY #2IE: 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

  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 #1IE: 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

  5. 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 • (Ellis, FFCFMT 2003)

  8. CERVICAL SPINE: LIGAMENTS → → ↓ →

  9. CERVICAL SPINE: MUSCLES →

  10. CERVICAL SPINE: NEUROANATOMY AND VASCULARIZATION • Vascularization • Significant blood/venous supply • 2 Carotid arteries/2 vertebral arteries supply most of the brain • Vertero-basilar system (Ellis, FFCFMT 2003)

  11. POSTCONCUSSIVE PATHOLOGY

  12. 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” • (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. 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. Post-Treatment #1 Pre-Treatment #1

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

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

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

  22. REFERENCES • American Academy of Manual Medicine. Suboccipital Muscle Group. www.webmanmed.com/disorders. 2012. • Brain Trauma Research Center. Sports-Related Concussions: Background and Significance. www.Neurosurgery.pitt.edu/trauma/concussion. 2001-12 • 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) 228-35 • Grady, Matthew. Concussion in the Adolescent Athlete. Current Problems in Adolescent Health Care 2010; 40:154-69. • Institute of Physical Art. Functional Orthopedics I. 2010. • Institute of Physical Art. Proprioceptive Neuromuscular Re-education. 2011. • Johnson, Gregory. Soft Tissue Mobilization. IPA Continuing Education; 599-639. • McKee, et al. TDP-43 Proteinopathy and Motor Neuron Disease in Chronic Traumatic Encephalopathy. Journal of Neuropathology Experimental Neurology 2010; 69(9) 918-29. • Moser, et al. Neuropsychological Evaluation in the diagnosis and management of sports related concussion. National Acadamy of Neuropsychology 2007; 22 909-16. • Signoretti, et al. The Pathology of Concussion. American Academy of Physical Medicine and Rehabilitation 2011; 3 359-68. • Tiidus, Peter. Manual Massage and Recovery of Muscle Function Following Exercise; a literature review. Journal of Orthopedic and Sports Physical Therapy 1997; 25(2) 107-112. • Toledo, et al. The young brain and concussion; Imaging as a biomarker for diagnosis and prognosis. Neuroscience and Biobehavioral Reviews 2012; 36 1510-31. • USA today online. Concussion Statistics. October 11, 2012.

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