CERVICAL SPINEGroup I Presentation

Outline

History Preliminary Diagnosis Examination Working Diagnosis Treatment / Management Outcome Measures / Results

HISTORY

Important Questions

Mechanism of Injury Pain Loss of Consciousness Previous History Concussive Sequelae

Did you lose consciousness? Or hit your head? How long were you out?

How was the impact? Front, Side, Roll-over?

Were you wearing your seatbelt? If any what injuries did you sustain? Have you had any previous MVA’s?

DIFFERENTIAL DIAGNOSIS

Preliminary Cervical Fracture

/Microfracture VSC Postural Paresis Muscle spasm Cervicogenic

headache Facet syndrome

Herniated Disc/ Disc involvment

Cervical Sprain/Strain

Cervical myelopathy Concussion and

concussive sequelae

EXAMINATION

5 Key Tests for Cervical injury X-ray – detect fracture

OrthopedicsSpurlings – detect disc involvement

Upper limb tension test – detect radiculopathy

ROM – detect joint dysfunction/muscle restriction

OPK strip – detect cerebellar injury

Saccades – detect cerebral injury

Assessment of Whiplash Smooth Pursuit Neck

Torsion Test (SPNT) Identifies altered eye movements

due to cervical spine problems.○ Nystagmus during slow pursuit with

head rotated○ Due to damaged Proprioceptors in

cervical Spine

Used to distinguish between WAD and alternative diagnoses. ○ SPNT is diagnostic for the

effect of acceleration-deceleration injuries

○ Focuses on the proprioceptors of the neck.

Assessment of Whiplash Joint Error Position test

(JEP)Patient puts head through

one plane of motionReturns to NeutralWill “over-shoot” neutralDamage to proprioceptors of

the Cervical spine.○ Must get additional “gain” from

increased motion○ And greater muscle stretch

Assessment of Concussion Standardized Assessment of Concussion

(SAC) – Mental Exam Orientation (month, date, year, day of week) Immediate memory (recall of 5 words in 3 separate trials) Neurologic screening

Loss of Consciousness (seconds, minutes) Amnesia (either retrograde or anterograde) Strength - MMS Sensation - Dermatome Coordination – Finger to Nose, etc

Concentration (counting backwards; saying months backwards)

Exertional maneuvers (jumping jacks, sit-ups, squats) Delayed recall (5 words)

Assessment of Concussion Balance Error Scoring

System (BESS) Developed by researchers and clinicians at the

University of North Carolina’s Sports Medicine Research Laboratory

Double leg, single leg, tandem stanceTwo Trials:

○ Floor○ Foam Pad

Maintain balance for 20 seconds

Hands on hips, Eyes closed Count the number of falls

More than 5 errors in 20 sec., suggests a concussion

Lateral Cervical Neutral

AP Lower Cervical

AP Open Mouth

Lateral Flexion / Extension

Labwork

Another way to recognize “what injury looks like in the body”

Often times with injury, clear objective findings may not be apparent

What should we see with whiplash or trauma?1. Inflammation

2. Tissue destruction

What type of tissues are likely to be damaged in whiplash?

Myoglobin

Oxygen building heme protein present in cardiac and skeletal muscle

Routinely used to rule out heart attack Reliable nonspecific indicator of

muscle damage

Creatine Kinase According to Croft, “petechia may be present

in the brain post whiplash injury”. Traction of the brainstem Shearing action between

1. Outer gray and inner white layers

2. Thalamus and cortex

Creatine Kinase AKA “CK” Enzyme Utilizes ATP rapidly Assess muscle diseases

Ex: muscular dystrophy Energy shuttle Higher levels during trauma

Creatine Kinase

Fraction is useful in locating trauma1. CK-MM

2. CK-MB

3. CK-BB

C Reactive Protein

Indicator general tissue inflammation Protein produced by the liver Elevates due to:

1. Heart attack

2. Joint tissue breakdown

3. Connective tissue breakdown

Highly Sensitive C Reactive Protein CRP fraction AKA hs-CRP Accurately detect lower values of the

protein Recognized cardiac stress “spikes”

associated with trauma More useful in detecting lower levels of

damage

WORKING DIAGNOSIS

Cervical Whiplash (847.0) Complicated with:

Postural Paresis (781.92)Traumatic brain injury/concussion with brief

loss of consciousness (850.1)Cervical Segmental Dysfunction (739.1)Thoracic Segmental Dysfunction (739.2)

TREATMENT

Phase I Treatment

Frequency: 6x/wk for 2 wks Adjustment Therapeutic Exercise

Wobble ChairOverhead ExtensionsProne Neck RotationWall Push-UpsSquats

Post-Isometric Relaxation

Outcome Measures: Phase I Reduce Pain Increase ROM Strengthen Muscles Reduce Inflammation with nutrition

Phase II Treatment

Frequency: 3x/wk for 10 wks Adjustment Therapeutic Exercises Neuromuscular Re-education

Cross-CrawlOne-Leg Stance

Vibe Plate Post-Isometric Relaxation

Outcome Measures: Phase II Eliminate Pain Full ROM TE=Strength and Endurance NMR = Balance, Coordination,

Neuroplastic Change Improve Posture; Cervical Curve

Phase III Treatment

Determine Necessity Determine Frequency

Wait 2wks Reassess ↑ or ↓ Frequency Lifelong Care

Outcome Measures: Phase III Read, Study, and Concentrate Pre-

accident Levels Remission of Concussion Sequelae Read with no Neck pain Full Cervical ROM Headache 1 per month Maintain balance on Blue pad

NUTRITION

Goals

Modulate pain and inflammation Arrest degeneration Strengthen connective tissues Regulate fibrinogen deposition Prevent dystrophic calcification

Inflammation Regulation Support normal adrenal function

1. Vitamin C

2. B2, B6, B3, B5 Proteolytic enzymes: Papain,

bromelain, trypsin Inflammation regulation

1. Modulate arachidonic acid cycles○ EPA

Inflammation Regulation

Modulate the lipoxygenase and cyclo-oxygenase pathways

Vitamin E, EPA, DHA Regulate C reactive protein levels

1. Protein made in the liver

2. Nonspecific, sensitive response to infection or trauma

Vitamin E

Inflammation Regulation

Modulate histamine response

1. Produced by mast cells

2. Serves to rapidly remove a noxious stimuli from the body tissues

Bioflavonoids: Quercetin, Rutin

Prevent Dystrophic Calcification

Calcium enters via mechanoporation May contribute to glutamate excitotoxicity

eventually ischemia Calcium is effectively mobilized by properly

balanced with: Magnesium Phosphorous

Prevent Tendon/Ligament Laxity

Manganese1. Ligament strengthener, muscle builder,

bone hardener○ Ligaplex I/II are speciality formulas○ Also contain vitamin E and other syngergists

Regulate Fibrinogen Deposition

Post trauma serves to support weakened structures.

Surrounds muscle, ligaments, tendons, organs.

Skyscraper analogy1. Serrapeptase (Serratia Peptidase)

○ AKA “Vitalzym”○ Strongest fibrinolytic enzyme known!

Fibrinogen

Manage Pain

Chemical messengers of pain: substance P, bradykinin1. Curcumin,

2. Ginger,

3. Boswelia

THE END