This document summarizes a presentation on concussions and cervical injuries. It discusses how concussions are caused by rotational forces on the brain and shares similarities in symptoms with cervical injuries, which result from neck muscle strains. Tests are presented to differentiate between concussion and cervical injury. The risk of lower extremity injuries in the 6 months following a concussion is significantly higher than in non-concussed athletes, with the knee and ankle being most commonly injured. Ongoing balance and strength training is recommended for several months after concussion recovery to prevent future injuries.

1. Concussion: cervical and
neuromuscular deficits
JON MINOR, MD
SPARCC, CO-MEDICAL DIRECTOR

2. Objectives
At the conclusion of this talk, attendees should feel more
capable of:
1. Recognizing the similarities in symptoms of cervical injury
and concussion/post-concussion syndrome.
2. Identifying students, athletes or patients who may benefit
from therapeutic intervention of the head, neck and/or upper
back.
3. Counseling and prevention of delayed lower extremity injury
following concussion injury.

3. Concussion: Background
•Incidence: 300K-3.8M annual
athletic concussions (estimated)
Marar M et al 2012; Yard EE et al 2009; Halstead ME et al 2010
• 50% of concussions in kids 11-15
are not sports-related

4. Concussion: Mechanism of Injury
4

5. Concussion: Mechanism of Injury
Biomechanics: ”spinning of the brain”
Rotational acceleration
◦Early 1900’s slaughterhouses (free to move,
accelerate)
◦Ommaya and Genarelli 1974 (experiment: proving
rotational vs. linear acceleration)

6. Concussion: Mechanism of Injury
Acceleration and rapid deceleration via rotation or angular
velocity force to head and brain (spinning the brain)

7. Concussion: Mechanism of Injury

8. Concussion: Mechanism of Injury

9. Is it really Concussion?
Depression
Anxiety
Thyroid disorder
Parathyroid d/o
Sleep disorder:
sleep apnea,
bruxism, leg d/o
ADD/ADHD
Sinus infection
URI
Dehydration
Migraines
Brain tumor
Labyrinthitis
Vestibular
dysfunction
Chiari malformation
Cervicogenic
headaches
PCS
Visual dysfunction
If it’s not concussion (or PCS), what else can it be?

10. Concussion Symptom Interplay

11. Concussion vs Cervical Injury
Headache
Dizziness
Tinnitus
Irritability
Sleep disturbances
Blurred vision
Neck Stiffness
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Concussion Cervical Injury

12. Concussion vs Cervical Injury
Balance disturbances
Depression
Cognitive deficits
Memory deficits
Attention deficits
Decreased cervical ROM
Decreased isometric
neck strength
X
X
X
X
X
X
X
X
X
X
X
Concussion Cervical Injury

13. Concussion vs Cervical Injury
Concussion:
Complex pathophysiologic process induced by biomechanical forces
affecting the brain
Cervical Injury:
Persistent impairments caused by dysfunction of the somatosensory
system of the cervical spine
◦ Likely caused by the strain placed on soft tissues of the neck
◦ Strain disrupts afferent pathways that relay information from the neck to brain

14. Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Initial neck position
Force

15. Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Retraction
Force
Initial compression
force

16. Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Extension

17. Cervical Injury: Mechanism
4 Phases of neck injury:
1. Initial position
2. Retraction
3. Extension
4. Rebound
Rebound
Result: myofascial strains

18. Cervical Injury: Pathways
Journal of Athletic Training,
2016; 51 (12): 1037-1044
Three checks and balances
systems for redundancy:
1. Ocular system
2. Central/vestibular system
3. Neck proprioception and
somatization (pain/sensation)

19. Cervical Injury: structures
Facet joint involvement associated
with cervical symptoms in mTBI:
C1-C2, C2- C3, C0-C1, and C3-C4
Note: C2 nerve root arises
from C1-C2; forms the
Greater Occipital Nerve

21. Evaluating & Treating Cervical Injury
Case Example:
• 16 y/o female (MVA, soccer collision, slip and fall- could be anything)
• 6 weeks since injury, and NOT FEELING LIKE SHE’S IMPROVING
• Significant headaches (light and sound sensitive, exercise and cognitively
induced), nausea & dizziness, “moody”
• In school for 2 hours per day, not tolerating well
• Working with PT
• Scheduled for neuro-optometry evaluation in 6 weeks

22. Cervical Injury: Differentiation Tests
1. Joint-reposition error test (JPET)
◦ Test ability to reposition after passive
flexion, extension and rotation
Journal of Athletic Training, 2016; 51 (12): 1037-1044
Assesses for spindle damage in muscles:
treat with neck proprioception

23. Cervical Injury: Differentiation Tests
2. Smooth-pursuit neck-torsion test
(SPNTT)
◦ Testing for cervicogenic causes of
dizziness
Journal of Athletic Training, 2016; 51 (12): 1037-1044
Assesses for afferent disturbance in the neck:
treat with manual therapy & gaze stabilization
@ 45o

24. Cervical Injury: Differentiation Tests
3. Head-neck differentiation test (HNDT)
◦ Testing for cervicocollic reflex, cerebellar function
Journal of Athletic Training, 2016; 51 (12): 1037-1044
If symptoms (dizziness/balance) treat with head & neck differentiation training

25. Cervical Injury: Differentiation Tests
4. Cervical flexion-rotation test (CFRT)
◦ Tests for afferent proprioception
disturbance in the neck
Journal of Athletic Training, 2016; 51 (12): 1037-1044
If dizziness treat with manual therapy

26. Cervical Injury: Headache Patterns
Journal of Athletic Training, 2016; 51 (12): 1037-1044

27. Cervical Injury: Additional Intervention
Injection Therapy
1. Greater occipital nerve trigger
point injection
◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose & anesthetic
agent)

28. Cervical Injury: Additional Treatment
Injection Therapy
2. Levator Scapula & trapezius
trigger point injection
◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose &
anesthetic agent)

29. Cervical Injury: Additional Treatment
Injection Therapy
3. Subscapular bursa trigger point
injection
◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose &
anesthetic agent)

30. Cervical Injury: Additional Treatment
Injection Therapy
4. Facet joint injection
◦ Cortisone
◦ Anesthetic agent only
◦ Prolotherapy (dextrose &
anesthetic agent)
◦ PRP

31. Cervical Injury: Additional Treatment
Non-invasive Therapy
1. Physical therapy
◦ Soft tissue & joint mobilization, dry
needling, strengthening, proprioception
2. Osteopathic Manual Manipulation
◦ Sub-occipital release & other treatments
3. Acupuncture/acupressure
4. Massage therapy
5. Cranio-sacral manipulation

33. Recent Summary: 2017 PhD dissertation
defense at U of Pittsburgh
Amy Aggelou (Micky Collins team)
PhD, LAT, ATC
Director and Instructor, Athletic Training
Education Program
4047 Forbes Tower
Pittsburgh, PA 15260
aaggelou@pitt.edu
Study Design:
Injury Surveillance at U of Pitt from
2007/2008 – 2016/2017 athletic
seasons

34. Recent Summary: 2017 PhD dissertation
defense at U of Pittsburgh
Amy Aggelou, PhD, LAT, ATC
Findings:
62% of concussed athletes sustained LE injury within
180 days (vs 26% of non-concussed controls)
Risk of subsequent LE injury 7.37 times higher for
concussed athlete within 180 days (vs controls)
Risk of subsequent LE injury 7 times higher for
concussed athlete within 180 days, when having a LE
injury within 90 days prior to concussion

35. Recent Summary: 2017 PhD dissertation
defense at U of Pittsburgh
Amy Aggelou, PhD, LAT, ATC
Location of LE injuries after concussion
Findings:
1. Knee (35%) and Ankle (33%) were most common joints
injured after concussion
2. Foot comprised 12% of injuries after concussion
3. Lateral ankle sprains were most common specific injury
(25.5%)

36. Lower Extremity MSK Injuries: Timeline
of injury
Lynall et al. Acute Lower Extremity Injury Rates Increase following
Concussion in College Athletes. Medicine and science in sports and
exercise. 2015.
Findings:
1. Significantly increased risk of LE injury at 180 and 365 days after
concussion
2. No increased risk of LE injury at 90 days after concussion

37. Lower Extremity MSK Injuries: Timeline
of injury
Consider:
Ongoing proprioception, balance, agility, hips & core
strengthening for months after recovering from concussion

38. Summary
1. Concussions will occur
2. Consider cervical origin of prolonged concussion symptoms, and
treat accordingly
3. Recovered individuals are at increased risk of lower extremity
injury for up to 1 year following concussion
4. Provide a plan to prevent future concussion and lower extremity
injury with ongoing dynamic exercise program

39. Thank you!
Questions?