The association of concussion history and symptom presentation in combat sport athletes.

OBJECTIVE: The purpose of this study was to describe the concussion-related symptoms reported among combat sport athletes with and without a history of concussion, and a history of neck injury. DESIGN: Cross-sectional survey. SETTING: Data were collected using an online survey instrument. PARTICIPANTS: Three hundred and nine adult combat sport athletes. MAIN OUTCOME MEASURES: Self-reported 12-month concussion history and neck injury history and a 22-item symptom checklist. RESULTS: A history of concussion was reported by 19.1% of athletes, a history of neck injury was reported by 23.0%, and 13.6% reported both injuries. Neck pain was the most frequently reported symptom. Athletes with a history of injury had significantly greater proportions of 'high' total symptoms and symptom severity scores compared with athletes with no history of injury. Athletes with a history of concussion had 2.35 times higher odds of reporting 'high' total symptoms and symptoms severity scores. CONCLUSION: Athletes with a history of concussion or neck injury have greater odds of presenting with higher symptom scores. The presence of high total symptom scores and high symptom severity scores may indicate a need for further investigation into domains commonly associated with concussion.

Thrombolysis for atlantoaxial dislocation mimicking acute ischemic stroke.

The frequency of stroke mimics among stroke patients has been reported to be up to 30%, and that in patients who receive thrombolytic therapy ranges between 1% and 16%. Atlantoaxial dislocation with myelopathy mimicking stroke is extremely rare. An 83-year-old man with a history of old cerebellar infarction presented to the emergency department with acute left hemiplegia after a chiropractic manipulation of the neck and back several hours before symptom onset. Mild hypoesthesia was observed on his left limbs. No speech disturbance, facial palsy, or neck or shoulder pain was observed. Intravenous thrombolytic treatment was given 238 min after symptom onset. Brown-Sequard syndrome subsequently developed 6 h after thrombolysis with a hypoesthetic sensory level below the right C5 dermatome. An emergent brain magnetic resonance angiography did not reveal an acute cerebral infarct but rather an atlantoaxial dislocation causing upper cervical spinal cord compression. Clinical symptoms did not deteriorate after thrombolysis. He received successful decompressive surgery 1 week later, and his muscle power gradually improved, with partial dependency when performing daily living activities 2 months later. A literature review revealed that only 15 patients (including the patient mentioned here) with spinal disorder mimicking acute stroke who received thrombolytic therapy have been reported. Atlantoaxial dislocation may present as acute hemiplegia mimicking acute stroke, followed by Brown-Sequard syndrome. Inadvertent thrombolytic therapy is likely not harmful for patients with atlantoaxial dislocation-induced cervical myelopathy. The neurological deficits of patients should be carefully and continuously evaluated to differentiate between stroke and myelopathy.

Population-based study of ischemic stroke risk after trauma in children and young adults.

OBJECTIVE: To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. METHODS: We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. RESULTS: From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). CONCLUSIONS: Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.

The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.

BACKGROUND: Cervicogenic dizziness is a disabling condition commonly associated with cervical dysfunction. Although the growing interest with the importance of normal sagittal configuration of cervical spine, the missing component in the management of cervicogenic dizziness might be altered structural alignment of the cervical spinal region itself. AIM: To investigate the immediate and long-term effects of a 1-year multimodal program, with the addition of cervical lordosis restoration and anterior head translation (AHT) correction, on the severity of dizziness, disability, cervicocephalic kinesthetic sensibility, and cervical pain in patients with cervicogenic dizziness. DESIGN: A randomized controlled study with a 1 year and 10 weeks' follow-up. SETTING: University research laboratory. POPULATION: Seventy-two patients (25 female) between 40 and 55 years with cervicogenic dizziness, a definite hypolordotic cervical spine and AHT posture were randomly assigned to the control or an experimental group. METHODS: Both groups received the multimodal program; additionally, the experimental group received the Denneroll™ cervical traction. Outcome measures included AHT distance, cervical lordosis, dizziness handicap inventory (DHI), severity of dizziness, dizziness frequency, head repositioning accuracy (HRA) and cervical pain. Measures were assessed at three time intervals: baseline, 10 weeks, and follow-up at 1 year and 10 weeks. RESULTS: Significant group × time effects at both the 10 week post treatment and the 1-year follow-up were identified favoring the experimental group for measures of cervical lordosis (P<0.0005) and anterior head translation (P<0.0005). At 10 weeks, the between group analysis showed equal improvements in dizziness outcome measures, pain intensity, and HRA; DHI scale (P=0.5), severity of dizziness (P=0.2), dizziness frequency (P=0.09), HRA (P=0.1) and neck pain (P=0.3). At 1-year follow-up, the between-group analysis identified statistically significant differences for all of the measured variables including anterior head translation (2.4 cm [-2.3;-1.8], P<0.0005), cervical lordosis (-14.4° [-11.6;-8.3], P<0.0005), dizziness handicap inventory (29.9 [-34.4;-29.9], P<0.0005), severity of dizziness (5.4 [-5.9;-4.9], P<0.0005), dizziness frequency (2.6 [-3.1;-2.5], P<0.0005), HRA for right rotation (2.8 [-3.9;-3.3], P<0.005), HRA for left rotation (3.1 [-3.5;-3.4, P<0.0005], neck pain (4.97 [-5.3;-4.3], P<0.0005); indicating greater improvements in the experimental group. CONCLUSIONS: The addition of Denneroll™ cervical extension traction to a multimodal program positively affected pain, cervicocephalic kinesthetic sensibility, dizziness management outcomes at long-term follow-up. CLINICAL REHABILITATION IMPACT: Appropriate physical therapy rehabilitation for cervicogenic dizziness should include structural rehabilitation of the cervical spine (lordosis and head posture correction), as it might to lead greater and longer lasting improved function.

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases.

OBJECTIVE: This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxial osteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy. CLINICAL FEATURES: A retrospective case review of 10 patients who were diagnosed with either degenerative or posttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographic presentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedic services. All 10 patients selected for this series were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatment period. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physical examination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to a mean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment was improved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinical improvement was described as "good" or "excellent" in about 80% of patients. Clinical improvements in pain and range of motion were seen in 80% and 90% of patients, respectively. CONCLUSION: Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.

Is surface EMG biofeedback an effective training method for persons with neck and shoulder complaints after whiplash-associated disorders concerning activities of daily living and pain -- a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of surface electromyographic (EMG) biofeedback training as a supplement to an interdisciplinary rehabilitation programme regarding consequences for activities of daily living and pain. DESIGN: A randomized controlled unblinded trial. SETTINGS: The study was carried out in a pain unit at a rehabilitation centre. SUBJECTS: Sixty-five people with chronic whiplash-associated disorders consecutively referred to the pain unit agreed to participate in the study. Participants were randomly assigned to either the treatment or control group. INTERVENTION: All participants received interdisciplinary rehabilitation and the treatment group also had four weeks of surface EMG biofeedback training. MAIN MEASURES: The Canadian Occupational Performance Measure was used at admission discharge and at six-month follow-up to register changes in activities of daily living. The Multidimensional Pain Inventory, Swedish version, was used at admission and at six-month follow-up to capture the multidimensional aspects of pain. RESULTS: Sixty-two people completed the study. Both treatment and control groups improved significantly according to the Canadian Occupational Performance Measure at discharge and the results remained after six months (P<0.001). The subscale 'Interference' on the Multidimensional Pain Inventory was significantly decreased at six months for the treatment group (P<0.001). No differences were found between the two groups for activities of daily living (performance P = 0.586; satisfaction P = 0.988) at follow-up or for pain level (P = 0.914), indicating no additional effect of the surface EMG biofeedback training. CONCLUSION: In this study there was no support for the effectiveness of surface EMG biofeedback training as a supplement to an interdisciplinary rehabilitation programme for people with long-lasting pain after whiplash.

Is it time for a population health approach to neck pain?

OBJECTIVE: Neck pain and its associated disorders (NPAD) cause significant health burden in the general population and after road traffic and occupational injury. Individual-level health care treatments have been well studied, but population-health approaches to this problem have not. We used a best-evidence synthesis to examine population-level approaches to the prevention and control of NPAD. METHODS: The systematic review examined studies published between 1980 and 2006 that addressed the incidence, prevalence, risk factors, prevention, cost, assessment and classification, interventions, and course and prognostic factors for NPAD. Citations were screened for relevance, scientifically reviewed, and synthesized. Valid studies addressing public policies or population-level approaches to the prevention and control of NPAD were identified and used in the evidence synthesis. RESULTS: Only 8 of the 552 scientifically admissible studies were considered relevant to a public or population health approach to preventing and controlling the burden of NPAD. For whiplash-associated disorders, active head restraints and seat backs were protective in rear-end collisions; insurance policies affected the incidence and recovery; government funding of multidisciplinary rehabilitation programs did not benefit recovery; and early intensive health care delayed recovery. In the workplace, 2 randomized trials failed to show any preventive effect for ergonomic interventions or physical training and stress management. One study documented the societal cost of neck pain. CONCLUSIONS: There is little evidence on which to make public or population-level recommendations, despite the important public health burden and costs of NPAD. Population-level approaches to preventing and controlling NPAD should be investigated.

The association of temporomandibular disorder pain with history of head and neck injury in adolescents.

AIMS: To evaluate the risk of self-reported temporomandibular disorder (TMD) pain among adolescents in relation to previous head and/or neck injury. METHODS: 3,101 enrollees (11 to 17 years of age) of a nonprofit integrated health-care system were interviewed by telephone. Two hundred four cases with self-reported TMD pain and 194 controls without self-reported TMD pain frequency-matched to the cases by age and gender completed standardized in-person interviews and physical examinations in which reports of previous head/neck injuries were recorded. Odds ratio (OR) estimates and 95% confidence intervals (CIs) of the relative risks of TMD pain associated with prior head and/or neck injuries were calculated using logistic regression. RESULTS: A greater proportion of subjects reporting TMD pain (36%) than controls (25%) had a history of head and/or neck injuries (OR = 1.8, 95% CI, 1.1-2.8). In a separate analysis, the presence of TMD based upon the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was assessed in relation to prior head and/or neck injury. Cases reporting TMD pain and meeting the RDC/TMD criteria for myofascial pain and/or arthralgia or arthritis were 2.0 (CI, 1.0-3.8) times more likely to have had a prior head injury than were controls with neither self-reported nor RDC/TMD pain diagnoses. CONCLUSION: The results suggest a modest association of prior head injuries with both self-reported and clinically diagnosed TMD pain in adolescents.

A pain in the back case.

I This article discusses a Supreme Court case involving a patient who was referred to a chiropractor for treatment of neck pain. The case highlights some important issues, including the: importance of good medical record keeping, duty to read patient documentation, including previous medical records, duty to perform a physical examination, and duty to consider if a referral is appropriate

The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation: a case report with long-term follow-up.

OBJECTIVE: To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis. CLINICAL FEATURES: A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident. INTERVENTION AND OUTCOMES: Additional diagnostic studies revealed that the patient was suffering from cervical spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient's complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident. CONCLUSION: There is a paucity of published reports describing the treatment of cervical spinal stenosis through manipulative methods. Existing reports of the manipulative management of cervical spondylosis suggest that traditional manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional, uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation. More research into the less traditional chiropractic systems of spinal manipulation should be undertaken.

Treatment of bipolar, seizure, and sleep disorders and migraine headaches utilizing a chiropractic technique.

OBJECTIVE: To discuss the use of an upper cervical technique in the case of a 23-year-old male patient with rapid-cycling bipolar disorder, sleep disorder, seizure disorder, neck and back pain, and migraine headaches. CLINICAL FEATURES: The patient participated in a high school track meet at age 17, landing on his head from a height of 10 ft while attempting a pole vault. Prior to the accident, no health problems were reported. Following the accident, the patient developed numerous neurological disorders. Symptoms persisted over the next 6 years, during which time the patient sought treatment from many physicians and other health care practitioners. INTERVENTION AND OUTCOME: At initial examination, evidence of a subluxation stemming from the upper cervical spine was found through thermography and radiography. Chiropractic care using an upper cervical technique was administered to correct and stabilize the patient's upper neck injury. Assessments at baseline, 2 months, and 4 months were conducted by the patient's neurologist. After 1 month of care, the patient reported an absence of seizures and manic episodes and improved sleep patterns. After 4 months of care, seizures and manic episodes remained absent and migraine headaches were reduced from 3 per week to 2 per month. After 7 months of care, the patient reported the complete absence of symptoms. Eighteen months later, the patient remains asymptomatic. CONCLUSION: The onset of the symptoms following the patient's accident, the immediate reduction in symptoms correlating with the initiation of care, and the complete absence of all symptoms within 7 months of care suggest a link between the patient's headfirst fall, the upper cervical subluxation, and his neurological conditions. Further investigation into upper cervical trauma as a contributing factor to bipolar disorder, sleep disorder, seizure disorder, and migraine headaches should be pursued.

Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients.

The highly variable clinical course of cervical artery dissections still poses a major challenge to the treating physician. This study was conducted (1) to describe the differences in clinical and angiographic presentation of patients with carotid and vertebral artery dissections (CAD, VAD), (2) to define the circumstances that are related to bilateral arterial dissections, and (3) to determine factors that predict a poor outcome. Retrospectively and by standardised interview, we studied 126 patients with cervical artery dissections. Preceding traumata, vascular risk factors, presenting local and ischemic symptoms, and patient-outcome were evaluated. Patients with CAD presented more often with a partial Horner's syndrome and had a higher prevalence of fibromuscular dysplasia than patients with VAD. Patients with VAD complained more often of neck pain, more frequently reported a preceding chiropractic manipulation and had a higher incidence of bilateral dissections than patients with CAD. Bilateral VAD was significantly related to a preceding chiropractic manipulation. Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome. This study emphasises the potential dangers of chiropractic manipulation of the cervical spine. Probably owing to the systematic use of forceful neck-rotation to both sides, this treatment was significantly associated with bilateral VAD. Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke.

A clinical guide to surface-EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation.

Therapeutic stretching is a vital component of chronic musculoskeletal pain rehabilitation for increasing range of motion and counteracting the effects of physical deconditioning. Surface EMG biofeedback is currently being used to facilitate movement and to maximize effective stretching with patients in an interdisciplinary chronic pain rehabilitation program for disabled workers. A clinical protocol with case examples is presented.

[Vertebral artery occlusion following neck trauma: report of two cases].

We are reporting two cases of vertebral artery occlusion resulting from cervical spine trauma. A 41-year-old man experienced vertigo and nausea 6 hrs after chiropractic manipulation. On admission, he was alert and demonstrated nystagmus, hypalgia of left leg, and right Horner sign. A MR image revealed infarction in the right cerebellar hemisphere. A MR angiogram did not show the proximal part of the right vertebral artery. A right vertebral angiogram revealed right vertebral artery occlusion at the level of C 1. He underwent anticoagulation and wore a cervical collar. He was discharged with hypalgia of left leg. A 53-year-old man was admitted to our hospital after an automobile accident. A CT scan revealed a subarachnoid hemorrhage and an intraventricular hemorrhage. A cervical CT scan revealed fractures of the C 5 facet joint and C 6 vertebral body. A MR angiogram did not show the proximal part of the left vertebral artery. A subsequent left vertebral angiogram revealed left vertebral artery occlusion at the level of C 6. He underwent anticoagulation and wore a cervical collar. In addition, he underwent coil embolization of the left vertebral artery. He was discharged with no neurological deficits. It is said that traumatic vertebral artery injuries cause cerebral infarction with time lags. The therapeutic point is to prevent propagation of the thrombus and distal embolism; therefore wearing a collar, anticoagulation, and endovascular interventional therapy is recommended.