AN OSTEOPATHIC APPROACH FOR THE CONCUSSED ATHLETE ALBERT J KOZAR, DO, FAOASM, R-MSK BOARD CERTIFIED NMMOMM, FP, CAQSM, RMSK PROGRAM DIRECTOR / ASSOCIATE PROFESSOR ONMM RESIDENCY & INTEGRATED SPORTS MED / ONMM RESIDENCY EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE DISCLOSURES My only disclosures are: • I am a Fighting Irish Fanatic !!! • I love Jazz !!! • really can’t stand country music OBJECTIVES ① Be able to discuss the Berlin Concussion Statement in relation to an Osteopathic Manipulative Approach ② Be able to discuss the anatomical connectivity and mobility of the cranial & spinal dura ③ Be able to discuss the newly discovered Glymphatic drainage system of the CNS and recent high quality OMT research of the lymphatic system by Lisa Hodges, PhD ④ Be able to formulate a manipulative approach to the mechanical and whiplash affects of concussion ?? ⑤ Be able to discuss the evidence in the literature ① Specific to OMT and concussions ② Specific to OMT and symptoms that occur in concussion ⑥ Be able to discuss the current active RTCs of OMT and concussion ⑦ Understand and be able to apply OMT techniques in the approach to treating concussion (Hands-On Lab) ⑧ Be able to discuss when to apply OMT in the treatment of concussions and the absolute / relative contra-indications (Hands-On Lab) OSTEOPATHY “Do you practice decorticate or decerebrate Osteopathy ?” Anthony Chila, DO, FAAO, FCA OSTEOPATHY “Even heads have bodies attached to them …” Viola Frymann, DO, FAAO, FCA CRANIAL CONCEPT William Garner Sutherland proposed the cranial concept in 1929 “Cranial” osteopathy is a misnomer since it was originally described in the head but in reality is a whole- body concept Cranial is not a separate treatment modality but an extension of osteopathy as originally described by A. T. Still Sutherland Berlin 2016 Consensus Statement on Concussion in Sport. McCrory P, et al. Br J Sport Med 2017; 0; 1-10 DEFINITION OF SRC “Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include: “ SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies Berlin 2016 Consensus Statement on Concussion in Sport. McCrory P, et al. Br J Sport Med 2017; 0; 1-10 SUSPECTED DX OF SRC CAN INCLUDE ONE OR MORE OF THE FOLLOWING … Symptoms • Somatic (HA, nausea, dizziness, fatigue, sensitivity to light & noise) • Cognitive (feeling slowed down, feeling mentally “foggy”) • Emotional (lability, sadness, nervousness, feeling more emotional) Signs • Physical (vomiting, LOC, amnesia, neuro deficits) • Balance Impairment (gait unsteadiness) • Behavioral Changes (irritability, personality changes) • Cognitive Impairment (slowed reaction time) • Sleep Disturbances (somnolence, drowsiness, change in sleep patterns, trouble falling asleep) First organized this way with Zurich 2012 Consensus Statement on Concussion in Sport. Clin J Sport Med 2013; 23(2) Berlin 2016 Consensus Statement on Concussion in Sport. McCrory P, et al. Br J Sport Med 2017; 0; 1-10 DIAGNOSIS OF PCS A standard definition for persistent post-concussive symptoms is needed to ensure consistency in clinical management and research outcomes ‘persistent symptoms’ … “following SRC should reflect failure of normal clinical recovery— that is, symptoms that persist beyond expected time frames (ie, >10–14 days in adults and >4 weeks in children)” “does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/ or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain” Berlin 2016 Consensus Statement on Concussion in Sport. McCrory P, et al. Br J Sport Med 2017; 0; 1-10 DIAGNOSIS OF PCS A standard definition for persistent post-concussive symptoms is needed to ensure consistency in clinical management and research outcomes ‘persistent symptoms’ … “detailed multimodal clinical assessment is required to identify specific primary and secondary pathologies that may be contributing to persisting post-traumatic symptoms” “Treatment should be individualized and target-specific medical, physical and psychosocial factors identified on assessment” SOMATIC DYSFUNCTION Impaired or altered function of related components of the somatic (body framework system) skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic and neural elements GOAL OMT ①Primary - direct change in physiologic function • Neurologic • Vascular • Lymphatic • Optimization of body rhythms • Optimization of movement of musculoskeletal system – the primary machinery of life ②Secondary - restoration of structure Berlin 2016 Consensus Statement on Concussion in Sport. McCrory P, et al. Br J Sport Med 2017; 0; 1-10 OMT FOR SRC & PCS “detailed multimodal clinical assessment is required to identify specific primary and secondary pathologies that may be contributing to persisting post- traumatic symptoms” “treatment should be individualized and target- specific medical, physical and psychosocial factors identified on assessment” OMT should be individualized and target …specific areas of impaired or altered functional STRUCTURE / FUNCTION RECIPROCITY Has moved beyond ‘simple’ muscle and bone to: – BioTensegrity (Levin) & Mechanical-transduction Macro - system integration Micro - Individual cellular structure Nuclear - Proteonomics – Neuromuscular Balance Systemic neuromotor integration of stability Engrams / Motor patterns – Real Word Muscle Function (Brolinson & Gray) Ecconcentric contraction Supination / Pronation Link (Spiral Power) LETS REVIEW SOME IMAGES & FACTS ABOUT THE DURA The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 Primal Pictures 37 WHY MIGHT CNS VENOUS SYSTEM VULNERABLE TO SOMATIC DYSFUNCTION (STASIS) ? 1. Cranial venous sinuses are carried within the dura mater 2. Lack of muscular system to promote flow – flow is dependent on primary respiratory mechanism (PRM) 3. Anatomical mechanical restrictors: 1. # obtuse & right angles to flow against current 2. Rigidity, width, & trabeculae crossings The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 DURAL TENSION “When the dural membrane of the cranium is subjected to tension in a certain direction over time, the fibers within the membrane seem to organize and align themselves with the direction of tension. Study of the fiber organization patterns may disclose the direction of principal tensions to which the membranes were subjected during life.” The cranial dura mater: a review of its history, embryology, & anatomy. Adeeb N, et al. Childs Nerv Syst (2012) 28:827–837 This would indicate that distortion of the cranial vault creates resultant tension in the cranial dura mater Dr. Alf Brieg Biomechanic of the Nervous System (1960) Precise & detailed movement in Rhesus monkeys Telescoping DURAL MOBILITY SUMMARY • The spinal Dura is suspended by the dentate ligaments, the brainstem by the cranial nerves • The pons-cord tract changes length by 4.5-7.5cm during dorsal extension & ventral flexion • 0.8-1.4 cm brainstem • 1.8-2.8 cervical • 0.9-1.3cm thoracic • 1-2cm in lumbosacral cord • The pons cord tract telescopes with dorsal extension • The Pons cord tract is continuous with the spinal nerve roots and peripheral nerves SPINAL DURAL BRIDGES 1ST report of a myodural connection to the atlas (Hack, et al, Spine 1995) • a “connective tissue bridge” between the posterior atlanto-occipital membrane and the rectus capitus posterior minor muscle • observed that in all cases, extension of the head and neck produced an “infolding” of the dura mater • protect the flow of cerebrospinal fluid during head extension Dura mater is firmly attached to the 2nd and 3rd cervical vertebrae (Mitchell and Humphrey’s- JMPT 1998) Dura mater is also attached, variably, to the posterior longitudinal ligament by fibrous slips denser toward the lumbar region Most anatomy authorities tend to agree that the dura mater of the spinal cord attaches to the anterior surface of the sacral canal at the level of the 2nd sacral segment Kourosh Kahkeshani And Peter J. Ward. Connection Between the Spinal Dura Mater and Suboccipital Musculature: Evidence for the Myodural Bridge and a Route for Its Dissection—A Review Clinical Anatomy 25:415–422 (2012) TAKE HOME PRINCIPLE “Core Link” between the Cranium & Spine Tensions that developed within the cranial dura mater may be transmitted to the spine and pelvis (AND Visa Versa) through ① the connections specifically at C1, C2, C3, the sacrum & coccyx, & ② via dural sheath to epineural connective tissue at each segmental level in the spine LETS REVIEW SOME FACTS ABOUT LYMPHATICS THE GLYMPHATIC