Concussion, Cervical, TMJ/TMD or a Combination Thereof?

Myofascial Release of the Temporalis

Welcome readers! Today's post is about a very recent case of mine straight from the clinic! This is a mini case-study about a 22 year old male collegiate basketball player. This patient took direct blow via an elbow to the anterolateral aspect of the cranium during a basketball game on Saturday evening. After the game the athlete presented with several concussion symptoms as well as TMJ pain and a palpable and audible click with opening and closing of the mouth.

The patient presented with these findings during the assessment:

• Cranial Nerve Testing all WNL
• Dermatomes & Myotomes WNL
• Concentration, Immediate Recall, Delayed Recall, Balance, and Orientation via the SCAT3 were all WNL
• Patient Reported Concussion Symptoms
• Headache, "pressure in head", "Not feeling right", Difficulty Concentration, and eventually added the symptom of difficulty sleeping the next morning.
• Glasgow Coma Scale: 15/15 (WNL)
• 1 Previous Concussion in the symptom prior where the patient suffered much more severely on the SCAT2 and had post-concussive symptoms for 2-3 weeks following initial injury.

Long before this case presented to myself I often wondered about possible connections between concussion symptoms, and temporomandibular joint(TMJ)/temporomandibular dysfunction(TMD)/ and cervicogenic headaches. I questioned whether a person could present with concussion symptoms due to potential muscle guarding/spasm and possible involvement of TMD/TMJ issues.

Obviously I still treated this patient as having a concussion and his symptoms had slightly increased the following morning(Sunday) as well. Nevertheless, despite the fact that I was treating him for a concussion and ordering complete neurocognitive rest (despite having perfectly acceptable objective test scores on the SCAT3) I decided to treat his TMJ and neck musculature using manual therapy. NOTE: Current policy with our team neurologist is to assume its a concussion and wait to imPACT test the patient with cessation of symptoms.

I only did a few minutes worth of manual therapy for this patient and they were done with very light pressure. I started with 1-2 minutes of light IASTM to the Masseter, and myofascial release of the Temporalis using my hands. (Both pictured in the above photos.) I followed these up with some light lateral mandibular glides bilaterally for about 30 seconds each.

Finally, I applied lateral-medial/posterior-anterior pressure with the pads of my second digit on both sides of the first palpable spinous process while the patient simultaneously performed an active cervical retraction or chin tuck, if you will. This was done in an alternating fashion with pressure on again/off again in 2-3 second cycles for about 30 seconds total.

The patient reported rapid improvement in their symptoms but not complete cessation and they started to slowly return about 40-50 minutes later...Which one might expect with a concussion...or with a rapid responding patient that wasn't given a HEP to perform after manual therapy. Which one is it? I can't be sure but I play on the safe side and assume the worst. Additionally, the click/pop of the TMJ was no longer present after treatment

The following day (Monday) the patient reported complete cessation of his symptoms and the TMJ issue had not returned. The patient underwent imPACT testing which came back normal and began the first step of a graduated return to play progression.

In conclusion, what does this all mean? I don't know. What if I wouldn't have chosen to treat the patient with manual therapy. Perhaps he would have awoken still with total cessation of symptoms and would have passed his imPACT as well. (This still doesn't even prove he didn't suffer a mild concussion!) Another potential alternative is that the patient could have continued to suffer from "concussion" symptoms for days at a time and perhaps this would have delayed his imPACT testing and subsequent return to play/activity/sport. 

This is not necessarily a bad thing because it is always best to play it safe. However, it also means that my patient/athlete would have had to suffer undue pain/discomfort related to his TMD/"concussion" symptoms. He also would potentially have to miss out on class/social activities/and experience a lot of undue psychological stress if I hadn't treated these findings. I am just curious if others if had these similar thoughts/case/experiences or what you all think of this? 

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A Year in Review: 13 Lessons of 2013

Happy New Year and welcome to 2014! This is my first post of the year and my 75th post overall.  This is going to be a reflection on some of the things that I learned in the previous 365 days. I was inspired to write this post after reading many of Mike Reinold's similar posts over the last few years. I guess I learned a lot this year because this turned into an epically long post. Sorry.

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The Edge Mobility Band Review

(Disclosure: This was not a free item given to me for review. I paid for this on my own but I have learned a lot from the creator of this product and that information has helped me and my patients a ton so maybe that makes me biased. If that is a bias I hope I continue this bias for a long time.)

Today I will be reviewing the Edge Mobility Band which is part of the Edge Mobility System by Dr. Erson Religioso, DPT of The Manual Therapist. I have been following his blog for quite awhile now and from the start I was very intrigued by the magical blue bands that he kept using on his patients and in his videos.

I would watch his videos and read his blog posts about the increased function, mobility and decreased pain associated with using these bands as part of his treatment protocol. At the time I was unaware of the Voodoo floss bands so this was my first exposure to compression wrapping for anything other than edema prevention/reduction. I even tweeted at him back in April of this year to inquire whether a poor graduate student like myself could substitute a resistance band for his bands and get the same effect. He answered my tweet with complete honesty and told me that there was nothing magical about the Edge Mobility Bands. He stated that a simple resistance band should suffice.

While there may be nothing magical about these bands there is definitely something special about their construction and design considering that I wasted many hours trying to experiment with resistance bands instead of coughing up $24 bucks for two Edge Mobility Bands of my own. Most of those experiments led to cutting off the circulation of extremities, excessive body hair pulling, and the constant rolling and tearing of many thera-bands. It simply wasn't a feasible substitute for me but maybe it works or would work for somebody that is more coordinated, stubborn or cheap than me.

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Wednesday Quick Links!

Eat.

This link is to a post by Jimmy Moore on where you can find his newly released book 'Cholesterol Clarity: What The HDL Is Wrong With My Numbers' and includes both international and US locations. I haven't read this book yet but I sure would like to eventually.

Run. 

Today's second post is an article by Dr. Phil Maffetone and is entitled "Gait 101: Learning to Run More Naturally." This part 1 of a  two part guest post series by him over at the Natural Running Center and is a little lengthy but Dr. Maffetone always seems to have a unique but quality opinion on running related matters.

Speaking of guest posts, Ben Greenfield just did a guest post for Mark Sisson on MarksDailyApple. The title of this post was '10 Rules for Becoming an Ancestral Athlete' and definitely gave me some introspective thoughts while reading it.

Rehabilitate.

Mike Reinold and Erson Religioso have recently put together a course on Instrument Assisted Soft Tissue Mobilization (IASTM) and you can learn about IASTM from them for cheap at IASTMTechnique.com Additionally, Mike Reinold just put together a post on his recommendations for choosing an IASTM instrument to use in the clinic.

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Putting The "soft" Back Into Soft Tissue: Video Post

Hey all! New video for you all today that follows the same theme as my last blog post regarding foam rolling. I hope you all learn something and sorry for my amateur videography. I forgot to comment on it in the video but it is important to note that these gains in mobility are only temporary.

However, this treatment can and should (in this case, she as she is still restricted in terms of mobility) be combined with other treatments like joint mobs, Mulligan MWM's and repeated end-range plantar flexion. This will produce a synergistic effect and reapplication can help lock in the temporary gains.

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Neck Pain and a Wedding: Ain’t Nobody Got Time For That!

I am back in my hometown for my little sister’s wedding this weekend. Yesterday, my dad spent the day preparing and setting up for the wedding. He was lifting and carrying around a lot of awkward and heavy objects for most of the day. This morning my dad awoke with debilitating neck pain with radiating pain down into his right shoulder. His neck mobility was very poor with limited rotation and side bending to the right.

A year ago, I may have suggested Tylenol, Ice, Rest and perhaps some slight stretching. If I had access to modalities I may have wanted to use electrical stimulation to help control his pain. This was the type of neck pain that would have sent him running to the chiropractor’s office in the past.

Recently, I have been working to incorporate a lot of stuff that I have learned from my OMPT Channel subscription from The Manual Therapist and from the content on his blog as well. If any of you are regular readers of my blog you probably know this little fact already. One of the biggest things that I have learned about is how a large portion of injuries or pain fall into a “rapid response” sort of category. Specifically, this means that there was a good chance that I would be able to make significant and quick changes with my father’s neck pain.

Another concept that I learned and have written about previously is the use of repeated-end range joint loading. This is done into the direction of preference to increase function, centralize pain and improve mobility. This was a concept I used to produce rapid changes in my dad’s neck pain this morning.

Specifically, I did some very light Instrument-Assisted Soft Tisse Mobilization (IASTM) to the right side of my dad’s neck. I followed specific tissue patterns that I learned in the subscription section of the OMPT channel from Dr. Erson but he has some related videos for free on YouTube. I spent 3-4 minutes working these patterns with the goal of helping my dad reach his end-range. After the light tissue IASTM I showed my dad how to do repeated side bending to the right (side of unilateral pain) and cervical retraction as well. I had him do about 2 sets of 12-15 of each of these repeated movements.

Once or twice I had to stop him and help him reach his end-range more effectively. After he finished, the shoulder pain had centralized and his neck rotation and side bending was now normal. These effects are transient so I gave him instructions on how he would need to repeat these exercises for 10-12 reps once a hour. He gave me a look of incredulity but about an hour and a half later while trying on our tuxedos his neck stiffness started to return.

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Hip Extension For Runners: Importance, Restrictions, and Quickies for Improvement.

Importance:

Sufficient hip extension is vital for proper running gait, form, posture and efficiency. Inhibited or restricted hip extension in running can result in:

• Over-striding
• Decreased running economy
• Poor movement patterns
• Potential risk for injury and/or compensation up and down the kinetic chain

The Gluteus Maximus is the primary hip extensor and the strongest muscle in the body. It is hypothesized that our massive glute max relative to other primates is due to an evolutionary adaptation. This allowed better bipedal locomotion and enhanced our running ability. Proper activation of the glute max and hip extension motion is needed for most primitive and basic movement patterns, especially skills requiring power. This is evident in many basic power skills such as:

• Squatting/Deadlifting
• Sprinting/Running
• Throwing
• Punching
• Jumping
• Bridging of the hips
• Swinging an object like a club, baseball bat or golf club.

Limitations in hip extension or gluteus maximus activation can also affect static postures like standing by influencing pelvic tilt, motor control activation strategies, lumbar curve and ultimately the body's center of gravity. For more reasons on why "running is all in the hips", see James Dunne's great post, here.

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