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Upper Cross System Headaches Head Injuries


Changes due to Upper Cross System. Occiput and C1/2 hyperextend with the head pushed forward ... Lower Cross System may occur due to eye gaze ... – PowerPoint PPT presentation

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Title: Upper Cross System Headaches Head Injuries

Upper Cross SystemHeadachesHead Injuries Neck
Upper Cross System
  • When a chain reaction evolved muscle shortening
    and reciprocal weakening in predictable patterns
    causing predictable imbalances or syndromes

Upper Cross System Imbalances
Changes due to Upper Cross System
  • Occiput and C1/2 hyperextend with the head pushed
  • Lower cervical to 4th thoracic vertebrae are
    stressed through posture
  • Rotation and abduction of the scapulae
  • Altered direction of the glenoid fossa
  • Results in the need for humeral stability
    (increases levator and upper trap activity

Cervical Spine Forces
  • A) Absolute rotation angle (ARA) of overall
    lordosis magnitude. B) Relative rotation angle
    (RRA) or magnitude of intersegmental angle. C)
    Linear measure of forward displacement of head
    relative to upper dorsal spine

Results of Postural Imbalance
  • Greater cervical segment strain with possible
    referred pain to the chest (trigger points)
  • Pain mimicking angina may be noted
  • Rotator Cuff strain/tendonitis
  • TMJ
  • Lower Cross System may occur due to eye gaze
  • In order to see straight ahead, individual must
    anteriorly tilt pelvis
  • Breathing dysfunction reduce in diaphragmatic
    efficiency due to postural restriction of lower
    rib cage

Boney Anatomy
  • The Skull has many specialized areas. We sill
    focus on Major areas
  • Frontal
  • Parietal
  • Temporal
  • Occipital

Special Boney Areas
  • External Occipial Protuberance (notch in
    occipital area
  • Mastoid Process (behind Ear)
  • Zygomatic Arch (Cheekbone)
  • Orbit (eye socket)
  • Maxilla (upper jaw)
  • Mandible (lower Jaw)

Anatomical Locations of Cranial Nerves
Cranial Membranes
  • The first step in treating our head pain is to
    get an accurate diagnosis. This is very important
    for a couple of reasons
  • Head pain can be a symptom of various diseases or
    physical anomalies such as tumors or aneurysms. A
    CAT Scan of the sinus cavities is helpful, as is
    an MRI to rule out tumors and other problems.
    Keeping a headache diary will also be helpful to
    your doctor for diagnosis purposes.
  • Treatment methods and medications for different
    types of head pain vary. For example, the triptan
    drugs used to treat migraine (e.g. Imitrex) do
    nothing for sinus/allergy headaches.

Types of Headaches
  • Migraine Headaches
  • TENSION A DULL ache on both sides of the head is
    the sign of a Tension Headache. It has been
    described as "feeling like a tight band across
    the head."
  • SINUS Rather uncommon, opposing to popular
    belief. Most people who feel they have a Sinus
    Headache essentially have Tension or Migraine
  • CLUSTER Signs of a Cluster Headache is
    reasonably infrequent sharp-as-knife pains around
    one eye. Around Ninety percent are male. Most are
    between the ages of Twenty-Thirty years old.

Migrane Headaches
  • A chronic aching pain that frequently affects one
    side of your head.
  • The pain usually begins in and around your eye
    or temple and ranges from mild to intense, severe
    or even devastating. This is usually accompanied
    by nausea, sensitivity to light and sound, and
    sometimes vomiting.
  • Over 25 million people around the world suffer
    from migraine headaches. 75 are women. Around
    Seventy percent of these individuals have family
    members who also suffer with similar conditions.
  • It is seen that approximately Twenty percent of
    migraine sufferers experience "aura." "Aura" is
    visual disturbances such as flashing lights or
    lines during an attack.
  • "classic Migraine," experienced by about 20 of
    Migraineurs is preceded by warning signs called
    an "Migraines without the aura are termed "common
    Migraine" aura" 

Headache Type
  • Cluster Headache
  • severe, sharp, stabbing pain
  • usually on one side of the head, centered around
    the eye
  • almost always severely incapacitating
  • occur in clusters of 1 - 4 headaches a day for
    several weeks, lasting 10 minutes to two hours
    each, then stopping for months
  • on the affected side, the eye tears, and the nose
    is often stuffy or runny
  • most frequent among men
  • occur most often in the fall and spring
  • Migraine Cont. 
  • throbbing, intense pain, generally moderate to
  • usually one-sided, though the pain can move from
    side to side, and sometimes affects both sides
  • may last hours, days, or even weeks
  • Migraines may continue long enough to require an
    emergency room visit, or even hospitalization, so
    that stronger medications can be given to break
    the cycle. (status migrainous) 

Headache Types
  • Sinus/Allergy Headache 
  • pain generally mild to moderate
  • centered around sinuses, above and below eyes
  • pressure often makes teeth ache as well
  • may be accompanied by feeling of pressure behind
    the eyes
  • often relieved by decongestants, antihistimines,
    or other allergy medications.
  • often seasonal
  • Tension Headache 
  • constant, dull pain, usually mild to moderate
  • not incapacitating
  • pain is often accompanied by muscle tightness in
    the shoulders and neck
  • often on both sides of the head
  • may last an hour, a week, or anywhere in between
  • the pain is often described as a band of pain
    around the head or "like a vise" 

Cervical Spine Correlation to Headaches
  • Cluster, migraine, and the many forms of tension
    headaches, as well as post-concussion and
    "whiplash" headache, may also be consequences of
    traumatic cervical spine injury.
  • Soft structures about the head, neck, and
    shoulder girdle play in the etiology of many

When to Refer
  • The headache gets worse instead of better, or has
    changed in nature.
  • Three or more headaches a week. Patient takes a
    pain reliever every day, or almost on a daily
    basis, to relieve headache.
  • Headache is accompanied by any of the following
  • 1. Stiff neck and/or fever
  • 2. Shortness of breath
  • 3. Unexpected symptoms that affect your eyes,
    ears, nose or throat
  • 4. Dizziness, slurred speech, weakness, lack of
    sensation or tingling
  • 5. Uncertainty or drowsiness6. Constant or severe

When to Refer Continued
  • Headaches begin after, or are triggered by, a
    head injury, hard work, coughing, bending or
    sexual activity.
  • Headaches began after you reached the age of

Referral Pain Patterns of C-Spine
  • Headache and pain in the head and face originate
    in weak fibro-osseous attachments of tendons to
    the occipital bone (A, B, C, D) as weak fibers
    relax under normal tension and allow
    tension-overstimulation of sensory nerves of the
    cervical spine. Such pain is almost always
    referable to a specific location

Injury Healing
  • Traumatic skeletal pain is most exquisite at the
    points of attachment of tendons and ligaments to
  • During the healing process, which requires three
    to four weeks, bone and fibrous tissue
    proliferate at these fibro-osseous junctions.
  • Another three to four weeks is needed for
    maturing and strengthening of the fibro-osseous
    bond. Interference with normal healing due to
    motion at the site of injury, or to a deficient
    healing capacity results in a weak attachment,
    designated as ligament relaxation.
  • If spontaneous repair has not occurred 1 1/2 to 2
    months after injury, it is not likely to occur
    later (Hackett, 1958).

Trigger Point Relationship
  • Trigger points often elicit muscle spasm and pain
    in patients with headache.
  • a. Prone patient. Laminar and articular points
  • b. Supine patient.
  • Points at scalenus, sternomastoid, and trapezius

Signs and Symptoms
  • Compression of the head downward on the neck
    often increases the pain
  • Manual traction of the head upward from the neck
    may relieve it.
  • Pain may also be increased by isometric pressure
    at the occiput, whereas pressure at the curve of
    the neck may decrease it.
  • Palpation often reveals muscle spasm of one or
    more of the supporting posterior neck muscles
  • Physical examination may reveal
  • one shoulder lower than the other
  • head rigid.
  • The examiner should determine the degree of
    limitation in the range of active and passive
    motion of the head on the neck in all directions
    and record the amount of pain produced by
    attempting to extend each motion.

Signs and Symptoms Cont.
  • Neurologic and general systemic evaluations are
    usually normal.
  • There may be non-specific changes in the reflexes
    and atrophy of muscles about the shoulder girdle
    or the arm.
  • X-ray examination may show narrowed
    intervertebral disk spaces and hypertrophic
    arthritic changes about the Luschka interbody
    joints representing previous pathology
  • Small, tender areas of spasm in other muscles
    (trigger points)
  • or exquisite tenderness at the origin or
    insertion of the muscles to the occiput, cervical
    spine, or shoulder girdle.
  • Coincidentally there often is limitation of
    motion and malalignment of the dorsal lumbar
    spine or lumbosacral or sacroiliac joints.

Acute Injury and Therapy
  • With an acute injury, there is usually loss or
    reversal of the normal lordotic curve or
    increased laxity of supporting ligaments, or
  • The range of motion is so restricted--either by
    spontaneous spasm, by attempting to hold the head
    rigidly on the neck, or by prolonged use of a
    cervical collar--that a cycle of spasm, reflex
    pain, weakness, and atrophy of the tissues exists.
  • Therapy must aim to
  • (1) remove the tender trigger areas which serve
    as foci of referred pain and spasm,
  • (2) correct malalignments, subluxations, and
    restricted range of motion to as near normal as
    possible, and
  • (3) strengthen the local supporting ligaments and
    tendons to prevent further malalignment and

Head Evaluation and Treatment
Head Injury Background
  • Skull - Hard casing with pudding like substance
  • Protected by coverings
  • Nutrients by rich blood supply
  • Neural Components at base of skull

Head Injury
  • Mechanism
  • Coupe
  • Contra-Coupe
  • These mechanisms can cause injury and swelling
  • Concussion
  • Epidural/subdural Hematoma

Bleeding in the Brain
Assessing Head Injury
  • Check
  • Visual Acuity eye movement
  • Facial movement
  • Headache
  • ringing in the ears
  • Nausea
  • Behavioral Changes (unlike normal personality)
  • Amnesia (retrograde/ post-concussive)
  • If symptoms increase send to emergency
  • This is a limited list

Head Injury
  • First Degree
  • No Concussion - Bell rung resolution of symptoms
    within Lucid Interval
  • Second Degree
  • Loss of Consciousness brief less than 15 seconds.
    No resolution within lucid interval
  • Third Degree
  • Loss of Consciousness more than 15 seconds
  • increasing severity within lucid interval
  • This is only one type of scale many variations

Post-Concussive Syndrome
  • Residual symptoms post concussion including
  • Nausea
  • Headache
  • Tinnitus
  • etc.
  • These may occur with movement, daily activities,
    rising from bed etc.
  • Must not participate during this period of time

Second Impact Syndrome
  • Injury while still recovering from initial
  • 100 morbidity
  • Very important that post-concussive syndrome has

Decisions on Head Injuries
  • Blood out of ears /or nose (from blow to head)
  • Any unconscious episode
  • Symptoms increase during 20 minute waiting period
    or when activity resumes
  • Symptoms are not resolved
  • Activity exacerbates headache

Blood Supply to the Brain
  • CSF is main nutrition to the neural structures.
  • Blood supply to the brain is via a paired
    arteriole system
  • Two internal carotid arteries enter the brain
    through the neck
  • Two vertebral arteries travel up the posterior
    aspect of the neck through the transverse foramen
    and at the level of the pons. This then becomes
    the basilar artery.
  • The basilar will nourish the pons and the
    cerebellum along the way to the area of the
    midbrain where it will divide into the posterior
    cerebral arteries

Athlete Return to Activity
  • First Concussion 1º
  • 1 week post resolution of Symptoms
  • Second Concussion or 2 º
  • 1 month post resolution of symptoms
  • Third Concussion or 3 º
  • End of Season needs discussion of career
  • Start with bike activity - if no symptoms
    increase functional activity before full return
  • Above subject to Dr Discretion

Circle of Willis
  • Two communicating links exist
  • Posterior communicating artery links the
    posterior and middle cerebral arteries
  • The anterior communicating artery unites the two
    anterior cerebral arteries

Circle of Willis
  • 1. Anterior Cerebral Arteries
  • 2. Inter-Carotid Arteries
  • 3/5. Middle Cerebral
  • 4. Posterior Communicating Arteries
  • 6/7.Posterior Cerebral Arteries
  • 8. Basilar Arteries
  • 9. Vertebral Arteries

Where the Head Ends and Neck Begins
  • Plane between the external occipital protuberance
    and inferior surface of the mandible
  • Neck
  • Anterior triangle is bordered by Mandible
    (above), Cervical midline(laterally) and
    Sternomastoid (anteriorly

Where the Head Ends and Neck Begins
  • Neck
  • Posterior triangle is bordered by Clavicle
    (below), trapezius (posteriorly) and
    Sternomastoid (anteriorly)

Middle Cerebral Artery
Posterior Cerebral Artery
Anterior Cerebral Artery
Neck Anatomy, Evaluation and Treatment
Boney Anatomy of the Neck
  • Typical Vertebrae are C3-C6
  • Characteristics
  • Small bodies with large vertebral foramen
  • bifed spinous process
  • foramen in each transverse process
  • articular facets lie at 45 in transverse plane
  • Atypical Vertebrae
  • Atlas - 1st cervical vertebrae
  • Axis - 2nd Cervical Vertebrae

  • Has a short anterior and long posterior arch
  • Atlas has no actual body
  • Has Circular facet (Fovia Dentis) in the anterior
    arch which is for the articulation of the dens of

Atlas/Axis Ligaments
  • Anterior Atlanto-Axial and atlanto-Occipital
  • Lie on the anterior surface of the axis and
    passes to the anterior surface of the anterior
    arch of the atlas and onto the the tubercle of
    the occiput

This is an extension of the anterior
longitudinal Ligament
Atlas/Axis Ligaments
  • Posterior Atlanto-Axial and atlanto-Occipital
  • Extends for the lamina of the axis to the
    posterior arch of the atlas and on up to the

Atlas/Axis Ligaments
  • Tectorial Membrane
  • Extends on the posterior aspect of the body of
    the axis covering the dens and its associated
    ligaments but not touching it. It continues up to
    the anterior edge of the foramen magnum

Axis Anatomy
  • Second Cervical Vertebra
  • DENS which is fused body of the atlas and axis
  • helps in the formation of the first
    intervertebral foramen which the second cervical
    nerve passes through

Lateral View
Overhead View
Axis Anatomy
  • Cruciform Ligament
  • Most vital of the ligaments. IF consists of 2
    ligaments (Apical Alar) which cross.
  • Apical Attaches the tip to the occiput
  • Alar Also attaches to occiput
  • Transverse lig over apical but does not attach
    to it

Lateral View
Odontoid Anterior View
Jefferson Fracture Burst Fracture
  • Etiology
  • Axial Loading of the head/compression of the
    atlas between occiptial condyles
  • Pathology
  • Bilateral burst fracture of both the anterior and
    posterior arched of C-1 with lateral displacement
    of masses - increasing the distance between
    anterior arch of the atlas and odontoid process
    of axis ( 3mm). AN UNSTABLE INJURY WITHOUT

Avulsion teardrop Fracture (Axis)
  • Etiology
  • Hyperextension
  • Pathology
  • Triangular shaped avulsion fracture of the
    anterior-inferior margin of the C-2 vertebral
    body at the insertion of the anterior
    longitudinal ligament

Teardrop Fracture (vertebral Body)
  • Etiology
  • Axial Loading/compression and Flexion Buckling
  • Pathology
  • A Burst fracture of the vertebral body with
    associated rupture of the posterior ligament,
    posterior displacement of the posterior fracture
    fragment and spinal cord encroachment acute
    anterior spinal cord injury syndrome TYPE IV
    compression fracture

Fractures of Neural Arch
  • Etiology
  • Axial Loading/flexion or extension buckling
  • Pathology
  • Unilateral or bilateral fractures of the lamina
    and/or pedicles
  • Avulsion fracture of the spinous process usually
    involving C-6, C-7 (most common)

Unilateral Facet Subluxation/Dislocation
  • Etiology
  • Axial Loading/flexion-rotation
  • Pathology
  • Rupture of the anterior and posterior ligaments,
    capsular ligaments (bilateral) and intervertebral
    disc with anterior subluxation (less than 50 of
    vertebral body) or dislocation (more than 50 of
    vertebral body/locked facets). An unstable injury

Atlantoaxial Subluxation/Dislocation
  • Etiology
  • Flexion or axial loading/flexion buckling
  • Pathology
  • Rupture of transverse and alar ligaments with
    anterior dislocation of C-1 on C-2/increase in
    ADI (distance between anterior arch of atlas and
    odontoid process of axis greater than 3mm)

Fracture of Posterior Arch (atlas)
  • Etiology
  • Extreme hyperextension or axial
    loading/compression of the atlas between the
    occipital condyle and the axis
  • Pathology
  • Fracture of the posterior arch , most commonly at
    the thin, weak junction. Possible associated
    fracture including pedicle of C2 (hangmans
    fracture) avulsion teardropfracture of the axis

Odontoid Fractures (Axis)
  • Etiology
  • Axial Loading/Compression shearing forces
  • Pathology
  • Type I - Avulsion fracture (Alar ligament) of the
    tip of the odontoid unstable
  • Type II - Fracture at the junction of odontoid
    and body of axis (unstable
  • Type III - Fracture of the body of the axis

Hangmans Fracture
  • Etiology
  • Hyperextension or axial loading/extension
  • Pathology
  • A bilateral arch fracture of C-2 (traumatic
    spondylolysis) with anterior dislocation of C-2
    and C-3 (spondylolithesis) An unstable injury

Face Injury - LaForte Fracture
  • LaForte I
  • LaForte II
  • LaForte III
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