Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review

Predicting chronic post-traumatic head and neck pain: the role of bedside parameters

ABSTRACT

Traumatic brain injury (TBI) annually impacts 69 million individuals worldwide. Mild TBI constitutes approximately 90% of all TBIs. Chronic pain post-mTBI occurs in 29% to 58% of patients. This study aims to introduce a predictive model for chronic pain development in individuals diagnosed with mild traumatic brain injury (mTBI) immediately postinjury. We included individuals who had sustained mTBI in motor vehicle accident (MVA). All patients had initial assessments within the first 72 hours (representing the subacute period) after the injury and performed follow-ups for 1 year. Machine learning model was applied to the integrated measures of clinical pain, pain-related psychological parameters, mTBI clinical signs, and sociodemographic information. This study included 203 patients experiencing acute head or neck pain attributable to mTBI post-MVA. We categorized these patients into 2 groups: patients who progressed to develop chronic head or neck pain (n = 89, 43.8%) and patients who recovered (low/mild pain) (n = 114, 56.2%). Severity of the subacute neck pain, number of painful body areas, and education years were identified as the most significant factors predicting chronic pain. The optimized predictive model demonstrated high efficacy, with an accuracy of 83%, a sensitivity of 92%, and an area under the receiver operating characteristic curve of 0.8. Our findings indicate feasibility in predicting chronic post-MVA pain within the critical 72-hour window postinjury using simple bedside metrics. This approach offers a promising avenue for the early detection of individuals at increased risk for chronic pain, enabling the implementation of targeted early interventions.

Poly-symptomatology of chronic multi-canalicular benign paroxysmal positional vertigo: a deductive, inductive, and abductive narrative review

This narrative review aims to present an overview of the symptomatology of chronic multi-canalicular benign paroxysmal positional vertigo (mc-BPPV) from deductive (what is believed to be known), inductive (what is likely), and abductive (hypothetical) perspectives. The purpose is to recognize these symptoms as expressions of an eventual mc-BPPV when they occur in patients with vestibular migraine, whiplash associated disorders (WAD) and other chronic pain disorders. These symptoms are often considered to be biopsychosocial conditions due to a lack of objective findings, that is, the absence of the findings one is looking for-not the absence of findings generally. The symptomatology of mc-BPPV follows a basic neurophysiologic principle: a disorder in one part of the vestibular system often affects the functions of other parts of the vestibular system. In patients with chronic mc-BPPV, abnormal signals are transmitted as afferents to the vestibular nuclei complex; from there, consistently abnormal efferent reflexes are transmitted. These symptoms can include dizziness, visual disturbances, headache, neck pain, temporomandibular joint region pain, other musculoskeletal pain, involuntary movements, tinnitus, temperature disturbance, and cognitive dysfunction. Therefore, it is necessary to consider the possibility of mc-BPPV in patients with vestibular migraine, WAD and other chronic pain disorders.

Deep learning modelling of structural brain MRI in chronic head and neck pain after mild TBI

ABSTRACT

Chronic headache is a common complication after mild traumatic brain injury (mTBI), which affects close to 70 million individuals annually worldwide. This study aims to test the utility of a unique, early predictive magnetic resonance imaging (MRI)-based classification model using structural brain MRI scans, a rarely used approach to identify high-risk individuals for post-mTBI chronic pain. We recruited 227 patients with mTBI after a vehicle collision, between March 30, 2016 and December 30, 2019. T1-weighted brain MRI scans from 128 patients within 72 hours postinjury were included and served as input for a pretrained 3D ResNet-18 deep learning model. All patients had initial assessments within the first 72 hours after the injury and performed follow-ups for 1 year. Chronic pain was reported in 43% at 12 months postinjury; remaining 57% were assigned to the recovery group. The best results were achieved for the axial plane with an average accuracy of 0.59 and an average area under the curve (AUC) of 0.56. Across the model's 8 folds. The highest performance across folds reached an AUC of 0.78, accuracy of 0.69, and recall of 0.83. Saliency maps highlighted the right insula, bilateral ventromedial prefrontal cortex, and periaqueductal gray matter as key regions. Our study provides insights at the intersection of neurology, neuroimaging, and predictive modeling, demonstrating that early T1-weighted MRI scans may offer useful information for predicting chronic head and neck pain. Saliency maps may help identify brain regions linked to chronic pain, representing an initial step toward targeted rehabilitation and early intervention for patients with mTBI to enhance clinical outcomes.

Differentiating the Structural and Functional Instability of the Craniocervical Junction

This paper presents the anatomical and biomechanical aspects of chronic instability of the craniocervical junction (CCJ) with a discussion on clinical diagnostics based on mobility tests and provocative tests related to ligamentous system injuries, as well as radiological criteria for CCJ instability. In addition to the structural instability of the CCJ, the hypothesis of its functional form resulting from cervical proprioceptive system (CPS) damage is discussed. Clinical and neurophysiological studies have shown that functional disorders or organic changes in the CPS cause symptoms similar to those of vestibular system diseases: dizziness, nystagmus, and balance disorders. The underlying cause of the functional form of CCJ instability may be the increased activity of mechanoreceptors, leading to "informational noise" which causes vestibular system disorientation. Due to the disharmony of mutual stimulation and the inhibition of impulses between the centers controlling eye movements, the cerebellum, spinal motoneurons, and the vestibular system, inadequate vestibulospinal and vestibulo-ocular reactions occur, manifesting as postural instability, dizziness, and nystagmus. The hyperactivity of craniocervical mechanoreceptors also leads to disturbances in the reflex regulation of postural muscle tone, manifesting as "general instability". Understanding this form of CCJ instability as a distinct clinical entity is important both diagnostically and therapeutically as it requires different management strategies compared to true instability. Chronic CCJ instability significantly impacts the quality of life (QOL) of affected patients, contributing to chronic pain, psychological distress, and functional impairments. Addressing both structural and functional instability is essential for improving patient outcomes and enhancing their overall QOL.

A 13-Year Long-Term Follow-Up of a Case Report With Continued Improvement in Severe Chronic Neck and Head Pain Alleviated With Chiropractic BioPhysics® Spinal Rehabilitation Protocols

Alleviation of headaches (HAs), neck pain (NP), and disability is a desirable clinical outcome for the billions globally who suffer from these conditions. Chiropractic BioPhysics® (CBP®) methods may provide an option for head and neck-injured patients. A 62-year-old female historically injured multiple times including two motor vehicle collisions (MVC), and a strike to the face with a hockey puck; all resulting in chronic pain and suffering. The subject sought and received successful treatment in 2016 using this conservative protocol at a facility in the USA. The resolution of symptoms following 36 treatments was previously reported. Following 13 years without treatment beyond home exercises, the subject was re-evaluated and found to be stable in the long term for pain, structural and functional assessment. Thirty-six treatments over 12 weeks in 2016 led to an improvement in numerical pain rating scale (NPRS) for NP (5/10 to 1/10), and HA (9+/10 to 0/10), resolution of NP disability (6/100 to 0/100) as well as normalization of ROM without pain and resumption of all activities of daily living including high-level athletics without pain and disability. A 13-year follow-up found continued stability objectively and subjectively. We provide a case of successful conservative treatment using specific traction, exercises, and spine manipulation procedures. CBP® provides an option to treat pain and this case adds to growing evidence.

Assessing the Effects of Mild Traumatic Brain Injury on Vestibular Home Exercise Performance with Wearable Sensors

After a mild traumatic brain injury (mTBI), dizziness and balance problems are frequently reported, affecting individuals' daily lives and functioning. Vestibular rehabilitation is a standard treatment approach for addressing these issues, but its efficacy in this population remains inconclusive. A potential reason for suboptimal outcomes is the lack of objective monitoring of exercise performance, which is crucial for therapeutic success. This study utilized wearable inertial measurement units (IMUs) to quantify exercise performance in individuals with mTBI during home-based vestibular rehabilitation exercises. Seventy-three people with mTBI and fifty healthy controls were enrolled. Vestibular exercises were performed, and IMUs measured forehead and sternum velocities and range of motions. The mTBI group demonstrated a slower forehead peak angular velocity in all exercises, which may be a compensatory strategy to manage balance issues or symptom exacerbation. Additionally, the mTBI group exhibited a larger forehead range of motion during specific exercises, potentially linked to proprioceptive deficits. These findings emphasize the usefulness of utilizing IMUs to monitor the quality of home-based vestibular exercises for individuals with mTBI and the potential for IMUs improving rehabilitation outcomes.