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Whiplash

Whiplash. Made by: Ashley Lewis *Credit to Mike McMorris*. Learning Objectives . Review how whiplash occurs and mechanism behind the injury Be able to recognize and identify common symptoms associated with whiplash injuries

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Whiplash

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  1. Whiplash Made by: Ashley Lewis *Credit to Mike McMorris*

  2. Learning Objectives • Review how whiplash occurs and mechanism behind the injury • Be able to recognize and identify common symptoms associated with whiplash injuries • Review common classification system associated with whiplash injuries • Identify clinical prediction rule factors related to full recovery versus long term disability • Review what to assess during a PT Initial Evaluation • Understand and learn PT treatment during each phase of recovery from whiplash

  3. What is whiplash or wad? • Commonly associated with MVC • Annual rate: 70-329 per 100,000 people in US1 • Typical occurrence2: • Sudden vehicle stops or turns • Causes rotation or rapid/violent flexion/extension • Creating injuries to MSK tissues in cervical spine2 • Typically described as: Acceleration-Deceleration Injury2 • Acceleration: Body pushed forward cervical extension posterior compression and anterior tissues stretched • Deceleration: Compressed anterior tissues and lengthened posterior aspect of neck https://www.hoffmannpersonalinjury.com/wp-content/uploads/2015/03/st-louis-neck-injury-lawyer.jpg

  4. Whiplash video • https://www.spineuniverse.com/conditions/whiplash/whiplash-animation

  5. https://southsidechiropracticcarinjuryclinic.com/wp-content/uploads/2017/03/Whiplash.pnghttps://southsidechiropracticcarinjuryclinic.com/wp-content/uploads/2017/03/Whiplash.png

  6. Common Symptoms http://www.loyaltylaw.com/blog/wp-content/uploads/2013/12/Loyalty-Law.png

  7. Severe Common Symptoms2 • Tingling or numbness in the arms • Blurry vision • Ringing in ears • Memory problems • Difficulty concentrating • Sleep disturbances • Irritability • Depression • https://www.chiropractorfreehold.com/wp-content/uploads/2012/06/whiplash-refer-pain3-300x171.jpg

  8. Classification of Whiplash Injuries3

  9. Diagnosis4 • Based on clinical findings: • Confirmation of sudden or excessive cervical extension, flexion, or rotation • Patient reported symptoms: cervical pain and related symptoms • Examination of: • Signs for point tenderness • Muscular spasm • UE/LE neuro issues • Assessment of cervical ROM • Red flags* • Identify possible psychosocial barriers to recovery

  10. Red and yellow flags after whiplash Red flags Yellow flags • Numbness and tingling into the arms • Changes in bowel/bladder • Older age (>50 years old) • Dizziness/syncope • Cervical instability • Blurry vision • Memory problems • Depression • Fear avoidance • Chronic pain • Anxiety • Fear of pain • Fear of moving • Pain catastrophizing https://d1f2yo4rht0zy2.cloudfront.net/wp-content/uploads/2018/03/scared-woman-phobia-fear-nail-biting.png

  11. Prognosis • Recovery time varies • Severity dependent • Most recover in first 2-3 months (acute whiplash)3 • Chronic whiplash syndrome: symptoms that persist longer than 3 months4 • >50% of people experience symptoms after 1 year post injury5 • High variability/low predictability of injury prognosis • Predictors of Poor Prognosis: • Rear impact > side impact • Pre-existing degenerative joint disease (DJD) • Developing neurological s/s soon after accident • Depression1 https://www.enjuris.com/personal-injury/images/whiplash.jpg

  12. Predictive models for prognosis of patients with Whiplash5 • Neck pain intensity* • Low back pain intensity* • Pain other than neck and back pain* • Negative recovery expectations* • Symptoms of post traumatic stress • Age • Number of days to reporting the collision • Headache before collision • High pain catastrophizing

  13. CPR to Predict Full Recovery vs Ongoing Moderate/Severe Disability6 • Full recovery: • Younger than 35 years old • Initial Neck Disability Index score of 32% or less • Ongoing Moderate/Severe Disability: • 35 years of age or older • Initial Neck Disability Index score of 40% or more • Presence of hyperarousal symptoms (Posttraumatic Stress Diagnostic Scale score of 6 or more) https://www.aaos.org/uploadedFiles/NDI.pdf: Neck Disability Index

  14. PT Patient History and Examination3 • History: • Measure pain/disability • VAS • Neck Disability Index • Psychological factors affecting recovery • Examination: • Use common cervical spine evaluation • Classify whiplash based on grading system • Check for sensory loss and muscle weakness • https://i0.wp.com/www.healthline.com/hlcmsresource/images/3667-pain-scales-visual-1296x728-body.jpg?w=1155&h=768

  15. PT Patient History and Examination3,9, 10 Common findings include: • Decreased motor control • Changes in morphology of cervical flexor and extensor muscle groups • Loss of strength and endurance of cervical flexor, extensor, and scapular muscle groups • Sensorimotor changes, including increased joint re-positioning errors • Poor kinesthetic awareness • Loss of ROM of cervical spine motions • Altered eye movement control • Delays in smooth pursuit neck torsion test (SPNT) • Dizziness • Loss of standing balance https://image.slidesharecdn.com/physiologyofequilibriumbalance-111029153537-phpapp01/95/physiology-of-equilibrium-balance-40-728.jpg?cb=1319902603

  16. Treatment- Acute phase (2-3 weeks) 3,7 Goal: allow cervical muscles to rest without developing stiffness, relieve pain and swelling Reassurance and positive outlook Vestibular exercises (Eye fixation) Relaxation techniques Head traction Motor control of neck musculature using laser light on head • Soft tissue massage • Grade I-II mobilizations for pain relief • Heat or ice • NSAIDs • Early AROM/PROM as tolerated • Postural retraining • Patient education on whiplash and prognosis

  17. Treatment- Sub-acute phase (2-10 weeks)3,7 Goal: restore flexibility to the cervical muscle groups and articular facets Proprioception/rhythmic stabilization Motor control of neck musculature using laser light on head Vestibular exercises • Joint mobilizations • Stretching • Light isometric and isotonic strengthening (deep neck flexors, multifidi)

  18. Exercise ExamplesAcute and subacute

  19. Stretches and joint mobilizationsacute and subacute https://learnmuscles.com/wp-content/uploads/2016/12/Spinal-Jt-Dys-Blog-photo-4.jpg

  20. Treatment- Chronic Phase (begins when acute healing ends)3,7 • Goal: Increase ROM, return person to full normal daily function • Continue using all treatments stated above • Gentle, repetitive stretching • Work to restore cervical lordosis by mobilization into extension and multifidus strength • General neck stability and strength • Manual joint manipulation8 • Myofeedback training8 • http://www.mainespinecare.com/assets/images/exlib-neck_towel.jpg

  21. Take home message • Whiplash is an acceleration-deceleration injury affecting both anterior and posterior cervical spine • Hard to diagnosis, most often based on patient report of injury and symptoms • Most common symptoms are neck pain and headaches • PTs play a key role in patients recovering from whiplash injuries during all phases: acute, subacute, and chronic • With the help of PTs most patients can recover in 2-3 months • Each patient will present differently, so have to evaluate each individual and create an individualized PT treatment plan based on their symptoms

  22. Thank you!! Questions?? This Photo by Unknown Author is licensed under CC BY This Photo by Unknown Author is licensed under CC BY-NC-ND

  23. References • Physical Therapy for Whiplash | Drayer Physical Therapy. Available at: https://drayerpt.com/physical-therapy-for-whiplash/. Accessed January 13, 2019. • Is Whiplash a Serious Injury? | Florida Physical Medicine. Available at: https://floridaphysicalmedicine.com/whiplash-serious-injury/. Accessed January 13, 2019. • Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother 2014;60(1):5-12. doi:10.1016/j.jphys.2013.12.004. • Tameem A, Kapur S, Mutagi H. Whiplash injury. Continuing Education in Anaesthesia Critical Care & Pain 2014;14(4):167-170. doi:10.1093/bjaceaccp/mkt052. • Bohman T, Côté P, Boyle E, Cassidy JD, Carroll LJ, Skillgate E. Prognosis of patients with whiplash-associated disorders consulting physiotherapy: development of a predictive model for recovery. BMC MusculoskeletDisord 2012;13:264. doi:10.1186/1471-2474-13-264. • Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. J Orthop Sports Phys Ther 2015;45(4):242-250. doi:10.2519/jospt.2015.5642. • Physical Therapy Treatments for Whiplash | ApexNetwork Physical Therapy. Available at: https://apexnetworkpt.com/physical-therapy-treatments-for-whiplash/. Accessed January 23, 2019. • Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary. Pain Res Manag 2010;15(5):287-294. • Treleaven J, Jull G, Lowchoy N. Standing balance in persistent whiplash: a comparison between subjects with and without dizziness. J Rehabil Med 2005;37(4):224-229. doi:10.1080/16501970510027989. • Treleaven J, Jull G, LowChoy N. The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash. Man Ther 2006;11(2):99-106. doi:10.1016/j.math.2005.04.003.

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