instability / TRAUMATIc Syndrome

1. instability / TRAUMATIcSyndrome

2. Outcomes • Be familiar with the mechanism of a instability / traumatic syndrome. • To be familiar with the clinical presentation of a typical patient with acute instability syndrome. • Be familiar with the most widely used medical as well as physiotherapy treatment protocols for a patient with a typical acute / sub-acute and chronic instability syndrome. • Be familiar with the possible pathological changes associated with an instability syndrome.

3. Outcomes • Be familiar with the clinical presentation of a typical patient with an instability syndrome. • Be familiar with the associated symptoms experienced by a patient with a typical instability syndrome.

4. Causes • Trauma as a result of a motor-vehicle accident or sport injury • Degenerative in the articular complex • Leads to irregular patterns of comparable signs and a variety of signs and symptoms

5. Hyperextension injuries • Acceleration when a car is hit from behind • The seat with the lower body accelerates forwards • The neck is unstable and can not control the movement of the head • The neck moves into sudden extension – reflex contraction of the neck flexors causes the neck to go into flexion

6. Hyperflexion injuries • Deceleration when a car is brought to a stand still due to the collision • Head and neck continues to move forwards causing hyperflexion until the chin bumps against the chest • Reflex contraction of the extensors causes extension

8. General • If the neck is rotated when the collusion occurs an excessive amount of lateral flexion and rotation will take place • Normal physiological ranges is exceeded and this leads to damage and anatomical changes of the soft tissue

9. Structures that are damaged • Ligaments • Intervertebraldisc • Facet joints • Surrounding muscles • Haematoma of especially the m sternocleidomastoïd

10. Symptoms • Pain during rest especially if the structures are placed on stretch • Pain through entire range of movement • Muscles are painful during stretch and contraction • Ligaments are painful when placed on stretch (except the interspinal ligament which is painful during extension)

11. Treatment: Acute • Total bed-rest for first 2-3 days • Supportive, soft neck support (when patient is in an upright position) • Ice for first 24 hours • Heat is contra-indicated for first 48 hours (Afterwards damp heat) • Anti-inflammatory medication and muscle relaxants • Careful, active non-weight bearing exercises (except rotation and lateral flexion) • Gentle massage

12. Treatment: Sub-Acute • Symptoms become more specific • Wean from neck support – still use support in a vehicle of when neck feels tired • Ultrasound and damp heat/ice • Mobilisations – short of pain • Cautious isometric exercises • Increase active exercises (introduce flexion and extension into exercise programme) • Commence with PNF patterns if pain will allow • Cautiously commence with distal neural mobilisations

13. Treatment: Chronic • Treat according to signs and symptoms • Pain at end of range (6-8 weeks after injury) • Totally wean from neck support • Isometric exercises are progressed into standing • Evaluate for muscle imbalance and treat accordingly • Make use of combined movements and neural mobilisation techniques for final rehabilitation

14. Possible pathological changes • Ligament injuries: Anterior longitudinal Posterior longitudinal Interspinal • Disc herniation • Fracture : Spinous process Vertebral bodies • Tear of the capsule and facet joints with acute synovitis • Tear of the neck muscles

15. Possible pathological changes (cont) • Tempomandibular joint injuries • Retropharingealheamatoma • Oesophageal haemorrhage • Sympatic chain injuries • Concussion and minor head injuries • Vertebral artery damage • Thoracic outlet syndrome

16. Clinical presentation • Pain and tenderness over affected structures • Referred pain – irritation of nerve root miofascial trigger points scleretome referral (deep burning pain which feels like it is in the bone itself) • Neck muscle spasm • Headaches (experienced as a deep pressure with pounding , nausea , vomiting and photophobia) • Normal range of movement restricted

17. Clinical presentation (cont) • Dysphagia with hoarseness in the acute phase • Sympathetic signs: Intermittent weak vision Headaches Horner’s syndrome • Dizziness: Vertebral artery symptoms Middle ear injuries • Oedema

18. Horner’s syndrome • Miosis (constriction of the pupil) • Pytosis (drooping eye) • Enophthalmia (sunken eye) • Anidosis (loss of perspiration on the one side of the face)

19. Clinical presentation (cont) • Anterior chest pain: presents as angina becomes worse with exercise tender anterior nausea sleeps poorly becomes worse with coughing and sneezing • Oedema

20. Associated symptoms • Thoracic outlet syndrome • Lower backache • Head injuries such as concussion • Tempromandibular joint injuries • Fibromialgia (chronic pain and stiffness in muscles with local tenderness) • Psychosis • Depression • Difficulty with acceptance

21. Associated symptoms (cont) • Anxiety • Rage • Frustration (financial and family) • Personality changes and interference in daily living • Post-traumatic stress syndrome

22. Treatment • Analgesics • Anti-depressants • Surgery • Psychiatric treatment