Transcript Whiplash: Assessment and Treatment to Optimise Recovery

Your Name
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Cost & Controversy
Biomechanics
Pathology
Clinical Features
 Subjective
▪ Pain, disability, dizziness,
▪ Psychological impairment
 Objective
▪ Sensorimotor, motor
control, sensory changes.
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Cost £3 billion per annum in UK alone.
 Half million people make claim for whiplash injury in UK
every year (ABI 2008)
 Claims increasing year on year
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Huge variations in cost between countries
 Switzerland average payout is 30,000 Euros / UK £2,500
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Whiplash culture blamed
for rising claims & cost
 Making a claim appears to
increase pain and disability
(Sterling 2010)
 For every £1 paid in
compensation, 87p is paid to
the solicitor.
“This is not
access to
justice, this
is incitement
to litigate –
and it must
stop.”
Lord Young of
Graffham
2010
In chronic whiplash treatment
only 10-20% have a
completely successful
outcome.
(Stewart et al 2007, Jull et al 2007)
Acute trials demonstrate no
efficacy in decreasing
incidence of those who develop
persistent symptoms.
(Provinciali et al 1996,
Rosenfeld et al 2000, 2003)
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Major point of contact is seatback
Lumbar extension 20ms
Thoracic extension 60ms – ‘ramping’
Sigmoid deformation cervical spine
 Upper cervical flexion / Lower cervical extension
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Muscle contraction onset 100-125ms after onset
of vehicle acceleration
Full cervical extension upper & lower
‘Rebound phase’ from extension into flexion
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Z-joint injury
 Capsule tear / synovial fold pinched / multifidus
attachment strain.
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Anterior Long. / Transverse / Alar Ligament injury
 Increased incidence alar injury with cervical rotation.
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Disc injury
Nerve / dorsal root ganglion injury
 Pressure changes in the spinal canal.
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Cervical arterial injury
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Subjective:
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Pain – NPRS / S-LANSS
Disability – Neck Disability Index.
Dizziness – Dizziness Handicap Inventory.
Psychological distress – Impact of Events Scale (Horowitz et al 1979)
Objective:
 Sensorimotor disturbance.
▪ Joint positioning error / Oculomotor control / Postural stability
 Muscle & motor control impairment.
 Sensory changes - pressure & thermal pain thresholds & ULTT
(Sterling et al 2005)
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Why assess proprioception, eye movement &
postural stability following whiplash ?
 Muscle spindle input merged with input from visual
and vestibular system.
 Dense network of muscle spindles in deep neck
muscles. (Peck 1984, Richmond & Bakker 1982)
 Experimental evidence of role in postural control.
(deJong et al 1977, Pyykko et al 1989, Gosselin et al 2004 )
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Laser on head, sitting, 90cm from wall.
A4 sheet of paper.
Perform one practice run with eyes open:
 L Rot, R rot, F, E
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Close eyes – remember starting position
 Perform L rot & attempt to return to starting position.
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Average of 3 trials L rot, R rot
Abnormal score >5cm
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Oculomotor control in
whiplash
 62% impaired (Heikilla
1998)
 Impaired oculomotor
control associated with
poor prognosis
(Hildingsson et al 1993).
 Cause ? = disturbed
afferent input vs brain
stem involvement.
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Smooth Pursuit Neck Torsion Test (Tjell and Rosenhall
1998)
 Assesses cervical afferent disturbance
 Perform smooth pursuit
 Rotate trunk 45deg left (right neck torsion)
▪ Repeat smooth pursuit
▪ Performance will deteriorate if positive ie increased effort,
dizziness, unable to perform test.
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Repeat to opposite side
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Standing balance:
 Increased AP sway in whiplash subjects >
idiopathic neck pain > normal (Field et al 2008)
 50% non dizzy whiplash unable tandem stand
eyes closed (Field et al 2008).
 74% dizzy whiplash subjects unable tandem
stand eyes closed (Treleaven et al 2008).
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Muscle composition changes
 Fibre type transformation Type I
to Type II
 Fatty infiltration: multifidus,
rectus capitis muscles.
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Muscle strength deficits
Motor control reorganisation
A - Whiplash, B – Normal control
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Deep Neck Flexors (DNF)
 Pressure biofeedback 5-stage
craniocervical flexion
▪ Starting pressure 20mmHg.
▪ Target 22 – 24 – 26 – 28 - 30mmHg.
▪ Hold each stage for 10 seconds.
(Falla et al 2004)
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Exercise MUST be specific:
 Low load training DNF (Jull et al 2005,2009, Falla et al 2007)
▪ Increases activation of DNF – decreases neck pain.
▪ Decreases activity in SCM & AS.
▪ These benefits NOT achieved with 6 weeks of higher load
strength and endurance training.
 High load strength and endurance training (Falla et al 2003)
▪ Required to increase strength of cervical muscles.
▪ Decreases neck pain.
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Hyperalgesia on manual examination
Reduced pressure pain threshold in neck and at
remote sites (eg Tibialis Anterior) - algometer
(Sterling et al 2005).
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Cold pain threshold reduced – thermoroller.
(Williams et al 2007, Sterling et al 2008).
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Bilateral restriction in ULTT with VAS > 4/10
during test (Sterling et al 2002).
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Strongest predictors of poor outcome:
 Pain NPRS / VAS > 8/10
 S-LANSS =>12
 Neck Disability Index >30 %
 Impact of Events Scale screen for PTSD =>26
 Cold hyperalgesia >15deg C
(Sterling et al 2006)
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Cost & Controversy
Biomechanics
Pathology
Clinical Features
 Subjective
▪ Pain, disability, dizziness,
▪ Psychological impairment
 Objective
▪ Sensorimotor, motor
control, sensory changes.
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Chris Worsfold MSc PGDipManPhys
Musculoskeletal Physiotherapist
Specialises in neck pain, whiplash &
headaches.
Further information  Blog / Courses:
www.ClinicalWhiplash.com
 Clinic:
www.KentNeckPainCentre.com
THANK YOU !