L22-23: Headache, Wry Neck and Acute Whiplash cases

Question 1

What are 5 decisions about patient’s headache for outcomes of patient interview and physical examination?

Answer 1

1. Red flag/ unknown – needs referral
2. Cervicogenic headache
3. Not Cervicogenic - Migraine or tension-type headache
4. Mixed headache - Cervicogenic + migraine/tension-type
5. Not cervicogenic - but co-morbid musculoskeletal signs
   
   • Eg. neck condition

Question 2

What is a cervicogenic headache? What is the treatment?

Answer 2

patient has a pattern of symptoms and pattern of cervical musculoskeletal impairment that fit the criteria

Question 3

What is a suspected migraine or tension-type headache? What is the treatment?

Answer 3

patient has headache and neck pain but no pattern of cervical musculoskeletal impairment that fits the criteria

Recommend referral to a Neurologist or Primary Care Physician

Question 4

What is the management decision for patients with migraine or T-T headache who gained temporary relief from physiotherapy management?

Answer 4

Physiotherapy acts centrally on a sensitised trigeminocervical nucleus to temporarily reduce pain

• Providing afferent input into cervical

Headache pattern may return

• Patient must understand that treatment is not ‘curative’ but palliative

Question 5

What is the management decision for patients with migraine or T-T headache with cervical musculoskeletal signs but which are not comparable to headache intensity or frequency?

Answer 5

1. Co-morbid cervical musculoskeletal disorder
2. Note also elders with headache have co-morbid cervical musculoskeletal disorders
3. Mixed headache type; transitional headache
   
   1. Trial of physiotherapy management
   2. Full understanding by the patient
   3. Careful monitoring of outcomes
   4. Honest reflection on effect of treatment

Question 6

What are the 4 management decision for patients with migraine or T-T headache with cervical musculoskeletal signs but which are not comparable to headache intensity or frequency (for mixed headache type; transitional)?

Answer 6

1. Trial of physiotherapy management
2. Full understanding by the patient
3. Careful monitoring of outcomes
4. Honest reflection on effect of treatment

Question 7

What are the 2 management decision for patients with two or more concurrent headaches, one of which is cervicogenic?

Answer 7

1. Treat cervicogenic headache and ensure patient has an understanding of treatment goals
2. Assess effect on other headache type
   
   1. addressing that level of sensitisation that they have that
   2. might be triggering off their migraine attention type headache

Question 8

What are 6 management of cervicogenic headache?

Answer 8

1. Explanation, education and assurance
2. Posture, ergonomic and work practice advice
3. Loss of movement and segmental joint dysfunction
   
   • Manual therapy and specific segmental active exercise
   • Part of cervicogenic headache criteria
4. Specific impairment in the neck flexors and extensors/axioscapular muscles (Muscle function)
   
   • Program of specific therapeutic exercise (motor control, strength and endurance)
5. Lightheaded or dizziness
   
   • Manual therapy, specific exercise for sensorimotor control joint position and movements training, smooth pursuit
6. Self management and maintenance program
   
   • Continued posture correction (every 15mins) or exercises
     
     • Depends on underlying pathology

Question 9

What are 4 tips about the management of cervicogenic headache?

Answer 9

Have evidence of effectiveness for physical therapies for cervicogenic headache

1. Evidence indicates management should be multimodal
   
   • Exercises and manual therapy –> combined (more effective)
2. Don’t forget the thoracic spine – often hypomobile C/Th
3. Must remove provocative factors – work, leisure activities
4. Headache (neck disorders) tendency for recurrence/chronicity
5. Must be effective self management strategies
6. Effective maintenance program

Question 10

What are 2 tips (1/2) about the management of headache?

Answer 10

1. Evaluate treatment effectiveness in the long term. Any headache type can respond in the short term
   
   1. change the patient’s original headache pattern
2. Lack of response to treatment
   
   1. Not cervicogenic
   2. Pathology far outweighs ability of conservative physical therapies to gain an effect
   3. significant joint pathology following whiplash
   4. marked cervical degenerative joint disease
   5. possibly require medical/surgical interventions

Question 11

What are 5 overall management of cervicogenic headache?

Answer 11

Multimodal management is the superior management approach for neck disorders

1. Physical therapies
2. Preventive medicines
3. Anaesthetic blocks
4. Neurolysis (medial branch of the dorsal ramus, or dorsal root ganglion)
5. Botox ??- Not effective CGH ? migraine
   
   • Injections into frontal and temporal head

Question 12

What are 4 criteria of cervicogenic headache? What are 3 probems?

Answer 12

1. Improved with physical activity
2. Unilateral (not shifting sides)
3. Some nausea but no light sensitivity
4. Joint dysfunction
5. Pain
6. Range

Question 13

What would be your 5 approaches to her management ?

Answer 13

1. Commence manual therapy to R C1/2 to increase right rotation and extension and to thoracic spine to improve extension and rotation- home program to maintian gains
2. Commence restoration of posture and formal and functional muscle function – neck flexors, upper cervical extensors and lower cervical extensors.
3. Address sensorimotor control –JPE and cervical movement sense
4. Ergonomic advice – regular position changes, postural correction
5. Advice re sleeping positions, ergonomics and gym work- needs further investigation.

Question 14

What is Jenny’s prognosis?

Answer 14

Good if does exercises in conjunction with modifications to work, gym and sleeping positions

Question 15

What would be your 6 specific early physiotherapy management and home program ?

Answer 15

1. Ergonomics, advice modification of activities sitting, computer rest breaks, gym, sleeping positions, pillow etc
2. Posture correction – lumbar and thoracic first, then cervical – progress as able to maintain positions.
3. Commence neuromotor control exercises DNF practice the action first with palpation to monitor SCMs and scalenes – 2 x day
4. Add 4 point kneel upper cervical rotation work
5. Manual therapy – C1/2 PIVVMS, PAIVMS right, thoracic PIVMS, PAIVMS
6. Self management – heat, neuromotor and sensorimotor exercises, segmental mobilisation exercises eg C1/2 strap and thoracic mobility over chair or over foam roller.

Question 16

How would you progress the exercise program (4)?

Answer 16

1. Progress CCFT as able to holds with the PBU gradually increase, add proprioception JPE, movement sense as required.
2. Progress to: isometrics, head lifts off wall, pillows- aim no pillow lower cervical extension with resistance, C1/2 number of reps
3. Segmental ROM exercises C1/2 and thoracic
4. Maintenance program- regular posture correction at work, segmental exercises mobility thoracic spine

Question 17

What is wry neck?

Answer 17

Held in lateral flexion

Question 18

What are the different cervical wry neck deformity?

Answer 18

Question 19

What are the 4 main presentations of the wry neck deformity in examination as general considerations?

Answer 19

1. is the joint is ‘locked’ or unlocked
2. is wry position for comfort eg whiplash
3. differentiate between sudden and spontaneous origins of acute wry neck (Z Jt versus disc)
4. differentiate Muscular, Traumatic, Acquired, Hysterical, Spasmodic torticollis

Question 20

What are the 4 methods-limited assessment of the wry neck deformity in examination as general considerations?

Answer 20

1. History
2. Posture/ deformity
3. Correction of deformity (sitting and lying)
4. PPIVMs, PAIVMs,

Question 21

What are the 4 history of acute Z joint wry neck deformity (locked or unlocked)?

Answer 21

1. Often younger person
2. Females>>males
3. Few to 24 hours in duration on presentation
4. Incident, e.g. sudden movement, turned quickly not uncommon to wake with thus need to differentiate discal origin with same history
5. Past history (previous episodes, not uncommon)
   
   • Need for prophylactic care
   • Immediate episode of pain
6. Localized unilateral neck pain (patient can localise with one finger)
7. Usually non –irritable

Question 22

What are the 5 posture physical examination of acute Z joint wry neck deformity (locked or unlocked)?

Answer 22

1. Contralateral list: Rot, LF away from (variable degree)
2. Correct deformity - Is it locked or not?
   
   • If can correct –> not locked
3. Movement pattern
   
   • Most limited usually LF >Rot >Ext towards side of pain
4. Non irritable
5. PPIVM’s, PAIVM’s – confirm if locked, localise segment
   
   • Relaxation of some muscle spasm in NWB position

Question 23

What are the 2 pathology of locked apophyseal acute Z joint wry neck deformity?

Answer 23

Pathology is unknown

1. entrapped or extrapped menisci
2. acute nipping of synovial fringe reactive inflammation, swelling and muscle spasm

Question 24

What are the 2 common segments of locked apophyseal acute Z joint wry neck deformity?

Answer 24

1. C1-2 or C2-3 (largest meniscii)
2. Older people- osteoarthritic changes

Question 25

What are the 5 treatments (Day 1) of locked apophyseal acute Z joint wry neck deformity?

Answer 25

1. manual traction initially in line of the deformity, progressively bringing neck into neutral position 2. LF away from the side of pain 3. Rot away from side of pain 4. Relaxation techniques at the segmental level (Contract/relax) 5. Localized manipulative technique (gapping technique) if proficient NB: limitations of vertebral artery testing, but need to do all usual preliminary tests prior to manip. Only: * Younger (no OA) * Locked wry neck * Do all tests (except VBI unable to do)

Question 26

What are the 6 treatments (Day 1) of unlocked or post-locked apophyseal acute Z joint wry neck deformity?

Answer 26

1. Gentle unilateral glides over affected Z joint 2. U.S. for inflammation and pain 3. Active movements in NWB position (eg on hot pack or ice pack if patient tolerates) * Depends on what the patient prefers 4. Disinhibit and activate deep neck flexors and extensors * Would be de-activated from pain 5. Address any axio-scapular muscle dysfunction 6. Advice re rest for 24 hours

Question 27

What are the 3 treatments (Day 2) of locked or unlocked apophyseal acute Z joint wry neck deformity?

Answer 27

1. Manual Therapy for residual joint pain 2. Ensure activation of all supporting muscles 3. Active segmental exercises * Might have some pain end of range * Condition should settle within 2-3 days * If the condition is recurrent, ensure that muscle stability function is retrained to prevent recurrent episodes.

Question 28

What are the 5 treatment approaches (similar) of unlocked or post-locked apophyseal acute Z joint wry neck deformity?

Answer 28

1. Avoid manipulation in older people * Condition is more irritable, more effusion, slower to respond 2. Joint mobilisation first, including manual traction 3. if unsuccessful can use manipulation (usually not) 1. ensure it is a technique to open the joint 2. ensure no C/I to manip (Not closing technique) 4. Consider the need for support in a collar for 24-48 hours for pain relief 5. Consider medication (Analgaesics, NSAIDs)

Question 29

What are the 4 characteristics of "discogenic" wry neck deformity?

Answer 29

1. Precise pathology in disc unknown 2. Usually affects lower cervical segments 3. Care: these patients vulnerable to development of a disc, nerve root syndrome * Can cause secondary injury (eg. radiculopathy) -\> if aggravating pain or wrong/unsuitable management 4. High velocity manipulation is contra-indicated

Question 30

What are the 6 history of "discogenic" wry neck deformity?

Answer 30

1. Often older person, 3rd or 4th decade 2. Insidious onset, patient may "wake with" 3. Can be a history of unaccustomed activity * Activity a few days before --\> wake up with pain 4. deep ache, builds up and spreads, 5. pain adjacent to the scapula 6. often slightly irritable

Question 31

What are the 4 physical examination of "discogenic" wry neck deformity?

Answer 31

1. Posture: LF, Rot, Flex away from side of pain (Not locked) 2. Correction; possible, painful, muscle spasm 3. Movement pattern: Most limited, usually **Ext \> LF \> Rot** towards side of pain 4. Confirm level, PPIVMs and PAIVMs

Question 32

What are the 8 treatment (treat in a position of ease) of "discogenic" wry neck deformity?

Answer 32

1. Rotation away from side of pain 2. PA or AP glides in a position of ease 3. Traction 4. Hot pack 5. Gentle active exercise in NWB position 6. Disinhibit / activate deep neck flexors and extensors 7. Address any axio-scapular muscle dysfunction 8. Advice re rest for 24 hours + Collar 9. Often require analgesics **Manipulation contra-indicated**

Question 33

What are the 2 subsequent treatments (treat in a position of ease) of "discogenic" wry neck deformity?

Answer 33

1. Note often a slower response to treatment may take 2 weeks +/- to subside 2. Note must monitor these patients carefully have the potential to develop into a full blown disc, nerve root syndrome (Radiculopathy) * Arm pain and pins and needles, numbness, check neurological test

Question 34

What is Atlanto-axial rotary fixation (Grisel's syndrome)?

Answer 34

RED FLAG **Be alert to the disorder and refer on for medical management** Rare disorder principally of children * Fixed rotary **subluxation** of C1 on C2

Question 35

What are 3 causes of Atlanto-axial rotary fixation (Grisel's syndrome)?

Answer 35

1. spontaneous 2. secondary to trauma, 3. congenital anomalies upper cervical spine and arthritides (eg juvenile onset RA)

Question 36

What are 3 primary injuries of Atlanto-axial rotary fixation (Grisel's syndrome) (as a secondary injury)?

Answer 36

1. upper respiratory tract infection 2. post surgical complication (mastoidectomy, tonsillectomy) 3. other causes – eg. retropharyngeal abscess

Question 37

What are 6 presentations of Atlanto-axial rotary fixation (Grisel's syndrome)?

Answer 37

1. Child presents with a ‘cock robin’ deformity 2. Neck pain or headache – occasionally VBI 3. Pain on attempted correction, cannot get passed the midline 4. C2 spinous process often palpated on the side of the deformity 5. **Many have rotation but no subluxation and expect resolution** 6. Radiographic diagnosis CT, MRI

Question 38

What are 4 managements of Atlanto-axial rotary fixation (Grisel's syndrome)? What happens if it is unstable?

Answer 38

1. Soft collar for a week see if resolves * If not resolved but stable 2. Hospital traction with analgesics and muscle relaxants 3. Halo traction if halter traction not effective 4. Discharged with soft collar or Philadelphia collar If unstable: surgical fixation

Question 39

What are 3 characteristics of muscular wry neck?

Answer 39

1. Most common is post minor trauma 2. involvement of SCM 3. Note: wry neck deformity, **towards** side of pain

Question 40

What are 2 characteristics of traumatic wry neck?

Answer 40

1. whiplash injury or sporting injury 2. High velocity manipulation is contra-indicated as uncertain of underlying pathology: * eg Microfracture and Cranio-cervical ligament instabilities

Question 41

What is a characteristic of acquired wry neck?

Answer 41

1. subtle deformity 2. eg undetected mild childhood torticollis

Question 42

What 2 characteristics of hysterical wry neck?

Answer 42

This condition is rare 1. an exaggerated deformity 2. signs do not match symptoms manual examination reveals no joint signs deformity is easily corrected If there are **no musculoskeletal signs**, do not prolong management

Question 43

What is Spasmodic torticollis (cervical dystonia) wry neck?

Answer 43

A CNS disorder of the basal ganglia. * Etiology is not yet well understood, imbalance in the chemical neurotransmitters or some aspect of cell inter-communication, basal ganglia? * **neurological** not musculoskeletal

Question 44

What are the 4 management of Spasmodic torticollis (cervical dystonia) wry neck?

Answer 44

No cure for spasmodic torticollis 1. Treatment is symptomatic 2. Prevention of secondary problems 3. Botox injections may prove effective 4. More radical treatments include surgery to interrupt the CNS at various levels

Question 45

What are 6 characteristics of Spasmodic torticollis (cervical dystonia) wry neck?

Answer 45

1. Pain can be a feature initially 2. It is often not overly painful in the long term 3. May resolve spontaneously (5 years) 4. patient will often have a “tick” with neck moving into a wry position 5. Physiotherapy has a very secondary role to play. 6. Referral to a neurologist is important if patient seeks the physiotherapist as a first contact practitioner

Question 46

* Wry neck is a specific condition on its own * Has ______ anatomicalcauses within it that can cause commonly cause pain eg z joint, disc pathology but presents uniquely and is assessed and treated differently. * Eg how would z joint usually present - how would disc pathology – usually present

Answer 46

anatomical

Question 47

What are 6 characteristics of Z joint?

Answer 47

1. Pain description 2. Agg/ easing factors 3. Posture 4. Restricted movements 5. Pain on which movements 6. PAIVVM, PIVVM findings

Question 48

What are 6 characteristics of disc?

Answer 48

1. Pain description 2. Agg/ easing factors 3. Posture 4. Likely restricted movements 5. Pain on which movements 6. PAIVVM, PIVVM findings

Question 49

What are the 3 terminology of whiplash?

Answer 49

1. Whiplash -Acc/deceleration mechanism of energy transfer to the neck 2. Whiplash injury- The impact can result in bony or soft tissue injuries 3. Whiplash associated disorders (WAD)- A variety of clinical manifestations

Question 50

What is the mechanism of injury of whiplash?

Answer 50

complex with compression, tension, shear, flexion, extension at different levels * Acceleration and deceleration injury

Question 51

What are the 2 preventions of whiplash?

Answer 51

restraints but most not adjusted properly 1. Don’t text and drive 2. Self drive cars

Question 52

What are the 5 heterogenenous characteristics of whiplash?

Answer 52

1. Ranges from mild to no symptoms to mild to moderate to severe 2. Mod group may have ongoing symptoms but within that group large variation from milder, moderate, severe and complex 3. Several different impairments – combinations of impairments that can see 1. Central sensitisation 2. Neuropathic 3. Sensory motor 4. Various different combinations of bio-psychosocial impairments * PTSD, pain catastrophising 5. Majority (80%) no psychological impairments- 20% some and this ranges

Question 53

What is the prognosis of whiplash?

Answer 53

**The good news - At least 50% recover** But what about the other 50%? Most RTW (unlike LBP) * 30% - persisting milder to moderate pain and disability * 20% - moderate to severe pain and disability * 10% very severe But all improve- just not completely recovered Do not have the answers as yet * especially for those with a persistent major pain state

Question 54

What are 11 symptoms and presentation of whiplash?

Answer 54

1. Pain immediate or several hours/days post (Eg. adrenaline from the accident) 2. ? Immediate associated with more severe pathology 3. Headache (50-90%) 4. Arm pain (40-70%) 5. Back pain (30-50%) 6. Para/anaesthesia (10-20%) 7. dizziness/unsteadiness (disturbances in mechanoreceptors– proprioception, vestibular, concussion) 8. visual and auditory disturbances 9. cognitive difficulties 10. fatigue 11. psychological distress (20%)

Question 55

What is whiplash in Australia?

Answer 55

* Injured people may go anywhere- A and E, GP, Physio, Chiro * States work under different compensation schemes * MAA- guidelines for management * MAIC- whiplash recovery booklet

Question 56

What are 4 characteristics of an identified pathology in whiplash?

Answer 56

1. Majority of cases not seen on current imaging 2. Is this a problem ? 3. What can be done if we see lesions ? * Not going to change management (eg. do not need surgery) 4. Peripheral driver

Question 57

What are 4 potential mild pathologies of whiplash?

Answer 57

1. Z – Jts sprain 2. I-V Discs sprain 3. Muscle strain 4. Combinations

Question 58

What are 8 main potential more severe pathologies of whiplash?

Answer 58

Question 59

What are 5 potential more severe pathologies of z-joint whiplash?

Answer 59

1. haemarthroses 2. capsular tears 3. articular cartilage 4. joint fractures 5. joint capsule rupture

Question 60

What are 4 potential more severe pathologies of IV disc whiplash?

Answer 60

1. rim lesions 2. bleeding 3. disruption/avulsion 4. disc herniation

Question 61

What are 2 potential more severe pathologies of ligament whiplash?

Answer 61

1. ant & post longitudinal ligs 2. lig Flavum

Question 62

What are 2 potential more severe pathologies of muscle whiplash?

Answer 62

1. pre-vertebral muscles 2. longus colli rupture

Question 63

What are 3 potential more severe pathologies of atlanto-axial complex whiplash?

Answer 63

1. synovial fold bruising 2. ligament ruptures 3. fractures

Question 64

What are 6 potential more severe pathologies of nerve tissue complex whiplash?

Answer 64

1. nerve root injuries 2. DRG 3. C2 bleeding 4. Spinal cord 5. Brainstem 6. Brachial plexus

Question 65

What are 2 potential more severe pathologies of vascular structure complex whiplash?

Answer 65

1. VBI, surrounds of artery 2. Cervical arterial dissection (CAD)

Question 66

What are 2 potential more severe pathologies of fractures complex whiplash?

Answer 66

1. Vertebral bodies 2. Transverse processes

Question 67

What are pathology often cannot be specifically identified system based approach often used?

Answer 67

Question 68

What are 3 possible function characteristics of whiplash?

Answer 68

1. **Motor function: most common even in milder presentations** 1. Range of movement 2. Muscle control 3. Sensori-motor function 2. **Sensory function: generally only in mod-severe but not all** 1. Pain thresholds- pressure, thermal 2. Central hypersensitivity 3. **Psych features: generally in mod-severe but not all with mod sev** 1. Event related and general distress- PTSD (17%) 2. Catastrophisation 3. Other psych factors (Injustice (not their fault))

Question 69

What are 3 possible motor function characteristics of whiplash?

Answer 69

most common even in milder presentations 1. Range of movement 2. Muscle control 3. Sensori-motor function

Question 70

What is a possible sensory function characteristics of whiplash?

Answer 70

generally only in mod-severe but not all 1. Pain thresholds- pressure, thermal * Central hypersensitivity

Question 71

What is a possible psych function characteristics of whiplash?

Answer 71

generally in mod-severe but not all with mod sev 1. Event related and general distress- PTSD (17%) 1. Catastrophisation 2. Other psych factors (Injustice (not their fault))

Question 72

What are the 2 types of heterogenous moderate whiplash?

Answer 72

Question 73

What is the Clinical Prediction Rule acute WAD?

Answer 73

Question 74

What are 3 assessment mild pain and disability important will vary according to presentation for whiplash?

Answer 74

1. Similar to idiopathic pain 2. Determine neuromuscular, articular and sensorimotor impairments 3. Basis for PT treatment

Question 75

What are 7 assessment moderate to severe pain and disability important will vary according to presentation for whiplash?

Answer 75

1. Determine differential diagnosis – red flags, pathology 2. Determine neuromuscular, articular and sensorimotor impairments 3. Determine if any psych, cognitive factors that may contribute to the clinical presentation 4. Determine any central hypersensitivity, pain mechanisms 5. Gauge prognosis 6. Basis for PT treatment 7. Basis for overall management- need for multi- professional

Question 76

What are 5 red flags of whiplash?

Answer 76

1. Paraesthesia/ numbness in arms or legs, tongue 2. Severe neck and arm pain 3. Breathing difficulties 4. Difficulty supporting the head 5. Deformity

Question 77

What are 11 characteristics of the patient interview of whiplash?

Answer 77

1. outcome measures might need 2. help direct objective assessment 3. possible pain mechanisms 4. psych considerations 5. help direct management 6. need for multimodal 7. when/ where start 8. others needed in management 9. advice 10. ergonomics, exercises 11. prognosis, clinical prediction rule in acute stage

Question 78

What are 3 useful outcome measures of pain of whiplash?

Answer 78

1. NDI- 0-10 recovered, 10-30 mild, 30-70 moderate, 70-100 severe, MCD 10% 2. VAS 3. PSFS 1. S-Lanns- if suspect neuropathic pain 2. \> 12/24 indication on neuropathic 1. Bursts of electric shocks 2. Burning pain in neck 3. Hyperalgesia to manual pressure 3. Most associated with higher NDI Eg. Are they driving? Intrusive thoughts? Sleeping?

Question 79

What are 3 additional physical examination as comprehensive as tolerable and as needed based on reported signs and symptoms of whiplash?

Answer 79

As per usual cervical spine But add 1. Sensorimotor – 2. Neurological – as required (Eg. arm pain) 3. Sensory assessment – as required (Widespread hyper-sensitivity)

Question 80

What are 4 clinical guidelines of acute WAD?

Answer 80

1. Assurance 2. Advice to stay active 3. Prescribed function 4. Active exercise 1. Movement 2. Strength

Question 81

What are 4 clinical guidelines of chronic WAD?

Answer 81

1. Assurance 2. Advice to stay active 3. Prescribed function 4. Active exercise 1. ± 1. CBT, Stress innoculation 2. Manual Therapy 3. Vestibular Exercises

Question 82

What are 7 management of acute whiplash?

Answer 82

1. **Pain management** – mild to moderate pain (the majority) simple analgesics, NSAIDs 2. **Facilitation of active movement** (4 point kneeling- Take gravity out, prone on elbows) 1. (use eye movement, gaze fixation) 2. (use eye strategies in sitting) 3. **Gentle manual therapy**: Non pain provocative (neurophysiol effects) 4. **Electrophysical modalities** – adjunct only 5. **Muscle facilitation and re-education** – safe low load exercises 1. Activation of CCF and extensors 2. Activation of scapular stabilizers 3. Education of posture 6. **Re-education of somatosensory function** 7. **Home Program** - Emphasis activity (replicates treatment) 8. Outcome measures: ROM, CCFT, JPE, PPT

Question 83

What are 10 management of acute severe whiplash?

Answer 83

(the minority but difficult) Do not provoke pain 1. Pain management 2. Medical management – opioid analgesia, NSAIDs (perhaps delay rehabilitation for 1 week in very severe cases) 3. Remote strategies to facilitate painless afferent input (eg start with re-education of somatosensory function - balance exercises) 4. Facilitation of active movement (4 point kneeling, prone on elbows) * (use eye movement, gaze fixation) 5. Electrophysical modalities – adjunct only 6. Soft collar if pain severe (Not for long term use) 7. Muscle facilitation and re-education as tolerated 8. Activation of CCF and extensors 9. Activation of scapular stabilizers 10. Education of posture, activation of supporting muscles

Question 84

What are 5 sebsequent management of acute severe whiplash?

Answer 84

Constant re-evaluation – PSFS; NDI 1. Progress therapeutic exercise and manual therapy as tolerated 2. Work related issues 3. Ergonomics 4. CBT approach 5. Early multiprofessional management 1. if adverse prognostic indicators present 2. if patient not progressing as expected * Treatment based on impairments seen- will vary each patient * Early referral to whiplash clinical specialist

Question 85

What are 6 multimodal physio program for whiplash?

Answer 85

1. Manipulative therapy 2. Electrophysical agents (adjunct only) Tens? 3. Needling? Trial promising results 4. Medication (as required) 5. Therapeutic exercise 1. Active stabilisation training 2. Active range of movement 3. Retrain patterns of muscle control 4. Sensorimotor 5. Strength and endurance 6. CBT approach? 6. Ergonomic strategies (ADL and Work)

Question 86

What are 9 other professionals may need to consult for whiplash?

Answer 86

1. Physiotherapist with more experience/ training whiplash 2. Psych- when, not too early (~1month (or getting worst)) 3. Dr – medication review 4. Pain specialist- RFN for those suitable 5. Neurologist – migraine/ headache 6. Vestibular – ENT, vestibular physiotherapist 7. Behavioural Optometrist 8. Egonomics/ Occ health 9. **Insurance provider, workplace**

Question 87

What is your 4 interpretations of processes underlying Sarah’s condition?

Answer 87

1. Ie mild joint sprain C2/3, with altered neuromotor control cervical spine 2. No signs altered sensorimotor control 3. No signs altered sensory 4. No signs pysch distress

Question 88

What would be your 5 approaches to her management?

Answer 88

1. Physio approach –commence restoration of muscle function, manual therapy 2. Advice- good prognosis, will need to do some exercises. 3. Education- whiplash course and muscle inhibition in response to pain. 4. Mild joint sprain should settle quickly 5. Advice stay active, avoid heavy upper limb weights for a few days

Question 89

What is Sarah’s prognosis (2)?

Answer 89

1. There are indicators of good recovery – age, pain/disability levels, no ptss, no altered pain processes 2. Should do well and require minimal intervention

Question 90

What would be your early physiotherapy management?

Answer 90

1. Education, Ergonomics, Advice 2. Commence neuromotor control exercises – DNF, extensors, posture correction 3. Manual therapy C2/3 unilat glides etc 4. Self management – heat, exercisesa

Question 91

What is your 4 interpretations of processes underlying Therese’s condition?

Answer 91

1. Joint sprain C2/3, with altered neuromotor control cervical spine and scapular 2. Altered sensorimotor control – likely altered cervical afferent input 3. No signs altered sensory 4. No signs pysch distress

Question 92

What would be your 2 approaches to her management?

Answer 92

1. Physio approach –commence restoration of muscle and sensorimotor function 2. Ergonomic advice- change position talks to clients in etc

Question 93

What is Therese’s prognosis (2)?

Answer 93

1. There are indicators of good recovery – pain/disability levels, no ptss, no altered pain processes 2. Should do well if adheres to exercise program

Question 94

What would be your 6 early physiotherapy management?

Answer 94

1. Ergonomics, advice modification of activities, sleeping positions, sitting, computer 2. Commence neuromotor control exercises – DNF, Scap in sidelying, extensors, posture correction 3. Commence JPE right, movement sense 4. Manual therapy 5. Commence gentle exercise eg walking 6. Self management – heat, exercises.