MSK scenario 1 (Whiplash)

Question 1

What does the pts NDI score of 38% tell you?

What are some limitations to it?

Answer 1

NDI = neck disability Index. Patient-completed, condition-specific functional status questionnaire
30-48% score = moderate disabilty.
Each activity is scored 0-5.
No headaches show pt is unlikely to have suffered from a concussion after the trauma. (post concussion headaches can last for 3-6 months). Unlikely to have any brain injury.
I would want to assess his posture during reading and his lifting posture as he says they are both limited due to neck pain.
I would ask how it interferes with his driving, ie is it because he can’t turn his head, or because of neck pain etc.
What recreational activities has he been unable to participate in due to pain?

The NDI does not include:
- psychosocial aspects
- emotional aspects
which are both very common in whiplash and chronic neck pain patients

Question 2

Explain your primary hypothesis to your pt

Answer 2

Whiplash

• injury associated with RTA where sudden acceleration-deceleration movements occur
• most WADs are considered to be minor soft-tissue injuries
• injury occurs in 3 stages:
  
  • upper and lower spines experience flexion
• hyperflexion and hyperextension of the cerviical vertebrae (neck) causes an S-shape curve in the spine
• reassure pt that prognosis of whiplash is good and that in most cases it usually gets better in 2-3 months

Question 3

What additional questions would you want to ask the pt?

Answer 3

• Red flags
• unexplained weight loss
• history of Ca
• night pains/sweats
• headaches? (concussion)
• Cervical myelopathy (problems with fine motor skills, poor balance or unsteady gait, numbness and paresthesia in one or both hands)
• Cauda Equina (lower back pain, disturbed gait, bladder and bowel, sexual dysfunction)
• S&S of vertebrobasilar ischemia (temporary set of symptoms due to decreased blood flow in the posterior circulation of the brain)
• Dysphagia (swallowing difficulties)
• Diplopia (double vision)
• Dizziness
• Drop attacks (sudden weakness in face/arm/legs)
• Dysarthria (speech disorder due to brain damage)
• Nausea
• Numbness
• Nystagmus (rhythmical, repetitive involuntary movement of the eyes)
• Ataxia of gait (uncoordinated and abnormal gait)
• Goals/ expectations
• History of smoking (smoking affects the body’s ability to absorb calcium, leading to lower bone density and weaker bones. increased risk of fractures)
• sensory dysfunction (yellow flags) - psychological distress, PTSD, sleep disturbance, anxiety, depression
• prior history of neck pain

Question 4

Give a secondary hypothesis for this pt

Answer 4

Cervical degenerative disc disease
One or more of the cushioning discs in the cervical spine starts to break down to wear & tear. Trauma can accelerate the development of degenerative changes.
Common symptoms:
- neck pain and stiffness
- can develop numbness and radiating pain
- pain worse with movement
- usually occurs between C5/6 and C6/7
Risk factors:
- genetics
- obesity
- smoking - can hinder nutrients from reaching the discs and cause them to lose hydration more quickly. smoking restricts the blood of oxygen-rich blood that nourishes the bones.it affects the body’s ability to absorb calcium leasing to lower bone density and therefore weaker bones. increases the risk of arthrogenic injuries.
Diagnosis:
- medical history
- physical examination
- imaging confirmation: most likely an MRI to determine whether and where degeneration is occurring.

Question 5

What treatment would you give this pt and why

Answer 5

1. Education
   - reassurance that prognosis following whiplash is good
   - encouragement to return to normal activities
   - reassurance that pain is normal and pts should use analgesics (paracetamol or ibuprofen) to control it
   - use of heat or ice to help with pain
   - advice against the use of soft collars
   - can lead to weakening and stiff neck muscles
2. Active treatment
   It is important to move neck, back, and shoulders ASAP
   - sit in a chair, cross arms in front, rotate body slowly through full ROM
   - sit in a chair, flex neck to both sides slowly
   - in sitting, lift both arms up in front as high as possible, also try rolling your shoulders - helps with posture
   - in standing, place both arms behind the back and grasp the injured side to lower shoulder. bend the neck in the opposite direction to stretch the neck
   - push head against the resistance of hand (isometric strengthening)
   - complete full ROM against theraband resistance

Question 6

What would you include in your objective assessment?

Answer 6

1. Clearing other joints
   - Shoulders
   - Elbow
   - thoracic spine
   - lumbar spine
2. Observation
   - observe posture in sitting and standing
   - kyphotic - head flexed (hunched)
   - lordotic - excessive inward curve of spine
   - colour, swelling, scars
3. Palpation
   - temperature of skin
   - obvious deformity
   - symmetry
4. Movement tests
   - PROM - performed in supine with head of foot end of the bed, to eliminate gravity pushing down on the discs. take out any muscle tension and compression through joints. when coming back up into sitting, ask pt to roll onto one side first to get used to controlling weight of head again.
   - AROM - neck flexion, extension, rotation and side flexion, retraction (upper flexion and lower extension), protraction (upper extension and lower extension) and overpressure - only if they have full ROM and low irritability