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PCM > Neck Pain/Whiplash/Torticollis > Flashcards

Neck Pain/Whiplash/Torticollis Flashcards

1
Q

HVLA Contraindications

A

R.A. - weak odontoid ligament is susceptible to rupture
Down Syndrome - weak odontoid ligament susceptible to rupture; patient may have incomplete or missing odontoid process
Osteoporosis
Patients on anticoagulants - shear stress => intracranial bleed

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2
Q

HVLA Complications

A

Occipitobasilar strokes (Wallenberg Syndrome)
Vertebral artery compression with thrombosis
Arterial dissections
Cerebellum infections

Primarily occur because of rotation of c-spine when already extended

  • right rotation occludes left vertebral artery
  • agent for injury to vertebral artery are young (35-40 yo)

Can also have problem if patient has a bulging disc, and you flex and rotate them

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3
Q

Whiplash

A

Acute hyperflexion-hyperextension injuries in the cervical spine
Actually “inertial” injuries
Usually due to MVA
Look at whiplash as insult to whole body

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4
Q

Whiplash - Mechanism of Injury

A

Impact propels body in a linear horizontal direction

  • head momentarily remains stationary
  • then abruptly moves in opposite direction of impact force vector
  • cessation of impact, combined with an acute stretch reflex, causes recoil in the same direction as the initial force vector

Hyperextension usually causes greater injuries

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5
Q

Whiplash Pathophysiology

A

Tissues susceptible to injury include

  • superficial soft tissues
  • vertebral complexes (vertebrae, ligaments, tendons)
  • peripheral and sympathetic nervous system
  • vascular system
  • cerebrum
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6
Q

Whiplash - Superficial Soft Tissues

A

Abrupt elongation initiates acute stretch reflex

  • mostly in intramural muscle fibers in the muscle spindles, which normally monitor muscle length
  • initiates reflex contraction
  • if stretch is severe enough, tearing can occur in extramural fibers (contractile elements of the muscle)

Usually injuries are microscopic in size, no major nervous structures are initially injuries, often no immediate signs or symptoms

Sever injury can occasionally occur - gross bleeding and nerve damage

Micro hemorrhage and subsequent edema serve as foci for muscle irritability

  • painful muscle spasms, inhibited motion, impeded circulation
  • fibrous contracture, trigger point formation, chronic pain and immobility
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7
Q

Whiplash - Anterior Superficial Soft Tissues

A

SCM = 1st muscle to become injured - head tilt and painful torticollis

Deeper muscles injured next - scalenes, longissimus colli

Other soft tissues affected - pharynx, esophagus, prevertebral fascia

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8
Q

Whiplash - Posterior Superficial Soft Tissues

A

Suboccipital Muscles - rectus capitis major and minor, semispinalis capitis, splenius capitis

Intrinsic muscles - multifid and rotator muscles

Shoulder girdle muscles - lavatory scapulae, rhomboid, trapezius

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9
Q

Whiplash - Vertebral Complex

A

Hyperextension

  • strain/tearing of anterior longitudinal ligament
  • vertebral body or spinous process fracture
  • facet encroachment due to posterior glide

Hyperflexion

  • sprain/tearing of supraspinal, intraspinal, or posterior longitudinal ligaments
  • capsular tears +/- facet subluxation or dislocation
  • rarely posterior disc herniation
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10
Q

Whiplash - Peripheral Nerves

A

Impingement as vertebral foramina

Acute irritation as it pierces contracted or inflamed muscle or fascia

Chronic irritation as perineural scar tissue forms
- greater and lesser occipital nerves as well as sub occipital nerve irritation produces much of cephalgia and neck pain associated with whiplash

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11
Q

Whiplash - Sympathetic Nerves

A

Cervical nerves connect to sympathetic system via preganglionic fibers in the lateral horn cells from T1-T6
- fibers proceed up the sympathetic chain to enter the cervical ganglia and synapse with postganglionic fibers

Symptoms result from stimulated peripheral nerves as they pierce inflamed tissues

  • aural symptoms: tinnitus, deafness, postural dizziness
  • ocular symptoms: blurred vision, retrobulbar pain, pupil dilation with turning of head
  • vestibular - vertigo
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12
Q

Whiplash - Vascular System

A

Vertebral artery compression and spasm

  • usually at C1-C2 level where it makes an acute turn to enter skull
  • vertigo, syncope, near syncope, nystagmus with head rotation
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13
Q

Whiplash - Cerebrum

A

Cerebral concussion

  • impact of brain against the vault
  • head trauma is NOT necessary for concussion
  • patients after describe a blinding or exploding sensation in head at time of injury
  • immediate headache, restlessness, insomnia, or mood changes often occur
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14
Q

Whiplash - Forces Affecting Injury

A

Position of hands
- bracing on steering wheel reduces anterior translation of body

Awareness of impact
- tension of muscles reduces excess motion of head and reduces degree of injury

Headrest position
- proper adjustment reduces injury risk

Preexisting conditions
- osteoporosis, DJD

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15
Q

Whiplash - Sacral Injury

A

Anterior and posterior longitudinal ligaments

Dura attachment at basiocciput and 1st 2 cervical vertebrae then down to anterior aspect of second sacral segment
- during injury sacrum lifted and moved from position between ilia, rebounds and lodges at varying degrees

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16
Q

Whiplash - Pelvic Injury

A

Ilial rotations and pubic shears frequently occur

- usually only one foot is planted (on break)

17
Q

Whiplash - Thoracic and Lumbar Injuries

A

Interconnection of musculature and ligamentous structures

Forces acting upon areas with anterior translation of body upon impact

18
Q

Whiplash - Cranial Injury

A

Usually occiput and sacrum exhibit same restrictions

Asymmetric contraction of attaching muscles result in torsion sand SB or rotatory dysfunctions
- temporal bones are highly susceptible

19
Q

Whiplash - Upper Extremity Injury

A

Usually from bracing against steering wheel

  • soft tissues of shoulder: glenohumeral capsule, acromioclavicular and coracoclavicular ligaments, rotator cuff muscles, trapezius
  • local dysfunction in hands, wrists, elbows

Pain radiating down arms does not necessarily indicate foramina like nerve root compression after whiplash injuries

20
Q

Whiplash - Lower Extremity Injury

A

Pain and depressed ROM due to sacral and iliac dysfunctions as well as iliopsoas strains

Injuries to hip, knee, foot, and ankle

Pelvic fracture can occur if the foot was firmly planted at impact

21
Q

Whiplash Symptoms

A

Often no immediate pain

Minor pain and stiffness few hours post injury
- severity increases due to sufficient edema and inflammation development

Pain

  • anterior or posterior neck, may radiate to occiput, either or both shoulders, and midthoracic region
  • headaches usually occipital and may radiate around to frontal region

Other symptoms may not be evident for a few days to 2-3 weeks

22
Q

Whiplash - Treatment

A

Avoid treating just cervical and thoracic regions and over treating injured tissues

23
Q

Whiplash - Treatment: Acute Stage

A

OTM - as soon as possible after stabilized

Minimize edema development and tissue reaction

  • gentile indirect treatment around areas adjacent to injured tissues
  • treat cranium and sacrum to restore motion
  • lymphatic drainage

Adjunct treatments

  • ice packs/ice massage 1-2 days
  • NSAIDs with acute inflammation

Physical activity

  • severe injuries: 1-3 days bedrest; passive exercises in bed to avoid tissue atrophy
  • moderate/mild injuries: limited activities immediately; passive ROM daily; avoid rapid movement of head
24
Q

Whiplash - Treatment: Early Chronic Stage (1 Week - 1 Month)

A

Acute inflammation subsided but increased muscle tension remains

OMT
- more aggressive treatments: ME, HVLA, lymphatic drainage, fascial release, ROM

Moist heat

NSAID therapy

Tricyclic antidepressants (TCAs) at low dose at night
- sedative

Physical activity

  • should be close to full activity
  • increase cervical ROM exercises
  • active and passive isometric exercises if tolerated
25
Q

Whiplash - Treatment: Late Chronic Stage (1 - 3 Months or Longer)

A

OMT to whole body

  • HVLA
  • soft tissue techniques
  • vigorous active range of motion treatment

Adjust therapy similar to early chronic stage

Electrical stimulation to avoid atrophy

Trigger point therapy as needed

PT to strengthen extremities and improve aerobic capacity

Physical activity
- encouraged to work toward full capacity

26
Q

Non-spinal Causes of Neck Pain

A

Malignancy - tumors involving cervical spine
Vascular - vertebral artery or carotid artery dissection
Cardiovascular - angina and myocardial infarction
Infection - pharyngeal abscess, meningitis, subdiaphragmatic abscess, herpes zoster, Lyme disease
Visceral - esophageal obstruction, biliary disease, apical lung tumor
Referred Shoulder Pain - impingement, adhesive capsulitis, rotator cuff tear
Rheumatologic - polymyalgia rheumatic, fibromyalgia
Neurologic - cervical dystopia, tension headache, Chiari malformations

27
Q

Symptoms Suggesting Serious Disease in Patients with Neck Pain

A 
History of recent significant fall or major trauma
Unexplained weight loss
Fever or chills
History of cancer
Immunosuppression
Intravenous drug use
Chronic steroid use
Neurological signs or symptoms (arm clumsiness, gait difficulty, bowel or bladder dysfunction, Babinski's sign)
28
Q

Torticollis

A

Twisted neck
Affected muscles may feel full/tight

Torticollis: SCM spasm => rotation
Laterocollis: trap spasm => lateral tilt
Anterocollis: spasm anterior neck muscles => flexion
Retrocollis: posterior neck muscle spasm => extension

29
Q

Torticollis - Muscles

A 
Splenius capitus m.
Levator scapulae m.
Omohyoid m.
Scalene m.
SCM m.
Trapezius m.
30
Q

Torticollis - Congenital

A

Rare
Injury or malformation to SCM - can’t lengthen to accommodate growing neck

May not be seen at birth, usually by 2 months old
Higher incidence of club feet, congenital hip dysplasia
May have history of difficult delivery
Not painful at rest

SCM may fee ropy; may feel ‘olive’ type structure

31
Q

Torticollis - Adult

A

Very common
Usually idiopathic
Acute = sleeping wrong, neck strain at work

32
Q

Torticollis - Congenital: Treatment

A

Without treatment: asymmetry of facial structures

Stretch SCM: tilt head away from contracted muscles and rotate chin towards contracted side
No response in 1-2 months, refer to ortho

Initial presentation over 1 yo - surgical release of SCM

33
Q

Torticollis - Adult: Treatment

A

OMT

  • indirect treatment then progress to ME
  • PT if refractory case

Meds

  • Botox: analgesic, reduces muscle spasm
  • anticholinergics
  • benzodiazepines
  • muscle relaxants

Surgical

  • muscle resection
  • nerve ablation
34
Q

HVLA

A 
AA - rotate opposite
OA - thrust towards eyes
Typical C Spine 
- SB focus - towards T1 spinous process
- Rotational focus - use rays of the sun

PCM (26 decks)

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