Neck Pain/Whiplash/Torticollis Flashcards
HVLA Contraindications
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
HVLA Complications
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
Whiplash
Acute hyperflexion-hyperextension injuries in the cervical spine
Actually “inertial” injuries
Usually due to MVA
Look at whiplash as insult to whole body
Whiplash - Mechanism of Injury
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
Whiplash Pathophysiology
Tissues susceptible to injury include
- superficial soft tissues
- vertebral complexes (vertebrae, ligaments, tendons)
- peripheral and sympathetic nervous system
- vascular system
- cerebrum
Whiplash - Superficial Soft Tissues
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
Whiplash - Anterior Superficial Soft Tissues
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
Whiplash - Posterior Superficial Soft Tissues
Suboccipital Muscles - rectus capitis major and minor, semispinalis capitis, splenius capitis
Intrinsic muscles - multifid and rotator muscles
Shoulder girdle muscles - lavatory scapulae, rhomboid, trapezius
Whiplash - Vertebral Complex
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
Whiplash - Peripheral Nerves
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
Whiplash - Sympathetic Nerves
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
Whiplash - Vascular System
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
Whiplash - Cerebrum
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
Whiplash - Forces Affecting Injury
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
Whiplash - Sacral Injury
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
Whiplash - Pelvic Injury
Ilial rotations and pubic shears frequently occur
- usually only one foot is planted (on break)
Whiplash - Thoracic and Lumbar Injuries
Interconnection of musculature and ligamentous structures
Forces acting upon areas with anterior translation of body upon impact
Whiplash - Cranial Injury
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
Whiplash - Upper Extremity Injury
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
Whiplash - Lower Extremity Injury
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
Whiplash Symptoms
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
Whiplash - Treatment
Avoid treating just cervical and thoracic regions and over treating injured tissues
Whiplash - Treatment: Acute Stage
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
Whiplash - Treatment: Early Chronic Stage (1 Week - 1 Month)
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
Whiplash - Treatment: Late Chronic Stage (1 - 3 Months or Longer)
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
Non-spinal Causes of Neck Pain
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
Symptoms Suggesting Serious Disease in Patients with Neck Pain
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)
Torticollis
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
Torticollis - Muscles
Splenius capitus m. Levator scapulae m. Omohyoid m. Scalene m. SCM m. Trapezius m.
Torticollis - Congenital
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
Torticollis - Adult
Very common
Usually idiopathic
Acute = sleeping wrong, neck strain at work
Torticollis - Congenital: Treatment
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
Torticollis - Adult: Treatment
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
HVLA
AA - rotate opposite OA - thrust towards eyes Typical C Spine - SB focus - towards T1 spinous process - Rotational focus - use rays of the sun
