Week 8 a WADs Flashcards
Outcome for people who have WADs
- 50% don’t recover
* 30 % remain moderately to severely disabled
What is whiplash
- Whiplash is an acceleration-deceleration mechanism
- of energy transfer to the neck. The impact may result
- in bony and/or soft tissue injuries which in turn may lead
- to a variety of clinical manifestations (Whiplash
- Associated Disorders)
Biomechanics of WAD
• S shape just after impact
• Upper cervical flexion continues with lower cervical
hyperextension beyond physiological range of movement
(ROM)
• Secondary upper thoracic spine movement of superior
directed acceleration and extension /rotation
Time needed to brace for whiplash
Maximum injury 75 ms post impact -200 ms required for
muscle bracing
Bone pathology/red flags WAD
• Bone (red flags!!)
• Severe pain, high velocity accident, on-going severe pain
(esp. at rest), neurological symptoms
Disc pathology after whiplash
Disc
• Rim lesions (anterior annulus)
• End-plate lesions
• Posterior protrusion ± radiculopathy
Posterior elements
Posterior elements
• Z-joint (articular cartilage, synovial folds)
• Capsule & ligament
• Nerve tissue (dorsal root ganglia, spinal nerve root, brain
Grade 0 WAD
No complaint about neck pain
No physical signs
Grade 1 WAD
C/O neck pain and stiffness or tenderness
only
No physical signs
Grade II WAD
Neck compliant & MS signs - ROM &
tenderness
Grade III WAD
Grade II + neurological signs including
↓DTR,s , muscle weakness, sensory
deficits
Grade IV WAD
Neck symptoms + fracture/ or dislocation
Criticisms of Qubec Task Force Classification
Some criticism of QTF system of classification since its release
• Guidelines adopted without scientific validation (Spine 1998, (23)
1043, Spine 2001, (26) 36-41, )
• Limited predictive capacity of the guidelines in terms of
recovery and non recovery
Proposed adaptation QTF, WAD IIA
Neck pain
Motor impairment -decreased ROM, altered
muscle recruitment patterns (CCFT)
Sensory impairment
Proposed adaptation QTF, WAD IIB
Neck pain Motor impairment – decreased ROM Sensory impairment ( local cervical mechanical hyperalgesia) Psychological impairment of elevated psychological distress
Proposed adaptation QTF, WAD IIC
Neck pain (severe initial)
Motor impairment (decreased ROM)
Sensory impairment
Local CX mechanical hyperalgesia
Generalized sensory hypersensitivity (mechanical, cold/thermal,
BPPT)
May show SNS disturbances : eg dizziness
Psychological impairment such as poor concentration
Psychological distress ( GHQ - 28, Tampa )
Symptoms of acute post-traumatic stress
Specific assessments WADs
• GHQ-28 28 – general health questionnaire • BPPT – brachial plexus provocation test = NTPT • Cervical muscle dysfunction (CCFT =cranio cervical flexion test) • Motor control of the cervical spine movement
Sensori-motor tests WADs
Sensori-motor tests: • Balance • Cervical spine joint position error • Eye follow • Gaze stability • GHQ 28
Central hyperexcitability
• Reports of mechanical allodynia or
hyperalgesia: pain with touch, bedclothes
• Thermal allodynia: pain with cold, ice
• High irritability of pain
• Sleep disturbances)
• Sensory hypersensitivity (decreased pain
threshold).
• Brachial plexus provocation tests (bilaterally)
What should you address in WAD treatment?
Address: • Motor: Improve ROM (joints and neural tissue) Retrain deep neck flexors and extensors • Sensori-motor: balance, head reposition, eye follow, gaze. • Psycho-social:cognitive, emotional & behavioural factors
Management of acute WAD
Grades I-III
• Crucial first 2-3 months
• Return to activity
• General and specific exercises
• Simple analgesics, TENS , acupuncture
• Education/ assurance/advice with coping
• Review of 8 studies: The evidence neither supports nor refutes
passive or active treatments (Cochrane review Verhagen et al
2007) (Sterling & Kenardy 2011)
Management of acute WAD
Grades I-III
• Those with mod or greater pain and disability,
central hyperexcitability and elevated distress
• Care not to provoke
• More gradual and graded progression of activity
• More specific Tx
• Decrease pain
• Help with psychological distress
• Careful coordinated care with patient included in
decisions
Management of Chronic WAD
• Manual therapy (Vicenzino et al 1998); lateral
glide (Sterling et al 2010)
• Multimodal (man ther, exs and advice) (Jull et al 2007)
• Active exercises for impairments and functional
goals
• Coordination exercises (eyes and head): pos
effect
• Medical interventions: injections
• Psychological interventions: CBT
A sensorimotor approach for
managing WAD
• Joint position error • Balance practice (add bouncing a ball, walking with head turns) • Eye head co-ordination exercises • Gaze stability training • Tailor the exercises to findings from assessment
