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5002 Case 3 Cheat Sheet by

Whiplash associated disorder (WAD) & C6 radiculopathy


- 37 y.o. SE carpenter
- R neck, upper traps & arm pain following RTA (road traffic accident) 3 weeks ago
- 20mph, rear ended by a car going 30mph, airbags went off
- Neck ache 5/10
- Sharp arm pain (when present) 7/10
- Neck pain hasn't changed
- Arm pain becoming more frequent
AF: Changing position, trying to stretch neck
- RF: Painki­llers (ibuprofen 1-2 200mg / day)
- AA: neck movement, work, cannot go gym (normally does cardio­& weights 3x / week)
- Associ­ated: numbness in lateral forearm +thumb; diminished grip strength
- Wakes 4-5x / night due to pain
- Usually sleeps on front but now has to sleep on side
- Saw GP 3 days after accident - Dx w/ whiplash (predicted 2-3 month recovery time)


Working diagnosis:
- Whiplash associated disorder (WAD) & C6 radiculopathy
→ Initially would classify as WAD grade II, but w/ later onset of neurol­ogical symptoms it could be classified as WAD grade III, but more likely as a C6 radicu­lopathy
Consid­ering age:
- Most likely cause of C6 radicu­lopathy is a disc herniation
- IVD's are very strong when healthy & need major force to be damaged ∴ although there's a temporal associ­ation between the onset of these symptoms & the whiplash injury it's likely that the trauma worsened some pre-ex­isting asympt­omatic disc derangement
→ Don't make casual link between the RTA & the onset if the C6 radicu­lop­athy; it's best to say "­there appears to be an associ­ation between the RTA & onset of the C6 radicular sympto­ms", without MRI before & after RTA we cannot assess the damage caused to the disc
Suggestive Cx disc hernia­tion:
- Pts with suggestive of this should also be assessed for signs of Cx myelopathy (fine motor skills, pain / stiffness in the neck, loss of balance, trouble walking)
"­Easter egg":
- The "­easter egg" in this case were the urinary symptoms which were unrelated to the presenting complaint but not normal & ∴ should be included conditions list

Learning outcomes

WAD diagnosis & manage­ment:
Signs & symptoms:
- Neck pain & stiffness: pain may be localised / spread to shoulders, upper back, or arms
- Headache: may be dull or throbbing in nature
- Dizziness: even lighth­ead­edness / vertigo
- Fatigue: may be due to disrupted sleep or increased stress
- Cognitive dysfun­ction: problems w/ concen­tra­tion, memory, & other cognitive functions
- Blurred vision: (or difficulty focusing)
- Tinnitus: ringing in ears
- Anxiety & depression
- Numbness or tingling: (or weakness) in arms or hands
- X-rays: rule out fractures or dislocations
- CT scans: more accurate at detecting fractures, disloc­ations, & other injuries
- MRI: more detailed for soft tissue in the neck, discs, ligaments, & nerves (most sensitive imaging modality for detecting soft tissue injuries)
- Ultras­ound: detects tears or other injuries in the muscles
- Acute stage: pain management (NSAIDS), rest, & gentle ROM exercises, ice therapy (reduce inflam­mation & pain)
- Sub-acute: manual therapy to help restore ROM, strengthen the neck muscles, & reducing pain; cognit­ive­-be­hav­ioural therapy to help pts cope w/ emotional & psycho­logical impact of the injury
- Chronic stage: managing long-term effects of the injury, manual therapy, exercise (maintain muscle strength) & pain management strategies
Cx radicu­lopathy diagnosis & manage­ment:
Signs & symptoms:
- Neck pain: may be sharp or dull, & may radiate to the shoulder, arm or hand
- Numbness & tingling: "pins & needle­s" sensation in neck, shoulder, arm, or hand
- Muscle weakness: neck, shoulder, arm, or hand, may make it difficult to grip objects or perform other daily activities
- Reflex changes: diminished or absent
- Reduced ROM: neck, shoulder, arm, or hand
- Headaches: often located in the back of the head or neck
- Loss of coordi­nation: partic­ularly in the hands or fingers, may make it difficult to perform fine motor tasks
- X-rays: initial assess­ment, rule out fractures or spinal instability
- MRI: most commonly used, detailed images of soft tissues, spinal cord, nerve roots, & IVDs; can help identify the location & severity of nerve compre­ssion or irritation
- CT: useful in identi­fying bony abnorm­alities that may be contri­buting nerve compre­ssion or irritation
- EMG: measures electrical activity in muscles &n­erves, used to confirm diagnosis of Cx radicu­lopathy & determines the severity of nerve damage
- Mild to moderate: rest & activity modifi­cation, manual therapy, medica­tions, steroid injections
- Severe symptoms: in this case conser­vative treatment failed & surgery is needed
Cx myelopathy diagnosis & manage­ment:
Signs & symptoms:
- Weakness: arms & legs
- Numbness & tingling: arms, legs, hands, & feet
- Loss of balance & coordination
- Changes in reflexes: hyperr­eflexia or diminished reflexes
- Bowel or bladder dysfun­ction: in severe cases
- Neck pain: result of compre­ssion or damaged spinal cord
- MRI: most commonly used, detailed images of spinal cord, etc; also show areas of compre­ssion or damage to the spinal cord
- CT: bony structures & any abnorm­alities that may be compre­ssing the spinal cord
- X-ray: identify bone abnorm­alities that may be compre­ssing the spinal cord
- Myelog­raphy: injecting a contrast material into the spinal canal to help visualise there spinal cord & nerves; used if MRI not available or contraindicative
- EMG: confirms diagnosis & helps determine location & severity of nerve damage
- Mild to moderate: rest & activity modifi­cation, manual therapy, medications
- Severe symptoms: in this case conser­vative treatment failed & surgery is needed
Most common causes of increased frequency of urination in a 37 y.o. female:
- Overactive bladder: muscles contract involu­ntary, causing sudden urge to urinate & frequent urination
- Pregnancy: hormonal changes that increase the frequency (espec­ially 1st & 3rd trimester)
- Inters­titial cystitis (IC): chronic condition that causes pain & discomfort in the bladder & pelvic region
- Diabetes: result of high blood sugar levels, which can lead to increases urine production
- Bladder or kidney stones: increased urination along w/ pain during, blood in urine, & lower abdominal or back pain
- Medica­tions: (e.g. diuretics) can increase urine production

Physical Examin­ation Findings

- C6 dermatome: reduced sharp sensation
- RR, RLF, & ext, all increase neck & shoulder / upper traps pain, movement guarded
- Locally over the upper traps & middle­-lower Cx
Clinical tests
- R maximal foraminal compre­ssion:
- Purpose: diagnosis Cx nerve root compre­ssion causing Cx radiculopathy
- Findings: reproduces sharp arm pain as well as neck pain
- Cx distra­ction:
- Purpose: joint space increased to relieve pressure on nerve root
- Findings: relieving
- Arm squeeze test:
- Purpose: distin­guish Cx nerve root compre­ssion from shoulder disease
- Findings: R 5/10 mid. upper traps, 2/10 in upper & lower upper arm
- Lhermi­tte's sign:
- Purpose: looking for electric like shock
- Findings: local neck pain but no pain into arms or legs


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