Biomechanics
- Hyperextension + Hyperflexion |
- SCM most affected |
- Myofascial damage |
- Head rotates into hyperextension, anterior cx muscles stretched - muscles at their tension limit - remaining forces put into the ALL and anterior fibres of the annulus fibrosis |
- CN affected - 2nd |
- Flexion - Damage in suboccipital region of the spine - muscles subocciptal and occipitofrontalis are more traumatised |
- PTSD occurs |
Mechanisms of Injury
- Rear end collisions mainly - linear + angular rearward motion of the head to the torso |
Shear, compression, tension and torque |
- Shearing is vertical in vertebral column + horizontally on the spine, more likely to occur during the head extension and torso accelerating forward stage, more likely at C5-C7 |
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- Compression - head is accelerated downward towards the spine/tissues are compression during extension phase. Forced extension - applies compressive forces to posterior structures and tensile forces to anterior structures |
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- Tension - Extension phase, anterior neck muscles, compression of posterior neck structures |
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- Torque Small force at the end can create a larger force at the base - rotational acceleration of the head on the fulcrum at the top of the cx spine |
Classfications - WAD
0 - No Neck complaints and NO physical signs |
Rarely presents to clinicians |
I - Neck complaints of stiffness, pain or tenderness but with no physical signs |
Very minor muscular damage |
II - Neck complaints AND MSK signs |
Limited ROM and point tenderness |
III - Neck complaints AND Neuro signs |
Decreased/absent DTR, weakness and sensory loss |
IV - Neck complains AND fracture/Dislocation |
REFER IMMEDIATELY |
most patients are Grade II WAD
Injury Severity
- There are factors and variables that could make people susceptible to severe injury: |
- Angle of the collision - More of an angle = more susceptible |
- Speed & Size of vehicles - Moving rear end collision |
- Road conditions - wet/icy roads |
- Occupant Head position - pt looking straight forward? Head turned? - Head turn = more severe |
- Gender - women more than men, anatomy/seating position |
- Occupant awareness of impact - bracing |
- Head Restraints - should be at back of the head touches anterior part, low restraints can act as a pivot during hyperextension |
- Seat Belts - Body held in place, momentum transferred to head and neck, head twists during flexion phase due to one shoulder being restrained |
- Direct body impact - Head or other parts of the body hitting object during collision |
- Loss of consciousness - Severe G forces |
- Medical Hx - cx spine degeneration, history of HA/chronic soft tissue pain can worse injury |
- Pain onset - immediate onset of pain, more likely to have pain post injury |
History
- Neck Pain - myofascial damage |
TMD |
Dysphagia |
Dizziness |
Deafness |
Tinnitus |
Nausea |
Fatigue |
Visual symptoms |
Memory Loss |
Poor Concentration |
Superficial tenderness of the scalp |
Pyschological symptoms - anxiety, depression, anger |
PTSD- PTSD questionnaire - 4 or more on a seven point scale, refer to a mental health professional |
Examination
- MAKE SURE IT IS SAFE |
Cx spine orthopaedic exam |
Neurological involvement |
Signs of myelopathy |
Potential causes of other symptoms |
Prognosis
Higher probability of prolonged disability: Women, Multiple injuries, Older People, Rear end collisions |
Delayed functional recovery: High initial pain intensity, More symptoms, Greater initial disability |
Psychological S&S Slower recovery - Passive coping style, Depressed mood, fear of movement |
Management
Acute Phase (2wks after injury) |
Education - explain, reassure, coping strats |
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Rest with mild, gentle ROM |
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Exercises should start within 4 days of injury |
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Cryotherapy |
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NSAIDs - 400-600mg 4 times a day for first 4 days |
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Gentle mobilisation (away from painful & restricted ROM) |
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Soft Tissue Techniques |
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Encourage return to normal activities when possible |
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TENS |
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Subacute phase (>2-12 weeks) |
Pain control - 1g Paracetamol four times a day |
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Active exercise - DNF + posture training , Isotonic, Isometrc, Ice + Heat after exercise |
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Mobilisation - traction/ gentle manipulation |
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Modalities (US, TENs) |
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Soft Tissue Techniques |
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Nutritional Support |
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Advice and coping strats |
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Chronic (>12 weeks) |
Manipulation/mobilisation + active Exercise |
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Proprioceptive retraining |
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Advice and coping strats |
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Strengthening exercises |
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Extension retraction exercises for cx spine |
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Late Whiplash |
Resist pressure to over treat and over investigate |
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Encourage return to normal activities |
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Motivational interviewing |
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Reduce influence of compensation claims |
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CBT |
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