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Whiplash injury. Prof. Eyal Lederman. C. 2006 Eyal Lederman. Lecture contents. A very brief history The consequences (WAD) Identifying the processes involved How to influence these processes: Tissue dimension Neuromuscular dimension Psychological dimension. Interesting facts.

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slide1

Whiplash injury

Prof. Eyal Lederman

C

2006 Eyal Lederman

lecture contents
Lecture contents
  • A very brief history
  • The consequences (WAD)
  • Identifying the processes involved
  • How to influence these processes:
    • Tissue dimension
    • Neuromuscular dimension
    • Psychological dimension
interesting facts
Interesting facts
  • 25% better within one week
  • Most better within 1 month
  • Only 2% not recover at 1 yr

With other injuries:

  • 19% better within 1 wk
  • 30% within 1 month
  • 4% not recover at 1 yr

N=2810 (all waiting for compensation)

The Effect of Socio-Demographic and Crash-Related Factors on the Prognosis of Whiplash. J Clin Epidemiol Vol. 51, No. 5, pp. 377–384, 1998

poorer recovery
Poorer recovery
  • Lower rate of recovery:
  • Multiple injuries
  • Female
  • Older age, every decade increase in age, likelihood of recovery decreases by 14%
  • Larger number of dependents,
  • Married status,
  • Not being employed full time, low income
  • Low education
  • Being in a truck time.or bus (less in cars)
  • Being a passenger, 15% lower for passengers than drivers
  • Collision with a moving object,
  • Colliding head-on or sideways (rear collision better)
  • Wearing a seatbelt! (Head restraints better outcome)
  • Neck rotated or side bent
  • Previous neck pain (females) and cervical deg. changes
  • Lawyer involvement! (proof they are a pain in the neck)

Those with continuing symptoms three months after the accident are likely to remain symptomatic for at least two years, possibly much longer

  • T McClune, A K Burton and G Waddell Whiplash associated disorders: a review of the literature to guide patient information and advice. Med J 2002; 19:499-506
    • Dufton JAPrognostic factors associated with minimal improvement following acute whiplash-associated disorders. Spine. 2006 Sep 15;31(20):E759-65
    • Holm LW, Factors influencing neck pain intensity in whiplash-associated disorders. Spine. 2006 Feb 15;31(4):E98-104
slide5

Whiplash Associated Disorder (WAD)

Tissue damage affecting neck, head shoulder and arm and other parts of spine

Vascular damage

Muscle & ligament damage

Oedema inflammation and joint effusion

  • Blurred vision

Muscle wasting

Referred shoulder and pain

Facets & disc damage

  • Ringing in ears

Proprioceptive losses

Increased muscle fatigability

Dysfunctional synergy between muscle groups

Tiredness

Local neck pain,

Muscle hyperexcitability

Concentration or memory problems

Sleeplessness

Hypersensitivity syndrome

Irritability

Paraesthesia

Back pain

slide6

The consequences as processes

DIMENSION

concentration or memory problems irritability sleeplessness tiredness

Psychological

Neuromuscular & sensory motor changes:

Muscle wasting, dysfunctional synergy between muscle groups, hyperexcitability (inability to relax?) and increased fatigability Proprioceptive losses

Pain:

Local pain, referred pain Hypersensitivity syndrome

Neural

Tissue damage:

Muscle, ligaments, joints (facet & disc), vascular damage Oedema inflammation and joint effusion. Nerve irritation / damage

Affecting neck, head shoulder and arm and other parts of spine

Physical /

Local tissue

slide7

The dimensional model of osteopathy

SIGNAL

DIMENSION

OUTCOME

Psychological change

Psychological

Psycho-physiological change

Neuromuscular changes

Neural

Reflex pain changes

Assist repair

Physical /

Local tissue

Assist fluid flow

Assist adaptation

From: Lederman E 2005 Science and practice of manual therapy

slide8

Treatment strategies

Psychological dimension

Neurological dimension

Tissue dimension

Support, comfort, reassurance + cognitive and behavioural +use techniques for re-integration and relaxation

Neuromuscular re-ab. if losses in abilities are present

Stretching only if true shortening is present

Movement and pump techniques

Acute

Subchronic

Chronic

Repair time-line

From: Lederman E 2005 Science and practice of manual therapy

the role of osteopathy
The role of osteopathy
  • Assist repair
  • Assist adaptation
slide10

Assisting repair

Tissue damage:

Muscle, ligaments, joints (facet & disc), vascular damage Oedema inflammation and joint effusion, Nerve damage

Affecting neck, head shoulder and arm and other parts of spine

Physical /

Local tissue

slide11

The osteopath’s good fortune

Musculo-skeletal tissue are highly responsive to mechanical signals for their homeostasis, repair and adaptation

From: Lederman E 2005 Science and practice of manual therapy

slide12

Process Centred Osteopathy

Provide the physical stimulation and signals that the patient cannot provide for themselves

From: Lederman E 2006 Manual therapy in sports rehabilitation. In: Sports specific rehabilitation, ed. E Donatelli, Elsevier

slide13

Phases of repair

Inflammation

Regeneration

Remodelling

Days…

Months…………

Weeks…

Time after injury

From: Lederman E 2005 Science and practice of manual therapy

slide14

Physical /

Local tissue

The signals for repair

  • Provide adequate mechanical stress
  • Dynamic

(initially passive > active?)

  • Repetitive

Assist repair

From: Lederman E 2005 Science and practice of manual therapy

slide15

Benefits of movement on connective tissue

  • Alignment of collagen fibres
  • Improve tissue strength
  • Reduce cross-linking (adhesions)
slide16

Collagen Fibrils

Collagen fibres

Effects on extensibility

From: Lederman E 2005 Science and practice of manual therapy

the trans synovial pump

Fluid flow

The trans-synovial pump

Movement

+

-

Increased blood flow around the joint

Increase lymphatic flow & drainage around the joint

Alteration in intra-articular pressure

From: Lederman E 2005 Science and practice of manual therapy

clearance rate studies
Clearance rate studies
  • Clearance in septic arthritis (Salter et al 1981)
  • Clearance of haemarthrosis (O’Driscoll et al 1983)
  • Reduce joint effusion (Giovanelli et al 1985)
  • Clearance of injected dye (Skyhar et al 1985)

From: Lederman E 2005 Science and practice of manual therapy

slide20

Physical /

Local tissue

The code for repair

  • Provide adequate mechanical stress
  • Dynamic

(initially passive > active?)

  • Repetitive

Assist repair

From: Lederman E 2005 Science and practice of manual therapy

tensile strength following injury
Tensile strength following injury

Manual forces

Tensile strength

Inflammatory

phase

Regeneration

phase

Remodelling

phase

Time after injury

From: Lederman E 2005 Science and practice of manual therapy

slide24

Neuromuscular & sensory motor changes:

Muscle wasting, dysfunctional synergy between muscle groups, hyperexcitability (inability to relax?) and increased fatigability Proprioceptive losses

Pain:

Local pain, referred pain Hypersensitivity syndrome

Neural

The neurological / neuromuscular costs

slide25

Psychological dimension

Perception of pain and injury

Neuromuscular dimension

Pain + altered sensory feedback

Reflexive neuromuscular responses

Tissue dimension

Tissue damage

Sequence of events

Psychomotor / behavioural responses

From: Lederman E 2005 Science and practice of manual therapy

slide26

Functional organisation of motor system

Executive stage

Effector stage

Correlation / comparison process

Motor programme

Executive stage

Correlation process?

Effector stage

Sensory stage

Motor stage

From: Lederman E 2005 Science and practice of manual therapy

slide27

Functional organisation to injury

Executive stage

Psychomotor

Effector stage

“Motor templates” for injury?

Reflexive motor

Altered proprioception

+ nociception

Motor stage

From: Lederman E 2005 Science and practice of manual therapy

abilities affected in injury

From: Lederman E 2005 Science and practice of manual therapy

Abilities affected in injury

Skills

Composite abilities

Relaxation ability, Balance, coordination, fine control, reaction time, multi-limb orientation, transition rate

Synergetic abilities

Co-contraction & reciprocal activation

Contraction abilities

Force (static & dynamic), velocity and length

slide31

+

From: Lederman E 2005 Science and practice of manual therapy

Protective motor organisation

Muscle wasting

Muscle hyperexcitability

Pain

-

Tensile strength

Inflammatory

phase

Regeneration

phase

Remodelling

phase

Time after injury

slide32

+

Protective motor organisation

Muscle wasting

Muscle hyperexcitability

Pain

-

Full recovery

Tensile strength

Time after injury

From: Lederman E 2005 Science and practice of manual therapy

slide34

Executive stage

Correlation / comparison process

Effector stage

Motor programme

Correlation process

Effector stage

Incomplete sensory input

Loss of fine motor control

Motor stage

Unrefined movement

From: Lederman E 2005 Science and practice of manual therapy

slide35

Reduced proprioception

From: Lederman E 2005 Science and practice of manual therapy

slide37

Potentiation of pain pathways (pain imprinting)

Intense or long term stimulation

From: Lederman E 2005 Science and practice of manual therapy

slide38

Pain starvation therapy

Avoid painful therapies – it may promote chronicity

slide39

Psychological

considerations

Whiplash as a post-traumatic disorder?

  • PTSD was related to the presence and severity of concurrent post-whiplash syndrome. More specifically, the intensity of hyperarousal symptoms that were related to PTSD at Q1 was found to have predictive validity for the persistence and severity of post-whiplash syndrome at 6 and 12 months follow-up. CONCLUSION: Results are consistent with the idea that PTSD hyperarousal symptoms have a detrimental influence on the recovery and severity of whiplash complaints following car accidents.
  • Buitenhuis J, de Jong PJ, Jaspers JP, Groothoff JW. Relationship between posttraumatic stress disorder symptoms and the course of whiplash complaints. J Psychosom Res. 2006 Nov;61(5):681-9
slide42

Characteristics of Instrumental & Expressive touch

Instrumental

Touch intent

Expressive

From: Lederman E 2005 Science and practice of manual therapy

slide43

Pain

Pleasure

Fragmentation

Integration

Broken movement

Flowing movement

Altered visceral motility

Normal visceral motility

Re-integration with pleasure

From: Lederman E 2005 Science and practice of manual therapy

creating a repair environment
Creating a repair environment

Repair & adaptation environment

Treatment

Functional activity

Specific exercise

From: Lederman E 2005 Science and practice of manual therapy

creating repair and adaptation environments
Creating repair and adaptation environments

From: Lederman E 2005 Science and practice of manual therapy

slide46

Treatment strategies

Psychological dimension

Neurological dimension

Tissue dimension

Support, comfort, reassurance + cognitive and behavioural +use techniques for re-integration and relaxation

Neuromuscular re-ab. if losses in abilities are present

Stretching only if shortening is present

Movement and pump techniques

Acute

Subchronic

Chronic

From: Lederman E 2005 Science and practice of manual therapy

Repair time-line

slide47

How to treat

Informative & reassurance

Physical serious injury is rare

Self-limiting conditiion

Good prognosis

Emphasise positive attitudes and beliefs

Early return to normal pre-accident activities

Minimise but don’t trivialise

Helpful

manual therapy

self exercise

Don’t

Medicalisation is detrimental

Collars

Rest

Negative attitudes and beliefs (don’t disable your patients)

Subjects are at substantial increased odds of developing chronic widespread pain if they display features of somatization, health-seeking behaviour and poor sleep. Psychosocial distress has a strong aetiological influence on chronic widespread pain.

Gupta A et al The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology (Oxford). 2006 Nov 4

T McClune. Whiplash associated disorders: a review of the literature to guide patient information and advice. Med J 2002; 19:499-506

slide48

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