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Whiplash injury
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Whiplash injury

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  1. Whiplash injury Prof. Eyal Lederman C 2006 Eyal Lederman

  2. Lecture contents • A very brief history • The consequences (WAD) • Identifying the processes involved • How to influence these processes: • Tissue dimension • Neuromuscular dimension • Psychological dimension

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. The role of osteopathy • Assist repair • Assist adaptation

  10. 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

  11. 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

  12. 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

  13. Phases of repair Inflammation Regeneration Remodelling Days… Months………… Weeks… Time after injury From: Lederman E 2005 Science and practice of manual therapy

  14. 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

  15. Benefits of movement on connective tissue • Alignment of collagen fibres • Improve tissue strength • Reduce cross-linking (adhesions)

  16. Collagen Fibrils Collagen fibres Effects on extensibility From: Lederman E 2005 Science and practice of manual therapy

  17. 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

  18. 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

  19. Which osteopathic technique provide the signals for repair?

  20. 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

  21. 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

  22. From: Lederman E 2005 Science and practice of manual therapy

  23. Generally dynamic / rhythmic are more effective in activating cellular processes

  24. 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

  25. 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

  26. 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

  27. 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

  28. The injury response

  29. 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

  30. Abilities affected in injury

  31. + 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

  32. + 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

  33. Proprioceptive changes

  34. 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

  35. Reduced proprioception From: Lederman E 2005 Science and practice of manual therapy

  36. Pain condition

  37. Potentiation of pain pathways (pain imprinting) Intense or long term stimulation From: Lederman E 2005 Science and practice of manual therapy

  38. Pain starvation therapy Avoid painful therapies – it may promote chronicity

  39. 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

  40. Psychological influence of technique

  41. Characteristics of Instrumental & Expressive touch Instrumental Touch intent Expressive From: Lederman E 2005 Science and practice of manual therapy

  42. 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

  43. Creating a repair environment Repair & adaptation environment Treatment Functional activity Specific exercise From: Lederman E 2005 Science and practice of manual therapy

  44. Creating repair and adaptation environments From: Lederman E 2005 Science and practice of manual therapy

  45. 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

  46. 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

  47. Find out more: Book CPDO courses Supervision groups