Whiplash injury
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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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Whiplash injury

Prof. Eyal Lederman

C

2006 Eyal Lederman


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Lecture contents

  • A very brief history

  • The consequences (WAD)

  • Identifying the processes involved

  • How to influence these processes:

    • Tissue dimension

    • Neuromuscular dimension

    • Psychological dimension


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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


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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


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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


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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


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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


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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


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The role of osteopathy

  • Assist repair

  • Assist adaptation


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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


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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


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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


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Phases of repair

Inflammation

Regeneration

Remodelling

Days…

Months…………

Weeks…

Time after injury

From: Lederman E 2005 Science and practice of manual therapy


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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


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Benefits of movement on connective tissue

  • Alignment of collagen fibres

  • Improve tissue strength

  • Reduce cross-linking (adhesions)


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Collagen Fibrils

Collagen fibres

Effects on extensibility

From: Lederman E 2005 Science and practice of manual therapy


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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


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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



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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


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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




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Neuromuscular & sensory motor changes: activating cellular processes

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


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Psychological dimension activating cellular processes

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


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Functional organisation of motor system activating cellular processes

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


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Functional organisation to injury activating cellular processes

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


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The injury response activating cellular processes


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From: Lederman E 2005 Science and practice of manual therapy activating cellular processes

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


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Abilities affected in injury activating cellular processes


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+ activating cellular processes

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


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+ activating cellular processes

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


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Proprioceptive changes activating cellular processes


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Executive stage activating cellular processes

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


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Reduced proprioception activating cellular processes

From: Lederman E 2005 Science and practice of manual therapy


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Pain condition activating cellular processes


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Potentiation of pain pathways (pain imprinting) activating cellular processes

Intense or long term stimulation

From: Lederman E 2005 Science and practice of manual therapy


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Pain starvation therapy activating cellular processes

Avoid painful therapies – it may promote chronicity


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Psychological activating cellular processes

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


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Psychological influence of technique activating cellular processes


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Characteristics of Instrumental & Expressive touch activating cellular processes

Instrumental

Touch intent

Expressive

From: Lederman E 2005 Science and practice of manual therapy


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Pain activating cellular processes

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


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Creating a repair environment activating cellular processes

Repair & adaptation environment

Treatment

Functional activity

Specific exercise

From: Lederman E 2005 Science and practice of manual therapy


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Creating repair and adaptation environments activating cellular processes

From: Lederman E 2005 Science and practice of manual therapy


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Treatment strategies activating cellular processes

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


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How to treat activating cellular processes

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


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Find out more: activating cellular processes

Book

CPDO courses

Supervision groups


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