Transcript Document

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
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
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
Those with continuing symptoms three
months after the accident are likely to
remain symptomatic for at least two
years, possibly much longer
• Previous neck pain (females) and cervical deg. changes
• Lawyer involvement! (proof they are a pain in the neck)
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 JA Prognostic 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
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
Facets & disc damage
Referred shoulder and pain
Ringing in ears
Proprioceptive losses
Increased muscle fatigability
Dysfunctional synergy between muscle groups
Tiredness
Local neck pain,
Muscle hyperexcitability
Concentration or memory problems
Irritability
Sleeplessness
Hypersensitivity syndrome
Back pain
Paraesthesia
The consequences as processes
concentration or memory problems
irritability sleeplessness
tiredness
Neuromuscular & sensory motor changes:
Muscle wasting, dysfunctional synergy between muscle groups,
hyperexcitability (inability to relax?) and increased fatigability
Proprioceptive losses
DIMENSION
Psychological
Neural
Pain:
Local pain, referred pain
Hypersensitivity syndrome
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
The dimensional
model of
osteopathy
SIGNAL
DIMENSION
Psychological
OUTCOME
Psychological
change
Psychophysiological
change
Neural
Neuromuscular
changes
Reflex pain
changes
Physical /
Local
tissue
Assist repair
Assist fluid flow
Assist adaptation
From: Lederman E 2005 Science and practice of manual therapy
Psychological dimension
Treatment strategies
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
From: Lederman E 2005 Science
and practice of manual therapy
Subchronic
Repair time-line
Chronic
The role of osteopathy
 Assist
repair
 Assist adaptation
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
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
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
Phases of repair
Inflammation
Regeneration
Remodelling
Days…
Weeks…
Months…………
Time after injury
From: Lederman E 2005 Science and practice of manual therapy
The signals for repair


Provide adequate mechanical
stress
Dynamic
(initially passive > active?)

Repetitive
Physical /
Local
tissue
Assist repair
From: Lederman E 2005 Science and practice of manual therapy
Benefits of movement on connective tissue
• Alignment of collagen fibres
• Improve tissue strength
• Reduce cross-linking
(adhesions)
Effects on extensibility
Collagen Fibrils
Collagen fibres
From: Lederman E 2005 Science and practice of manual therapy
The trans-synovial
pump
Movement
+
Increased blood flow
around the joint
Alteration in intraarticular pressure
Increase lymphatic flow &
drainage around the joint
Fluid flow
From: Lederman E 2005 Science and practice of manual therapy
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
Which osteopathic technique
provide the signals for repair?
The code for repair


Provide adequate mechanical
stress
Dynamic
(initially passive > active?)

Repetitive
Physical /
Local
tissue
Assist repair
From: Lederman E 2005 Science and practice of manual therapy
Tensile strength following injury
Manual forces
Inflammatory
phase
Regeneration
phase
Remodelling
phase
Time after injury
From: Lederman E 2005 Science and practice of manual therapy
Technique
Adequate Dynamic
stress
Repetitive
HVT
Too much force
+ stretching
Yes but too fast
no
Massage ST
Yes if in
compression
Yes
yes
Cranial
No
No
No
Functional
No
No
No
Articulation
Yes (within the
slack or early
elastic)
Yes
Yes
(may be
fatiguing)
Stretch
Too much
No
No (not
sufficiently)
Traction
Too much
No
No
Harmonic
Yes
Yes
Yes
From: Lederman E 2005 Science and practice of manual therapy
Generally dynamic /
rhythmic are more
effective in activating
cellular processes
The neurological /
neuromuscular costs
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
Sequence of
events
Psychological
dimension
Perception of pain
and injury
Psychomotor /
behavioural
responses
Neuromuscular
dimension
Pain + altered
sensory feedback
Reflexive
neuromuscular
responses
Tissue
dimension
Tissue damage
From: Lederman E 2005 Science and practice of manual therapy
Functional organisation of
motor system
Executive stage
Effector stage
Motor
programme
Correlation /
comparison
process
Executive stage
Correlation
process?
Effector stage
Sensory stage
Motor stage
From: Lederman E 2005 Science and practice of manual therapy
Functional organisation to injury
Effector stage
Reflexive
motor
“Motor
templates” for
injury?
Psychomotor
Executive stage
Altered proprioception
+ nociception
Motor stage
From: Lederman E 2005 Science and practice of manual therapy
The injury response
Reflexive :
Pain / hyperalgesia
Avoidance & hypersensitisation
Koelbaek Johansen M. Generalised muscular hyperalgesia in chronic whiplash
syndrome. Pain. 1999 Nov;83(2):229-34.
Force loss (with or without atrophy)
Prushansky T. Cervical muscles weakness in chronic whiplash patients. Clin
Biomech (Bristol, Avon). 2005 Oct;20(8):794-8.
Kristjansson E. Reliability of ultrasonography for the cervical multifidus muscle
in asymptomatic and symptomatic subjects. Man Ther. 2004 May;9(2):83-8.
Dall'Alba PT. Cervical range of motion discriminates between asymptomatic
persons and those with whiplash. Spine. 2001 Oct 1;26(19):2090-4
Reduced range
Reduce velocity
Increased fatigability
Kumbhare DA. Measurement of cervical flexor endurance following whiplash.
Disabil Rehabil. 2005 Jul 22;27(14):801-7
Psychological / psychomotor:
Fear of use &
Pain avoidance (behavioural)
Increased pain perception &
reduced tolerance to pain
Nederhand MJ. Predictive value of fear avoidance in developing chronic neck
pain disability: consequences for clinical decision making. Achives of Physical
Medicine and Rehabilitation. 2005:85:3,p 496-501
Koelbaek Johansen M. Generalised muscular hyperalgesia in chronic whiplash
syndrome. Pain. 1999 Nov;83(2):229-34.
Sense of weakness
General fatigue
Nausea
Ferrari R. A re-examination of the whiplash associated disorders (WAD) as a
systemic illness Annals of the Rheumatic Diseases 2005;64:1337-1342
Ferrari R. A re-examination of the whiplash associated disorders (WAD) as a
systemic illness Annals of the Rheumatic Diseases 2005;64:1337-1342
Abilities affected in
injury
From: Lederman E 2005 Science
and practice of manual therapy
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
Abilities affected in injury
Inability to relax
Nederhand MJ. Cervical muscle dysfunction in the
chronic whiplash associated disorder grade II (WAD-II).
Spine. 2000 Aug 1;25(15):1938-43
Elert J. Chronic pain and difficulty in relaxing postural
muscles in patients with fibromyalgia and chronic
whiplash associated disorders. J Rheumatol. 2001
Jun;28(6):1361-8
Synergism
(excessive co-contraction)
Nederhand MJ. Cervical muscle dysfunction in the
chronic whiplash associated disorder grade II (WAD-II).
Spine. 2000 Aug 1;25(15):1938-43
Force
Prushansky T. Cervical muscles weakness in chronic
whiplash patients. Clin Biomech (Bristol, Avon). 2005
Oct;20(8):794-8.
Length
Dall'Alba PT. Cervical range of motion discriminates
between asymptomatic persons and those with
whiplash. Spine. 2001 Oct 1;26(19):2090-4
Velocity
Reduced endurance
Kumbhare DA.
Measurement of cervical flexor
endurance following whiplash. Disabil Rehabil. 2005 Jul
22;27(14):801-7
From: Lederman E 2005
Science and practice of
manual therapy
+
Protective motor
organisation
Muscle wasting
Muscle
hyperexcitability
Pain
-
Inflammatory
phase
Regeneration
phase
Time after injury
Remodelling
phase
+
Protective motor
organisation
Muscle wasting
Muscle
hyperexcitability
Pain
Full recovery
Time after injury
From: Lederman E 2005 Science and practice of manual therapy
Proprioceptive
changes
Executive stage
Effector stage
Correlation /
comparison
process
Motor
programme
Correlation
process
Effector
stage
Incomplete
sensory input
Loss of fine
motor control
Motor stage
From: Lederman E 2005 Science and practice of manual therapy
Unrefined movement
Reduced proprioception
From: Lederman E 2005 Science and practice of
manual therapy
Pain condition
Potentiation of pain pathways (pain imprinting)
Intense or long term stimulation
From: Lederman E 2005 Science and practice of manual therapy
Pain starvation therapy
Avoid painful therapies –
it may promote chronicity
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
BIOPSYCHOSOCIAL CONSIDERATION
Fear of use & Pain
avoidance (behavioural)
Nederhand MJ. Predictive value of fear avoidance in developing chronic
neck pain disability: consequences for clinical decision making. Achives
of Physical Medicine and Rehabilitation. 2005:85:3,p 496-501
Catastrophising
Raak R, Wallin M. Thermal thresholds and catastrophizing in individuals
with chronic pain after whiplash injury. Biol Res Nurs. 2006 Oct;8(2):13846
Somatisation
Guez M. Chronic neck pain. An epidemiological, psychological and
SPECT study with emphasis on whiplash-associated disorders. Acta
Orthop Suppl. 2006 Feb;77(320):preceding 1, 3-33
Increased pain perception
& reduced tolerance to pain
Koelbaek Johansen M. Generalised muscular hyperalgesia in chronic
whiplash syndrome. Pain. 1999 Nov;83(2):229-34.
General fatigue
Ferrari R. A re-examination of the whiplash associated disorders (WAD)
as a systemic illness Annals of the Rheumatic Diseases 2005;64:13371342
Nausea
Ferrari R. A re-examination of the whiplash associated disorders (WAD)
as a systemic illness Annals of the Rheumatic Diseases 2005;64:13371342
Psychological influence of technique
Manual technique
Possible body image consequences
Passive
Soft tissue
Massage
Techniques with joint
movement
Give confidence that movement is OK
Able to see that neck is not badly damaged
Give a sense of continuity in the body
Give a sense of flow
Give a sense of whole
Take away focus from pain
Reduce catastrophising and the fear of use
Active
Active techniques
Give confidence that movement is OK
Provide a sense of weakness to strength;
helplessness to empowerment
Reduce catastrophising and the fear of use
Characteristics of Instrumental &
Expressive touch
Instrumental
Touch intent
Expressive
Local / Focal
Broad, integrative
Brief
Maintain contact
Force dependent
Force irrelevant
May be painful
Pleasurable
Investigative, prodding
Touching the ‘whole person’
Mechanistic
Attentive & responsive
Uninvolved
Expressive
Corrective
communicative
From: Lederman E 2005 Science and practice of manual therapy
Re-integration with pleasure
Pain
Pleasure
Fragmentation
Integration
Broken movement
Flowing movement
Altered visceral
motility
Normal visceral
motility
From: Lederman E 2005 Science and practice of manual therapy
Creating a repair environment
Treatment
Functional activity
Specific exercise
From: Lederman E 2005 Science and practice of manual therapy
Creating repair and adaptation environments
Character
Aim
Technique
Exercise
Functional
adaptation
Soft
condition
Inflammation
Oedema
Effusion
Impediment to
flow
Increase flow
Assist repair
Movement
Intermittent
compression
Rhythmic
counter rotation
Yes, Yes No, No
exercise
Turn fully in
daily activity
etc.
Solid
condition
Shortening
Adhesions
Elongate
Brake
adhesions
Tensional forces
Stretching
Normal cervical
stretches
As above
From: Lederman E 2005 Science and practice of manual therapy
Psychological dimension
Treatment strategies
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
From: Lederman E 2005 Science
and practice of manual therapy
Subchronic
Repair time-line
Chronic
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
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
Medicalisation is detrimental
Collars
Rest
Negative attitudes and beliefs (don’t disable your patients)
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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