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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 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 Find out more: Book CPDO courses Supervision groups