RLMAR2008 Layout rest; sleep interruption of 2-3 times per night and interscapular pain of 4-5/10. The patient considered the nature of the disorder as impairing to his work as a police officer. Present history included the onset of symptoms shortly after being rear-ended. He described the impact as unexpected and strong, forc- ing the back of his head into the head support. Past history was unremark- able with no previous injuries, neck or back pain. Special Questions revealed good general health and no neurological signs. The patient denied sub-occipital pain, headaches, nausea, vomiting, dizzi- ness, diplopia, dysarthria, dysphagia or drop attacks. Cervical spine x-rays taken at the emergency room were unremark- able and he was discharged with a pre- scription for pain medicine. Since pain was increased to 6/10 by standing or sit- ting for periods longer than 15-minutes and subsiding to its prior level after only a few minutes of resting, the injury was considered to be none irritable. The total score of the patient specific func- tional scale (PSFS) was 3.3/10. In the absence of contraindications, a physical examination focusing primarily on the cervical spine was planned. The physiotherapy clinical practice guide- line for WAD advises that the physical examination should include general 2 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3 Physiotherapy in a Whiplash Injury: A Case Report C a s e R e p o r t INTRODUCTION The Quebec Task Force on Whiplash Associated Disorders (WAD) defines whiplash as an acceleration-deceleration mechanism of energy transfer to the neck. It may result from a rear-end or side-impact motor vehicle accident (MVA), or other mishaps. After a MVA, 62% of vehicle occupants develop neck pain. The most common symptoms of whiplash injury include neck pain, headache, stiffness, shoulder/arm pain, muscle fatigue, paraesthesia, dysphagia, visual and auditory disturbances, dizziness, poor concentration and sleep disturbances. The Quebec Severity Classi fication of WAD is based on clinical presentation and graded 0-IV. WAD II classification is defined as a whiplash injury with neck symptoms and muscu- loskeletal sign(s). Inconsistencies in the literature exist regarding the prognosis of whiplash injury, ranging from favorable to non-favorable. Only 22% of whiplash patients resume usual acti - vities within a month after the incident and up to 60% report pain and disability at 6 months. Chronic whiplash disorders (symptoms or disabilities persisting for more than six months) have significant long-term economic implications. In patients with normal recovery a gradual improvement in physical and mental function, activities of daily living (ADL) and participation in work are expected. Contributing factors associated with delayed recovery include previous injury, headache, neck pain after the accident, employment status, type of collision, compensation, clinical findings, cultural differences, coping strategies and phy - sical as well as psychosocial well-being. METHODS THE SUBJECTIVE EVALUATION Background: The patient was a 29-year old male complaining of neck pain and tightness as well as low back pain following a MVA. He was referred to physiotherapy two weeks after the acci- dent. The patient described his main complaint as an “ache and tightness” in his neck (left worse than right), extending towards his shoulder blades. Behavior of symptoms included neck pain of 4-5/10 on a Numeric Pain Rating Scale (NPRS), aggravated by movement, prolonged standing or sitting; fatigue when “holding his head up”, relieved with Correspondence to: Corné van Eck Cell: 076 137 0084 Email: fcvaneck@vodamail.co.za A BST R A CT: Study Design: Case Report Objectives: To describe physiotherapy intervention in an individual with a suspected whiplash injury. Back ground: The patient was a 29-year old male with complaints of neck pain and tightness following a motor vehicle accident. M ethods and M easures: The focus of the case study is physiotherapy assessment and intervention in a stage II whiplash injury. R esults: Following intervention, positive changes occurred in outcome measures such as pain, work status and activi- ties of daily living. Conclusion: Physiotherapy intervention is successful in addressing whiplash associated disorders. KEY W ORDS: PHY SIOTHERA PY, W HIPLA SH INJURY, MOBILIZATION, THERA PEUTIC EX ERCISE, NEURA L TISSUE MOBILIZATION, PATIENT EDUCATION. Van Eck C, PT, DPT, OCS, COMT, FAAOMPT B Physiotherapy (Cum Laude)1 1 University of Pretoria, South Africa. SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3 3 observation, regional examination, range of motion, quality of movement, symp- tom provocation, muscle strength and cervical proprioception. THE PHYSICAL EXAMINATION Observation: The patient lacked spon- taneous neck movement and appeared to be in discomfort. Postural assessment revealed decreased cervical lordosis, upper cervical extension and a kyphotic cervical-thoracic junction. Neurological testing was not indicated at this time. Active physiological movement: A CROM Instrument (product of Performance Attainment Association, 958 Lydia Drive, Roseville, Minnesota, 5513) was used to measure active cer - vical range of motion. The patient was instructed to report any symptoms and to stop moving at the first onset of pain (P1) or stiffness (R1). Active movement was restricted in all directions. The patient complained of muscle pulling on both sides of his neck during extension, left side bend (LSB) and left rotation (LR). Differentiation between the upper and lower cervical spine revealed the latter to be more involved. Alar and transverse ligament stability testing and provocation testing of the odontoid process were unremarkable. Palpation revealed a slight increase in skin tem - pe rature as well as tenderness of the musculature in the cervico-thoracic region and over facet capsules of C3/4- C5/6 bilaterally. Passive physiological inter-vertebral movement (PPIVM) was performed to further isolate the source of the disorder and to identify possible treatment techniques. The patient was instructed to communicate reproduction of symptoms while the therapist was palpating for a joint sign. Segmental extension at C3/4 - C5/6 (L) was limited and segmental side bend (SB) findings included painful levels at C3/4 - C5/6 bilaterally. Manual examina- tion of inter-segmental mobility is widely used and accurate in identifying symptomatic levels. Relevant findings of passive inter-vertebral accessory movements (PAIVM) are described in table 2. Cervical muscle testing of the deep neck flexors (DNF) was tested with an inflatable biofeedback cuff, (Chattanooga Group, Chattanooga, TN) holding a 4-mmHg increase in pressure for 1 second x7. The patient expressed fatigue after performing the test. Mild substitution using sternocleidomastoid muscles was palpated at the clavicle. Neural tissue mobility of the median nerve was restricted at -45º (R) elbow extension and -30º (L). Thoracic and lumbar neural tissue mobility was not assessed at this time. At the conclusion of the subjective and objective eva - luation, no specific contraindications were identified. COURSE OF TREATMENT This case study provides a detailed account of physiotherapy intervention in a patient with WAD II presenting with articular, soft tissue, proprioceptive and postural dysfunction. Primary goals of physiotherapy intervention in WAD II are early mobilization, pain reduction, optimizing quality of life, patient edu - cation on behavior modification, quick return to ADL and reducing a patient’s dependence on medicine. Positive out- comes were found with multi-model physiotherapy intervention, specifically Maitland/McKenzie mobilizations and exercises in the recovery from whiplash injury, prevention of chronic disorders and controlling social and economic costs. In patients with normal recovery, treatment goals are determined by func- tional impairments and in patients with delayed recovery, special emphasis is placed on coping strategies. Table 1 is a detailed description of the plan of care used for the patient with WAD II, as described in this case study. Special techniques used in proprio- ceptive and kinesthetic rehabilitation are based on studies described by Soderlund et al. The patient was treated for six ses- sions over a 14-day period. Table 2 is a summary of the outcome measures before and after physiotherapy inter - v en tion. DISCUSSION Clinical decision-making is guided by the patient’s clinical presentation, the stage of the injury, goals and the provider’s formal knowledge and expe- rience. Following a rear-impact collision of only 5x gravitational force (gs), a sig- nificant increase in the inter-vertebral neutral zone and range of motion occurs, leaving the lower cervical spine, spe - cifically C5/6 most at risk for injury. During an acceleration of 3.5gs and above, facet joint components such as the synovial fold, articular cartilage and capsular ligaments are at risk of injury, due to facet joint compression and excessive capsular ligament strain during impact. Facet joint compression that exceeds physiologic limits could injure articular cartilage when the upper facet collides with the lower facet. When the collision force is enough, irreversible damage to the cartilage matrix and chondrocytes occur. Mechanoreceptors in the facet capsule and synovial fold can be damaged during whiplash causing Figure 1. The patient’s proprioceptive progression from large to small circles. 4 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3 Table 1: Physiotherapy intervention and each sessions’ outcome in session one through six. SESSION 1 (DAY 1) TREATMENT OUTCOME Soft tissue mobilization Mobilization with movement (MWM), preferred direction Decreased pain and muscle guarding Joint mobilization Passive RSB grade III; Transverse (L) C4 grade II Patient Education Encouraged to continue working; Avoid inactivity leading to the development of chronic pain SESSION 2 (DAY 2) Soft tissue mobilization Continued SB (L/R) = 31º Joint mobilization SB (L) decreased pain/stiffness Continued, added UPA (L) C3/4 grade III; Bilateral UPA C3/4, C4/5 grade III Flexion/extension = 45º Therapeutic Exercise DNF (20mmHg 5x5sec) Improved neck posture Scapular retraction (1x30 with 7kg) SESSION 3 (DAY 5) Soft tissue mobilization Plastic response and change in collagen Continued, added muscle stretching to rhomboids, extensibility levator scapulae and upper trapezius (L) Joint mobilization SB (L/R) = 75º. Extension with bilateral UPA C4/5 Flexion/extension = 95º Therapeutic Exercise DNF (22mmHg 10x5sec) Scapular retraction (2x30 at 60% of 1RM) Vascularization and opening capillary Scalene (SB (L), in side laying, 3 x 7 on each side) shunts/collaterals Patient Education Posture and pathology of whiplash injuries Neural Tissue mobilization Stiffness and pain (B) UE decreased Median nerve (L); Cervico-Thoracic neural tissue Home Program Trapezius/ levator scapulae stretching; Self-mobilization median nerve (B) Plastic response and change in collagen adding wrist/elbow extension extensibility SESSION 4 (DAY 6) Soft tissue mobilization MWM (L) scapula; Active/passive pump (L) Trapezius Joint mobilization Transverse (R) C4-C6 grade III; Rotation (L) with SB (L/R) = 62º UPA (R) C5/6 grade III Total rotation = 88º Therapeutic Exercise DNF (22mmHg 10x10sec) Scalene (SB (B) on incline bench) Scapular retraction (3x30 60% of 1RM) Neural tissue mobilization Lumbar and thoracic in Slump position -30º knee ext (L); -20º knee ext (R) Home Program Neural tissue stretching using “sliders” Table 1 continued on next page SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3 5 Table 1: Physiotherapy intervention and each sessions’ outcome in session one through six. Session 5 (Day 13) Joint mobilization UAP (R) C5/6 grade III+ ;Transverse (L) C6 grade III+ Combined SB = 64º; Therapeutic Exercise Flexion/extension = 106º DNF (24mmHg 5x10sec) Total rotation = 106º Scalene (Combined SB and Rotation) Scapular retraction at wall pulley (2x11 at 80% 1RM) Neural tissue mobilization Decreased stiffness in trunk and lower back Sympathetic Slump in long sitting Kinesthetic awareness Square corner/diagonal squeezes (3x3sec hold each) Proprioception Eyes open (black) 30 sec each Black/red pen in mouth making dots in circles Eyes closed (red) 30 sec each Home Program Slump “tensioners” Square corner/diagonal squeezes Session 6 (Day 14) Joint mobilization Combined SB=62º UAP (R) C5/6; Combined RSB/ Transverse (L) C6 Total rotation=112º Therapeutic Exercise Flexion/extension=124º DNF (24mmHg 10x10sec) Scapular retraction at wall pulley (3x7 at 85% 1RM) Improved joint motion around a (L) Shoulder coordination exercises normal physiological axis Neural tissue mobilizations Sympathetic Slump in long sitting with trunk rotation, Decreased stiffness in CT-junction, adding ankle dorsiflexion as tolerated trunk and lower back Kinesthetic awareness Square corner/diagonal squeezes (5x5sec hold each) Improved neck posture Proprioception Increased number of red dots Same as fifth session in smaller circle Figure 2: Summary of cervical range of motion changes during physiotherapy sessions. Normal CROM values Initial Visit Second visit Third visit Fourth visit Fifth visit Sixth visit 6 SA JOURNAL OF PHYSIOTHERAPY 2008 VOL 64 NO 3 disruption of proprioceptive transmis- sion, leading to dysfunction of the spinal stabilizing system and the poten- tial for spinal instability or uncoordinated, painful muscle contraction, as well as inaccurate perception of head and neck position. Pain is generated from inflam- mation in the facet articular cartilage, synovial fold, ligaments, capsule and sensitized peripheral and central nocicep- tive neurons. Sensitization can lead to lowering nociceptive firing-thresholds, resulting in pain during normal motion. Excessive facet joint compression or capsular ligament strain is likely to lead to the chronic symptoms associated with whiplash injury. Decreased neural tissue mobility could indicate intra- neural or intra-dural inflammation, pos- sibly explaining widespread symptoms into the thoracic and lumbar areas. CONCLUSION The results of this case report cannot be generalized for the WAD II popula- tion. A definite need for continued research in physiotherapy intervention for WAD exists. As far as the author’s knowledge, the intervention and clinical reasoning process was in accordance with current literature on physiotherapy for WAD II. It is also the author’s believe that 4-6 additional treatment sessions, spread out over the next six months would have addressed goals not yet fully accomplished. REFERENCES Barnsley L, Lord S, Bogduk N. Whiplash injury. Pain. 1994;58:283-307. Bogduk N. Post whiplash syndrome. Aust Fam Physician. 1994;23:2303-7. Butler DS. The Sensitive Nervous System. Unley, Australia: Noigroup Publications; 2001. Crawford JR, Khan RJK, Varley GW. Early management and utcome following soft tissue injuries of the neck - a randomised controlled trial. Injury, Int J. Care Injured. 2004;35: 891-895. Deans GT, Magalliard JN, Kerr M, Rutherford WH. 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Outcome Measures Before Intervention After Intervention Main Complaint Tight ache in neck, fatigue and Neck slight soreness soreness in back LBP Pain Cervical = 4.5/10; Thoracic = 4.5/10 Cervical = 1.5/10; Thoracic = 1.5/10 (NPRS) Lumbar = 4.5/10 Lumbar = 3.5/10 Area of symptoms Sides of neck, between Slight tightness in neck shoulder blades, LBP Soreness in lower back. PSFS Turning neck = 7/10 Turning neck = 3/10 Straightening up = 9/10 Straightening up = 3/10 Standing > 15mins = 8/10 Standing > 15mins = 4/10 Total PSFS = 8/10 Total PSFS = 3.3/10 Patient Goals Relief from back and neck pain Relief from LBP Cervical ROM Deficit total range = 250º Deficit total range = 62º DNF Pressure Increase: 4mmHg Pressure Increase: 15mmHg 1 second x7 10 seconds x15 Experienced fatigue Good endurance PAIVM CPA C3-C6, T2-T4 grade 1 UPA (R) C5/6 grade 2 UPA (R) C4/5, C5/6 grade 1 *Transverse (R) C6 grade 2 UPA (L) C3/4, C4/5 grade 1 *Transverse (L) C6 grade 2 *Transverse (R) and (L) C4 grade 1 Median nerve mobility R: -45ºelb extension R: WNL L: -30ºelb extension L: WNL