Whiplash

Had this patient

19 yr old, whiplash patient, whiplash 3 months ago.
No neuro signs, full rom, slight pain at end range, decrease mobility c2/3, c6/c7, also present in transversep processes.

I advised on use of heat, used TNS for 3 times, patient was getting better very slowly. Started isometrics and cerv stability exs.

Every treatment session, took 10 minutes to start with neck traction, someoscillatory grade 3/4 mobes to maintani full range, and did PA grades 1/2 to dec pain in the affected cerv spine. Finsihed off with Mulligans mobes to increase transverse mobility during the actual movement.

The patient is upset that the mobes is making her worse and wants to stop attending!

Am i doing something wrong here?

the more u care, the less they care!

[Physiobase]

Mulligans is a general reference so be a bit more specific which techniques you have chosen to use. I have found MWM's from Mulligan are very useful in treating whiplash. It is common that this approach will restore range but can lead to some discomfort. Therefore you should consider finishing a treatment session with something pain relieving, e.g. some interferrential or perhaps even some ultrasound paraspinally.

Assuming there is no boney lesion (checked via xray,scan etc) your are really dealing with significant ligamentous damage (+/- discal damage), much like a badly sprained ankle. Heat on a sprained ankle might increase that deep noring pain?

The heat isn't really that useful here as the pain is probably deeper ligamentous pain. Isometrics in various ranges of rotation would be better than static isometrics in neutral. Also McKenzies supine exercise with a towel where the client lifts the head slightly off the floor in midline (using the towel as a cradle for the head), then does a retraction into the towel (isometric contraction) and then while maintaining the retraction pressure uses the towel via the arms to rotate the head through range is a great home exercise.

Sounds like you are on the right track but maybe are simply being a little to vigorous with your technique application.

[alophysio]

Hi Physioo,

My question is why are you doing the traction and PA gr 3/4 mobes? For the stiffness at C2/3 and C6/7 I presume. It is interesting as you state that she has full ROM.

Are the PA mobes true Maitland style mobilisations? Because if they are, they might indeed be making the pain worse. Since the facets are roughly aligned at 45deg, boucing on the joints are just going to jam them up.

I have found that if joints are excessively compressed (from overactive muscles, spasm, etc) then joint mobes just aggravate the problem.

You haven't stated what her muscles are like except to say that you have started exercises with her.

I am not a fan of electro so i my biased opinion is to let her do the heat and TENS at home on her own - I don't think it would help anyway - but you can make good money selling wheatbags! Having said that, the U/S at the end of treatment is a nice thing to do for the anxious patient, even if it doesn't do much to get them better :b

From the limited amount of information you have given us, I would assess her overall posture - if my guess is right and she is overactive, she will have a flat thoracic spine (loss of normal kyphosis) when trying to sit up straight. Restoring the natural lumbar lordosis and thoracic kyphosis would be a good start. I often get my patients to sit how they normally would and ask them to rotate their head both ways and note how it feels. I then correct their posture, get relaxed sitting with the curves in place and get them to reassess themselves with rotation again and the ROM and reduced muscular pull is amazing (in fact try it now!).

Therefore, i would be hesitant to give the exercise as described by Physiobase if she is overactive as she will start to overuse her SCM and Scalenes (even though it is a nice exercise).

You can assess her core stability in the C/S by having her lie supine, feel the TPs at a given level, ask her flex her arm to 90 (i.e. point it at the ceiling) and then ask her to do horizontal extension (or move it to parallel with the ground). A clinical instability will result in the feel of the vertebra not staying still during this low load activity. You can then train her cervical multifidus to contract and try to achieve segmental stability.

So the process is similar in the C/S as for L/S problems - retrain local muscle system to replace tired, overactive global muscle system.

I hope this helps...

[Physiobase]

overuse her SCM

The mcKenzie exercise mentioned above is designed to reduce the SCM activity not increase it. Of course that does assume it is taught, and practised, correctly! It should also reduce accessory mm use and work more directly on deep neck flexors.

Thanks for your replies
Extremely grateful, this was my first whiplash patient after graduation, so still learning I guess!!

As regards to posture, she had an increase in th Kyphosis, and worked a bit on arranging her posture.

Interesting cervical stability exercises, inccoprorating UL mobility, thanks who posted that!

I might have been too agressive with PA Maitland mobes, however MWM (Mull) seemed to help her.

Will continue monitoring. Off to my Canadian Licence exam on SUnday!! way to die!

[alophysio]

My apologies physiobase ! I musn't be clear on how the exercise is done...

Which muscles do the lifting if the patient is to lift their head off the floor? I just tried to do the exercise as described but couldn't do it without SCM activating - maybe i just have a stuffed C/S, or doing it wrong...?

Having written the above - is it lifting the head via the towel, then retracting (without SCM/Scalenes) then using the arms to rotate the head????

[farooqphysio]

better u go for steam bath for perticular area and than go for traction and than go for streaching of scm & upper trapezius with mulligans mob.

[ginger]

Whiplash patients can certainly tests a physio's ability in many ways . Not the least of which is to be able to construct a usefull treatment regimen that minimises post Rx irritation and sets a course for stability, movement and comfort. Post Rx irritation is common with these people. In some cases even pulsed US can irritate. As long as you are both prepared to comunicate , to modify , to establish a good relationship based on mutual trust and respect you will work out the way to proceed together.
Hands are great things. Use them with care and restraint here though.

[linbin]

hi
hows is his neural mobility.any signs of neural tension.if present try neural mobilization too.
"the more we care,less they care" .dont feel bad."people doesnot care how much you know unless and until they know how much you care"

[Yarok]

Hi
very helpfull gentle global and segmental postisometric relaxation followowed by PNF neck pattern.check trigger points in SCM,trape, levator scap if present apply mucle energy tech.

thanks