MANAGEMENT

iotherapists do have training in detection of minor instability in spinal joints and there is some evidence that they can make accurate mobility assessments.

Trigger points Sudden stretch of muscular nociceptors can create trigger points such that muscle around the cervical spine becomes hyper- sensitive and tender to palpation. This can lead to weakness of cervical stabilis- ing muscles along with stiffness of move- ment. Myofascial trigger points can be demonstrated through examination and there is evidence that fibromyalgia can develop as a result.

Nerve injury After this type of injury many nerves can become hypersensitive to stimuli causing spontaneous neuropathic type pain and abnormal sensations. Nerve roots may be compressed as a result of oedema, scarring or osteophyte formation, although routine radiological studies may be negative.

Postural dysfunction Changes in posture due to any of these mechanisms may alter the loading on spinal joints and muscles, most common- ly the head can be drawn down and forwards by tight muscles and a flexion contracture.

Brain injury Experimentally a whiplash injury can cause haemorrhages or contusions of the brain even though there is no direct injury. This may account for the cognitive and behavioural symptoms occurring after some road traffic accidents. Although unproven, injury to the sympathetic trunk, particularly at the C3/4 level, could cause deafness, visual blurring, vertigo and tinnitus through the ciliospinal reflex and accommodative dysfunction.

Most of the proprioceptive receptors of the vestibulospinal tracts are found in the deep muscles of the neck and joint cap- sules of the first through to the third cer- vical vertebrae. These are major regulators of equilibrium. There may also be damage to the inner ear function leading to poor balance and postural control.

Degenerative arthritis Some studies have shown that spondylosis occurs more often after whiplash injury but some of the evidence is conflicting

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TABLE 1: THE QUEBEC TASKFORCE CLASSIFICATION OF WHIPLASH ASSOCIATION DISORDERS

Grade 0 - No complaint of neck pain and no physical signs Grade I - Neck pain, stiffness or tenderness only - no physical signs

Grade 2 - Neck complaints AND musculoskeletal signs (decreased range of movement and point tenderness)

Grade 3 - Neck complaint AND neurological signs (decreased or absent tendon reflexes, weakness and deficits)

Grade 4 - Neck complaints AND fracture or dislocation

and some of the studies are inadequate. Based on experience with knees and hips, one would expect degenerative change to be a likely consequence of injury. Other studies have shown no link between WAD and the development of degeneration in the cervical spine.

Much is to be gained from information and hypotheses put forward by osteopaths, chiropractors and physiother- apists regarding the aetiology and treat- ment of whiplash injury.

DIAGNOSIS A full examination of the neck, shoulder and thoracic spine should be carried out using active and passive movements along with a neurological examination of the upper and lower extremities and cranial nerves. Upper limb tension testing (ULTT) is also an invaluable aid to diagnosis.

Imaging is usually unhelpful in WAD as the problem is normally due to dysfunc- tion and not a structural injury. Flexion- extension views of the cervical spine could be considered for any patient in whom neck motion causes an unexpected amount of pain two months after the ini- tial injury. These x-ray views can detect intervertebral instability. Positive findings are rare but important when found as sur- gical fusion may be curative.

MANAGEMENT A wide range of treatments has been pro- posed for WAD, ranging from spinal man- ual therapy, manipulation and traction to facet joint injections, acupuncture and massage.

Common recommendations for an acute injury include rest intially, using a soft or hard collar with ice compresses, gentle massage and a gentle range-of-motion exercise for the first few days. The length

of time a collar should be worn is still in question but many authorities advise against this use for more than a few days. Postural guidance on sitting and sleeping using an orthopaedic pillow is helpful in maintaining the alignment of the cervical spine. Analgesics, including low dose tri- cyclics, may be useful for pain relief but there is no good evidence to support the use of any particular analgesic. There is increasing evidence that some of these treatments can be helpful in whiplash but one must remember that for the therapies with no proof of efficacy, “absence of evi- dence” is not “evidence of absence”.

Manipulation is widely used by osteopath- ic and chiropractic therapists and increas- ingly so by physiotherapists. This tech- nique treats the hypo-mobile segments and frees up apophyseal joint dysfunction. Manipulation is helpful in the acute and chronic phases of WAD, preferably a short course lasting no more than eight weeks.

BOX 1: POSSIBLE EMPIRICAL THERAPIES FOR WAD

■ Muscle stretching ■ Trigger point therapy ■ Myofascial techniques ■ High velocity low amplitude manipulation

■ Transcutaneous electrical nerve stimulation (TENS)

■ Mobilisation ■ Postural training ■ Traction

MANUAL THERAPY Many different approaches are used with- in the professions of physiotherapy, osteopathy and chiropractic. The type of treatment depends upon the nature and severity of the injury, as well as the stage of presentation.

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