cervicothoracic: whiplash, headaches and cervicogenic dizziness

whiplash overview

- as low as 10 mph MVA can cause injury

- rear impact the most common

- females

- 35-55 y/o

- smaller/thinner or shorter necks more prone to injury

which injuries are worse in terms of tissue damage and prognosis

extension injuries

whiplash phases

1. normal position

2. S-Shape - horizontal shear creating upper c/s at risk of flexion injury and lower c/s at risk of hyperextension

3. cervical spine extension

4. cervical spine flexion accelerated

factors that may reduce injury from MVA

- airbags

- front crash detection sensors

- properly adjusted headrest

- proper seat back height

WAD prognostic factors

- high pain intensity

- high self-reported disability scores

- high posttraumatic stress symptoms

- strong catastrophic beliefs

- cold hyperalgesia

Quebec Classification for WAD

0 - no complain about neck

I - complaint of pain, stiffness or tenderness; no physical signs

II - neck complaints and MSK signs

III - neck complaint AND neurological signs (DTR, myotomes, dermatomes) *more likely to be chronic

IV - neck complaint and fracture/dislocation

whiplash management

- pain control

- motor control and coordination exercises

- proprioceptive, kinesthetic and postural control

- psychological interventions

- c/s, ts mobs and manips

manual therapy for WAD

- start outside the most painful area

- STM gently at first

- traction may not be a good idea

positional release

shortened/relaxed position w/ light pressure for 60-90 sec

active release

trigger point and active lengthen for 5-8 reps

primary types of headaches

- migraine

- tension-type

- trigeminal autonomic cephalalgias

headache behavior for referral

- sudden onset

- worsening pattern of headache

- change in pattern from previous headache

- fixed laterality

- triggered by cough, exertion or posture change

- nocturnal onset

- new onset after 50+ y/o

- systemic sx and s

- seizures

- focal neurologic sx

- new, worst pain

- cognitive impairment

- no response to appropriate treatment

tension type headache

most common type of headache

- lack of: aura, nausea, photophobia, phonophobia, hx of trauma, upper c/s mobility restrictions

- often related to stress, poor sleep, anxiety

- common bilateral and described as a tight ache around forehead

- myofascial trigger points

- responds well to pain meds, STM, stress manage

cervicogenic HA

- often unilateral w/ neck sx aggravated by movements or position

- HA aggravated w/ provocation of ipsilateral soft tissue or joint segments

- limited c/s ROM

- upper c/s motion restriction

- (+) CFRT

- weak DNF

- active trigger points

migraines

associated sx of nausea, vomiting, photophobia, phonophobia, and visual changes are quite common

- also have concurrent c/s dysfunction but that is correlative not necessarily causative

- less active, less fit and higher levels of kinesiophobia

evidence for tension-type or cervicogenic headaches

- expect higher levels of irritability and proceed w/ caution

- manual therapy equal to medications

- HVLA not indicated in early stages

- manual therapy > general practice in both short and long term chronic tension-type

- use of SNAG

Mulligan SNAG

towel on C2 SP and pt does cervical retraction into it

- 10 second holds, 6-10 reps

possible causes of dizziness

- CV

- neurological

- metabolic

- psychiatric

- vestibular

- cervicogenic

cervicogenic dizziness

specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activities from the neck

- sensory mismatch between somatosensory from neck and input from visual/vestibular

- related to trauma, degenerative processes, inflammation or mechanical disorder's

causes of abnormal input

ROM, joint dysfunction, neuromotor dysfunction, hyperalgesia, whiplash, etc

- we don't move = mechanoreceptors and brain stop paying attention to it

goal for reflex connections

get our head and eyes where they need to be at the right time and amplitude

1. VOR may be impaired

2. cervico-ocular reflex can upregulate if VOR impaired

3. cervico-collic reflex: allows for head to stay stable when body is moving

consequences of impaired cervical afferent input

- sensory mismatch -> disturbances in sensorimotor control

- afferent input can be either increased or decreased

- dizziness/unsteady, visual disturbances, tinnitus

things to exclude first of cervicogenic dizziness

- cervical fracture

- central disorders

- cervical artery disorders

- cervical myelopathy

- cervical instability

diagnosing cervicogenic dizziness

- intermittent dizziness precipitated by head and neck movement

- onset of sx is immediate w/ provoking position

- associated s s/x include neck pain, suboccipital headache, occasional trigeminal paresthesias

- hx of c/s trauma or degeneration

- upper c/s mobility deficits

- (+) neck torsion test and joint position error test

cervical torsion test

eyes closed to take away visual afferents and head stabilized to take away vestibular afferents

(+) if pt returns to neutral and opens eyes, patient reports:

- dizziness, visual disturbances, unusual eye movements, speech disturbances, motion sickness/nausea, headache, paresthesia

CGD treatment

manual therapy

- significant improvement at short term and 12 months

- helps pain, dizziness intensity