Wednesday, December 28, 2011

Whiplash Disorders - Atlanta Chiropractor

Assessment and Treatment of Whiplash Associated Disorders (WAD) in First 12 Weeks

Initial Assessment

Classify the WAD injury. Although higher WAD grades indicate greater severity, poor prognosis is most likely associated with a high Visual Analogue Scale (VAS)/numeric pain score (NPS) >7/10) or high Neck Disability Index (NDI) score (>20/50). The SF-36 may be also be used. Orthopedic & neurological examination. Clinician determines imaging necessity.

Apply recommended treatments.

Seven Day Reassessment

Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are high or unchanged, treatment type and intensity should be reviewed. Other treatments may be considered. The effectiveness of such treatments should be closely monitored and only continued if there is evidence of benefit (at least 10% change on VAS and NDI).

Three Week Reassessment

Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are unchanged, a more complex assessment may need to be considered and treatment type and intensity should again be reviewed. The Impact of Event Scale (IES) may be used as a baseline for psychological assessment. Other recommended scales can be used. If pain and disability are still high (VAS, NPS >5.5) and NDI (>20/50) or unchanged, consider referral to a specialist in Whiplash Associated Disorders (WAD).
A specialist is considered a practitioner with specialized expertise in the management of WAD. These may include chiropractors, medical physicians, pain medicine specialists and other physicians who specialize in WAD. Among other things, if the VAS/NPS and NDI are unchanged, the specialist should undertake a more complex physical and/or psychological examination. They should direct more appropriate care and liaise with the treating practitioner to ensure this is implemented.

Six Week Reassessment

Reassess again at this point. In at least 30% of cases resolution should be occurring, and the process of reducing treatment in these cases should commence or continue. If resolution is not occurring and the VAS/NPS and NDI have not changed by at least 10% from the last review, specialist care should still be followed, or a specialist should be referred to if this has not already been done. Prescribe home programs for functional improvement. Consultation with a whiplash specialist may be needed if pain or disability are still high (VAS, NPS >5.5, NDI >20/50) or unchanged.

Three Month Reassessment

Assessment should Include VAS/NPS and NDI. Resolution usually occurs in approximately 50% of cases. If the patient is still improving, continue treatment; independence should be promoted (e.g., focus on active exercise). In these resolving cases, the patient should be reviewed intermittently over the next six to 12 months until resolution. Prescribe home programs to maintain improvement. Consultation with a whiplash specialist is usually required. At this point, referral to a clinical psychologist may also be considered if the psychological assessment data is markedly below norms (for the IES this means a score of >26 at six weeks after injury).

Coordinated Care

Patients whose VAS/ NPS and/or NDI scores are not improving at this point are likely to require coordinated care that is multidisciplinary. It is likely that a combination of physical, psychological and medical care is required. The primary practitioner should facilitate this process.

Range of Possible Symptoms in Whiplash Disorders

Refer to the original guideline document for a description of the possible symptoms of WAD, which include:
  • Neck pain
  • Headache
  • Radiating pains to the head, shoulder, arms or interscapular areas
  • Generalized hypersensitivity
  • Paresthesia and muscle weakness
  • Symptoms from the temporomandibular joint
  • Visual disturbances
  • Proprioceptive control of head and neck position
  • Vertigo/dizziness
  • Impaired cognitive function
  • Low back pain
  • Carpal tunnel syndrome
  • Double crush syndrome
Delay in symptoms is not uncommon. Symptoms may be delayed for hours, days, or longer.

Physical Examination

Taking Patient History
Taking a patient's history is important during all visits for the treatment of patients with WAD of all grades. A patient's history should include information about: date of birth, gender and education level; circumstances of injury such as relevant crash factors; symptoms, particularly including pain intensity (using the Visual Analogue Scale [VAS] or similar). Stiffness, numbness, weakness and associated extra cervical symptoms; localization, time of onset and profile of onset should also be recorded for all symptoms; disability level, preferably using the Neck Disability Index (NDI). Other scales such as the Functional Rating Index, Patient-Specific Functional Scale, Short Form Health Survey SF-36, or similar may also be used. Such an assessment should be conducted on a patient’s second visit at seven days, if not initially; and prior history of neck problems including previous whiplash injury.
Where appropriate, further assessment to determine psychological status may be undertaken at three or six week review. The preferred tool is the Impact of Event Scale (IES), which is a validated tool. Other scales may be useful. History details should be recorded. A standard form may be used.
Observation (particularly of head position/posture); palpation for tender points; assessment of range of movement (ROM) including flexion (chin to chest), extension, rotation and lateral flexion; neurological testing; assessment of associated injuries; and an assessment of general medical condition(s), including psychological state (as appropriate).
A further, more specialized, physical examination assessment might include: assessment of joint position error; assessment of neck muscle activity; and an assessment of widespread sensitivity (which may include cold sensitivity, pressure pain threshold and/or the brachial plexus provocation test, qualitative sensory perception).
Tools, such as a universal goniometer or inclinometer, can be used to measure neck ROM, and are more reliable than observation.
A standardized form may be used.

History and Physical Examination
  • Date of birth, gender, height weight, blood pressure, pulse rate, education level
  • Prior medical history, general medical condition, and pre-existing conditions
  • Symptoms including stiffness, numbness, onset of symptoms
  • Prior history of whiplash symptoms, neck injury, or pain or chronic pain symptoms
  • Observation of head position and posture
  • Palpation for tenderness in the neck region
  • Cervical range of motion
  • Neurological testing of sensation, reflexes and muscle strength
  • Assess associated injuries and co-morbidities
Baseline Assessment
  • Disability level using self report instrument (NDI)
  • Pain intensity using a visual analogue scale (VAS) or numeric pain scale (NPS)
  • Look for lacerations, fractures, or other abnormalities requiring urgent intervention
  • Note any deformities, swelling, asymmetry, atrophy or erythema
  • Feel the areas of pain and surrounding structures. Examine for tenderness, deformity, crepitus and muscle spasm. Flaccidity, fasciculations and spasticity may indicate nervous system damage. Note particularly sensitive areas of palpation as this may help to determine etiology of pain (e.g., muscular versus facet)
  • Palpate the temporomandibular joints (TMJs) and adjacent musculature, including the masseter and temporalis muscles. Assess these joints by having the patient open, close and move the jaw from side to side. Note any pain, tenderness, clicking, popping or asymmetric jaw movement. Make note of jaw excursion and the location of pain that limits it. Have the patient move the region being tested. If the patient’s movement is restricted, passive movement should be attempted as the pain allows. It may not be possible to passively move the region farther due to pain, but this also allows the examiner to gauge the source of pain, limitation and degree of musculature tautness.
Screening Neurological Motor Exam
The integrity and mobility of the nervous system needs to be examined and tests should include:
  • The integrity of the nervous system including testing myotomes, dermatomes and reflexes when indicated by the distribution of the symptoms
  • Mobility tests may include passive neck flexion (PNF), upper limb tension tests (ULTT), passive knee bend, straight leg raise (SLR) and the slump test.
  • The plantar response should be examined to exclude an upper motor neuron lesion.
  • Tests for clonus should be carried out to exclude an upper motor neuron lesion.
Subluxation Assessment

Vertebral Position Assessed Radiographically; Abnormal Segmental Motion Assessed Radiography
To demonstrate a subluxation based on physical examination, two of the four criteria mentioned below are required, one of which must be asymmetry/misalignment or range of motion abnormality.
  • Pain/tenderness evaluated in terms of location, quality, and intensity; Pain, facet syndrome, trigger points, etc.
  • Asymmetry/misalignment identified on a sectional or segmental level; Asymmetric or Hypertonic Muscle Contraction.
  • Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); Abnormal Segmental Motion/Lack of Joint End-play.
  • Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament; Soft Tissue Compliance and Tenderness.
Special Tests
  • Thoracic outlet syndrome. Various tests for this complex syndrome include the Allen Test, Adson’s maneuver and provocative elevation tests.
  • Upper cervical stability. Test for instability in the presence of certain signs (inability to support the head, dysphagia, tongue paresthesia, a metallic taste in the mouth, facial or lip paresthesia, bilateral limb paresthesia, quadrilateral limb paresthesia, nystagmus, gait disturbance).

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