Physiotherapy in a Whiplash Injury : A Case Report

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, forcing the back of his head into the head support. Past history was unremarkable 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, dizziness, diplopia, dysarthria, dysphagia or drop attacks. Cervical spine x-rays taken at the emergency room were unremarkable and he was discharged with a prescription for pain medicine. Since pain was increased to 6/10 by standing or sitting 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 functional 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 guideline for WAD advises that the physical examination should include general


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 musculoskeletal 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 activities 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 physical as well as psychosocial well-being.

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 accident.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 observation, regional examination, range of motion, quality of movement, symptom provocation, muscle strength and cervical proprioception.

THE PHYSICAL EXAMINATION Observation:
The patient lacked spontaneous 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 cervical 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 tempe 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 examination 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 evaluation, 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 education on behavior modification, quick return to ADL and reducing a patient's dependence on medicine.Positive outcomes 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 functional 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 proprioceptive and kinesthetic rehabilitation are based on studies described by Soderlund et al.
The patient was treated for six sessions over a 14-day period.Table 2 is a summary of the outcome measures before and after physiotherapy interv 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 experience.Following a rear-impact collision of only 5x gravitational force (gs), a significant increase in the inter-vertebral neutral zone and range of motion occurs, leaving the lower cervical spine, specifically 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

Home Program
Neural tissue stretching using "sliders"

Figure 1 .
Figure 1.The patient's proprioceptive progression from large to small circles.

Table 1 : Physiotherapy intervention and each sessions' outcome in session one through six.
Table 1 continued on next page