CERVICOTHORACIC MVA:

Transcription

1 CERVICOTHORACIC MVA: TIPS AND PROGRESSIONS FOR BEST OUTCOMES KAREN WALZ, PT, DPT, OCS, COMT, FAAOMPT FREEIMAGES.COM

2 ACUTE MVA KINEMATICS Rear End Collision Mechanics Stage 1- Retraction; "S" Curve Stage 2- Hyperextension Stage 3- Hyperflexion Yoganandan 2013;

3 CASE #1 55 YR OLD MALE, 3 WEEKS POST REAR- END MVA. NECK PAIN 3/10 WITH SUBOCCIPITAL HEADACHE AND CERVICOTHORACIC ACHE. SYMPTOMS AGGRAVATED BY SUSTAINED NECK POSTURES, COMPUTER WORK, DRIVING. SLEEP OK. EASED SOMEWHAT WITH LYING DOWN, ICING. NUMBNESS/TINGLING RT DOMINANT ARM RT 1-2ND FINGERS AND OCCASIONALLY LT THUMB IS PATIENT APPROPRIATE FOR PT? PAIN 'STORY'? DIFFERENTIAL DIAGNOSIS? KEY TESTS? TREATMENT FOCUS? Fortin et al, 2017

4 PAIN 'STORY'- WHAT DRIVES THEIR PAIN SYMPTOMS? Biomechanical, MSK- tissue, system Socioeconomicmotivational, litigation Psychological - coping,stress reactions

5 PAIN DRIVER EARLY INFLUENCE ON OUTCOMES 45% show 'rapid recovery' 39% trend toward 'moderate recovery' 16% trended toward 'poor recovery' and chronic symptoms over 12 months, at 1 month post assessments Sterling et al. 2010; HYPERSENSITIVITY PTSD COLD HYPERALGESIA (cold hyperalgesia test method) PTSD self test Rivest et al 2010 ; Ritchie 2013

6 EMERGING CLINICAL PREDICTION RULE- MVA OUTCOMES >/ 40% NDI >/35 yr old PDS >/ PTSD sc POOR POST-MVA CLINICAL OUTCOMES Ritchie 2013; Rivest et al 2010; PCS

7 CASE #2 39 yr old male, retail IT troubleshooter, involved in rear-end MVA 3 months ago. He complains of mild Lt neck pain 2/10, fatigue, feeling "foggy" (especially with looking up), difficulty concentrating and with some long term memory skills. Imaging negative, gross neuro screen WNL. Mild Lt cerv rotation AROM loss. Past 4 chiro treatments helped neck pain somewhat IS PATIENT APPROPRIATE FOR PT? PAIN 'STORY'? DIFFERENTIAL DIAGNOSIS? KEY TESTS? TREATMENT FOCUS? Mucha, et al 2014

8 DIFFERENTIAL DIAGNOSIS Vestibulo- Oculomotor Dix-Hallpike BPPV VOMS Where to Start? Concussion SCAT 3 Postconcussion Symptom Scale Sensorimotor Joint position sense Neck movement control

9 CASE #3 23 yr old female, involved in side impact collision 2 months ago in commercial parking lot (estimated speed 8 mph). Neck pain 7/10, head feels "heavy" at times (end of work day, lifting head from lying in bed) as receptionist at busy legal office. She worries a lot about her neck "never getting better" IS PATIENT APPROPRIATE FOR PT? PAIN 'STORY'? DIFFERENTIAL DIAGNOSIS? KEY TESTS? TREATMENT FOCUS? Initial imaging & neuro screen negative. PCP prescribed muscle relaxer and OTC pain meds; she feels these helped initially

10 TREATMENT Deep neck flexor activation (CCFT) O'Leary S, Jull G, et al. 2007

11 TREATMENT Deep neck extensor activation Schomacher 2015

12 TREATMENT Somatosensory Kristjannson E et al. 2009

13 Consider the patient's "pain story" SUMMARY KAREN WALZ, PT, DPT Use appropriate screening tools and predictive analytics to help you gauge outcomes and progress of patient Classify and prioritize any multiregional or multi-system diagnoses to progress your plan of care Treat acute neuro/vestibulo-ocular symptoms and MSK to allow full progression to functional activity Give the patient tools 'for success' in long term management

14 References: OPTA MVA 3/11/2017 course Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefining whiplash and its management. Spine. 1995; 20(8S): 1S-2S. Sterling M. Physiotherapy Management of whiplash-associated disorders (WAD). Journal of Physiotherapy. 2014; 60: Yoganandan N, Stemper BD, Rao RD. Patient Mechanisms of Injury in Whiplash-Associated Disorders. Seminars in Spine Surgery. 2013;25: Rushton A. et al.international framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopedic Manual Therapy. Manual Therapy. 2014; (19)3: Fortin M, Dobrescu O, Courtemanche M, Sparrey CJ, Santaguida C, Fehlings MG, Weber MH. Association Between Paraspinal Muscle Morphology, Clinical Symptoms, and Functional Status in Patients With Degenerative Cervical Myelopathy. Spine Feb 15; 42(4): Sterling M, Hendrikz J, Kenardy J. Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: A prospective study. PAIN 150 (2010) Elliott, JM. Are there implications for morphological changes in neck muscles after whiplash injury? Spine. 2011;36(25S):S205-S210. Ritchie C, Hendrikz J, Kenardy J, Sterling M. Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury. PAIN. 2013; 154: Rivest K, Cote JN, Dumas JP, et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Man Ther 2010 ; 15 : M.J.L. Sullivan, S. Bishop, J. Pivik. The pain catastrophizing scale: development and validation. Psychological Assessment, 7 (1995), pp Mucha A, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med Oct; 42(10): O'Leary S, Jull G, Kim M, Vicenzino B. Specificity in retraining craniocervical flexor muscle performance.j Orthop Sports Phys Ther Jan; 37(1):3-9. Schomacher J, Erlenwein J, Dieterich A, Petzke F, Falla D. Can neck exercises enhance the activation of the semispinalis cervicis relative to the splenius capitis at specific spinal levels? Manual Therapy 20 (2015) Kristjansson E & Treleaven J. Sensorimotor Function and Dizziness in Neck Pain: Implications for Assessment and Management. JOSPT. 2009; 39 (5):