This course will examine this patient and attempt to explain why such a poor outcome is the rule rather than the exception in many whiplash and non-whiplash patients.

The post-whiplash patient who is either having recurrent problems or who simply is not improving is one of the most difficult problems encountered by the physical therapist. Why is there a lack of improvement? Radiographs, MRI, and other studies fail to detect any obvious structural deficit and segmental examination frequently fails to establish extraordinary dysfunctions that would explain the spectacular lack of recovery. In almost every respect this long-term sufferer of neck pain, thoracic pain, headaches and arm pain appears to be a standard non-traumatic cervical patient who would normally respond within a few sessions of specifically applied treatment.

This course will examine this patient and attempt to explain why such a poor outcome is the rule rather than the exception in many whiplash and non-whiplash patients. In order to explain this phenomenon, all locomotor systems, not just the orthopedic, must be addressed. Consequently, this course will deal with the examination and treatment of the neurological, neurophysiological, equilibrium and other somatosensory systems in addition to the musculoskeletal system.

Objectives

At the end of this course, the involved student will be able to:

1. understand and discuss the anatomy of the neurological system as it pertains to the whiplash patient particularly the brain stem
2. understand and discuss the anatomy of the musculoskeletal system of the craniovertebral, the cervical spine and the upper thoracic spine as they pertain to the whiplash patient
3. understand and discuss the anatomy and pathology of the carotovertebrobasilar system as it pertains to the whiplash patient
4. understand the neurophysiology of pain and pain modulation as it pertains to the whiplash patient
5. understand the physiology and pathophysiology of balance as it pertains to the whiplash patient
6. understand the common and uncommon pathologies of long term cervical whiplash disorder including:
   1. neck pain
      1. rim lesions
      2. facet joint lesions
      3. disc herniations
      4. instability
      5. upper thoracic facet and transverse segmental dysfunctions
      6. covert fractures
      7. muscle hypertonicity
      8. circumferential nerve root hemorrhagic fibrosis
   2. headache
      1. posttraumatic migraine
      2. intracranial dural adhesions
      3. cervicogenic
      4. posttraumatic occipital neuralgia
   3. arm pain
      1. cervical referral
      2. “adverse neural tension”
      3. radiculopathy
      4. local injury
   4. concusion and other types of head injury
   5. vertigo and dizziness
      1. vertebrobasilar ischemia
      2. labyrinthine concussion
         1. posttraumatic otoconic displancement (BPPV)
         2. traumatic hydrops
         3. perilymph fistulae
         4. middle ear compromise
      3. cervicogenic
      4. post-concussion
      5. iatrogenic
   6. disequilibrium
      1. neurological
      2. neurophysiological
   7. chronic pain syndromes
   8. cervicovestibular dysreflexia
7. understand the principles and concepts of the biomechanics and pathomechanics of the cervical and upper thoracic spine in long term neck pain
8. within the context of the orthopedic therapist, understand the principles of, carry out and be able to interpret the examinations for:
   1. the musculoskeletal system
   2. the spinal segments
   3. the brain stem
   4. the spinal cord, nerves and roots
   5. the vestibular system
   6. the neurovascular system
   7. the balance system
   8. the cervicovestibular reflexes
9. understand the indications for referral to a specialist or back to the physician
10. identify and appropriately manage the following conditions:
    1. acute and chronic inflammation
    2. cervical and thoracic facet joint hypomobility
    3. cervical and thoracic facet joint hypermobility
    4. segmental instability
    5. BBPV
    6. neurovascular dizziness*
    7. radiculopathy
    8. “adverse neural tension”
    9. balance disturbances
    10. cervicovestibular dysreflexia
    11. non-BBPV vestibular dysfunctions*
    12. fibromyalgia and other chronic pain syndromes*
11. The following treatment techniques will be discussed, presented and practiced:
    1. manual cervical traction
    2. segmental mobilization
    3. segmental and regional stabilization
    4. reducing tone
    5. stretching structurally tight tissues including the upper limb neural tissues
    6. strengthening structurally weak muscles
    7. Epley’s maneuver
    8. balance exercises
    9. phasic eye exercises
    10. basic vestibular techniques
    11. movement pattern re-education exercises

*the specific treatment is beyond the scope of this course and management refers recognition and referral back to the physician or to a specialist therapist.

Topical Outline

The following subjects will be presented and where appropriate practiced.

1. Clinical reasoning strategies for the therapist in referred and direct patient care pertaining to chronic neck pain, headaches and dizziness including:
   1. Hypothetic-deductive reasoning
   2. Evolving algorithms
   3. Pattern recognition
   4. Pathognomia
2. The etiologies of chronic neck pain, headaches and dizziness including:
   1. Trauma from MVA, sports and industrial injury, falls etc
   2. Idiopathic causes
   3. Neurological, cancer, and orthopedic diseases
3. The mechanics of the MVA and their relationship to ongoing pain states
4. Long lasting pathologies
5. Serious pathologies
6. Segmental dysfunction
7. Combined mechanical and neurophysiological dysfunction resulting in long lasting pain
8. Differences between long term pain and chronic pain states
9. Differential diagnosis from the subjective and objective examinations
10. Neurovascular and ligamentous stability examinations
11. Segmental examination including that for pathomechanical dysfunction and for neurophysiological dysfunction
12. Segmental neurophysiological and pathomechanical treatments
13. Prognosis
14. Rehabilitation after manual therapy