Kathleen’s story – Whiplash
Kathleen is a 53 year old woman who had a car accident. Her car was stationary while she was waiting to make a right turn when she was hit from behind by another car. At the time she felt shocked and shaken and noticed mild aching in her neck. However over the next 2 months she developed severe pain in her neck and head with a constant headache and had dizziness when she moved her head suddenly. She had seen an orthopaedic spinal surgeon who had sent her for an MRI scan and reviewed her with the results. He told her that there was no nerve damage or fractures in her neck and recommended physiotherapy.
In 2005, the Chartered Society of Physiotherapy in the UK published guidelines on the physiotherapy management of people with Whiplash and related disorders. These guidelines have synthesised research literature and also expert opinion to produce a set of recommendations for assessment and treatment. At EBTC we use these guidelines and also more recent research to help us to effectively manage this complex condition.
When I first assessed Kathleen, one of the most obvious features was that she was hardly moving her neck. Rather than turning her head and neck she was rotating her trunk. She was extremely anxious about flaring up the pain and causing more damage. In addition there was weakness of the neck muscles and tenderness at almost all of the joints of the neck. Associated with this was a reduction in the control and co-ordination of head and neck movements. She also scored very highly on the Patient Catastrophising Score – meaning that her worry about her condition was very significant – a factor that has been shown to be associated with poorer outcomes from injuries. On further questioning, Kathleen confided that she was fearful of driving again, was having nightmares and found it difficult to stop thinking about the accident.
Some people with Whiplash have significant psychological problems related to their accident. In fact post-traumatic stress disorder (PTSD) is not uncommon and it has been shown that those who are suffering from symptoms of PTSD such as nightmares, flashbacks and severe anxiety have a much poorer prognosis for recovery. Therefore it is very important to screen for these problems before commencing physiotherapy as it has been shown that these patients will not improve with physiotherapy until the psychological problems are under control. Kathleen was given a questionnaire to complete called the Impacts of Events Scale and because her score indicated that she had PTSD, I referred her to see a Clinical Psychologist.
Following assessment by a Clinical Psychologist, Kathleen commenced a course of cognitive behaviour therapy. Within 6 weeks, she and her therapist thought that although she was still undergoing psychological treatment, she could now commence physiotherapy too.
When I reassessed her, I found that there had been some improvement in the ability to move the head and neck and she was less fearful of these movements. She could now commence treatment for the muscle weakness and neck movement control and co-ordination problems. Her physiotherapy treatment involved the following phases:
1) Interventions to reduce pain and improve movement
As recommended by the CSP guidelines, Kathleen had a few sessions of manual therapy treatment and she was given gentle exercises to carry out at home.
The manual therapy (which involved mobilisation of the neck joints and also soft tissue treatment) helped to provide pain relief and a window of opportunity for her to improve her neck movements with exercises. She responded well to the treatment and after 3 sessions reported feeling approximately 40% improved and the constant headache that she had been experiencing reduced so that now was only intermittent.
2) Improving co-ordination and control of neck movements
There is a growing body of research that demonstrates that people with neck pain move their head in a less controlled way. The movement can be jerky, inaccurate, slow and lack precision. At EBTC, we use a novel system devised by Chris Worsfold to re-train these subtle movements.
Kathleen demonstrated good improvements in the movement control of her head and neck and an associated improvement in her pain levels. After 6 weeks of treatment she now felt 70% better and crucially she was only getting very occasional dizziness if she had a very busy and active day or moved very suddenly.
3) Improving strength and function and general conditioning
Most patients with Whiplash dramatically reduce their activity levels because they find that any physical activity makes the symptoms worse. This results in marked reduction in fitness and general conditioning which in turn can lead to increases in pain. Kathleen was no exception and was stuck in this vicious cycle.
Therefore the next phase of her treatment was to capitalise on the improvements in movement, co-ordination, pain and dizziness by integrating gentle aerobic exercise into her physiotherapy programme. We chatted about what types of exercise would suit Kathleen and came up with a tailored plan. Kathleen had an old static exercise bike that was gathering dust in her garage. She moved this into her sitting room and initiated a gently progressive programme which dove-tailed in with one of her interests – watching Coronation Street. Every time Coronation Street (which she watched religiously) was on, she would get on her exercise bike and gradually build up the time she cycled for. During the breaks, she would do her physiotherapy co-ordination and control exercises.
In this manner, Kathleen improved her stamina, conditioning and general fitness and also found that she was getting less pain. Over time she got 90% resolution of her symptoms.
She also completed her course of cognitive behaviour therapy with the Clinical Psychologist and was no longer having nightmares or anxiety and was back to driving regularly.
