Whiplash injuries sign

Whiplash.

Bismillahirahmanirahim.

Definition and Introduction.

Imagine yourself driving when a car behind you rear-ends your

vehicle. The impact pushes your car forward. It takes about 100

milliseconds for your body to catch up to the forward movement.

Your shoulders travel forward until they are under your head, and

Your neck extends forward as your head tilts slightly down toward

Your steering wheel. You step on the brakes, bringing the car to

an abrupt halt. The sudden stop throws your head and neck

backward, and they bounce against the headrest.

In a matter of seconds, you've experienced the classic mechanism of injury for

whiplash.

Anatomy Of lessons

l  7 cervical vertebrae:

·         C1  = Atlas

·         C2 = Axis

·         C7 = Vertebra Prominens

·         C3-C6 = Typical vertebra

l  Ligaments assist stability and allow mobility:

·         Anterior longitudinal ligament

·         Ligamentum nuchae – protects the joints posteriorly

·         Ligamentum flavum – important as very elastic and assists in the neck’s return to upright posture from flexion.

·         Posterior longitudinal ligament

l  Intervertebral discs:

·         Help transmit load

·         5mm thick (thinnest of all the discs)

·         Collagen content is higher in the cervical nucleus and exists for a relatively short period of time                     

Information

Whiplash neck sprains are common

About 2 in 3 people involved in car crashes develop neck pain.

Even slow car bumps may cause enough whipping of the neck to cause symptoms.

Less commonly, whiplash neck sprains can occur with everyday activities such as jolting of the neck when you trip or fall.

80% of patients reporting symptoms following a car crash will be better within 3-4 weeks

Mechanism Of whiplash.

·         At the moment of impact the head is first thrown backward as the vehicle is suddenly jolted forward, often without warning.

·         This is followed by rebound flexion of the neck, often so extreme that the chin reaches the sternum, and by a second extension movement.

·         There will be a strain of the deep muscles and ligaments of the cervical spine.

·         If the head happens to be turned to one side at the moment of collision, there will also be a strain of the lateral muscles (mainly trapezius) on the side to which the head is turned.

  

  Signs & Symptoms

·         Often there is no severe pain initially and the patient may think they have escaped injury. This is because it can take a while for inflammation to build up around the injured muscles

·         However, within hours of the injury, sometimes as late as a day or more later, there is increasing pain and ‘stiffness’ in the back of the neck, often with pain also to the top and back of one or other shoulder.

·         The neck pain is usually accompanied by severe headache, which may be persistent. Other symptoms can include blurred vision and tinnitus (these may be caused by the impact of the brain being moved from side to side)

What will you do

·         When a patient is brought into A&E having sustained whiplash, the neck is x-rayed, if there is any suspicion of a fracture, the patient will remain in collar and blocks until reviewed by an orthopaedic consultant, sometimes this can be the next morning.

·         If the patient is still painful on palpation over the suspicious area, an MRI scan will be done to rule out more serious injuries.

·         Once serious injury has been ruled out and the collar and blocks have been removed, the

·         physiotherapist can see the patient

Physiotherapy Management

1.      The patient may have been lying flat for quite a while and it is important to help them sit up gradually.

2.      Give advice on posture, sleeping positions etc. warn the patient that often the pain gets worse before it gets better

3.      Advice re ice if required

4.      Advice re regular ROM exercises, as pain allows, and importance of doing them. OPD if required

5.      Sometimes, if in severe pain patients will be given a soft collar to take home, important to tell them this is only for a couple of days max and they need to remove regularly to exercise.

Outcome

·         Over 75% of people with whiplash get better over a few weeks

·         In about 1 in 4 cases there is still some pain or stiffness after six months

·         A few people develop continuing symptoms after whiplash trauma – “whiplash syndrome”

·         In a very small number of people symptoms can persist for months if not years

Technique of Prevention

72% of front seat drivers fail to adjust their head restraints correctly or have head restraints incapable of offering any protection.

To be effective, a head restraint must be as close to the back of the head as possible (touching is best) and the top of the head restraint should be as high as the top of the head

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Chest percussion to remove secretion for baby

Percussion Therapy and Postural Drainage

Bismillahirahmanirahim

Definitions

·         Postural drainage is a technique in which different positions are assumed to facilitate the drainage of secretions from the bronchial airways.

·         Gravity helps to move the secretions to the trachea to be coughed up easily.

·         The goal of postural drainage and manual therapy is to help drain mucus from each of these lobes into the larger airways of the lungs so it can be coughed up more readily.

Anatomy of the Lungs

The lungs consist of 5 lobes -- 3 on the right and 2 on the left side of the chest cavity, each of which are further divided into segments.  To be most effective, postural drainage should be accompanied by chest physiotherapy, which includes percussion and vibration, deep breathing and coughing.

Once a patient assumes the correct postural drainage position, the caregiver performs chest  percussion and vibration to the desired area.

 Chest physiotherapy is generally performed for 3 to 5 minutes on each segment. During this time, the patient is encouraged to take a slow, deep breath followed by a vigorous cough in an attempt to clear the airways of mucus. This technique should be repeated several times during the chest physiotherapy session.

Percussion

Chest percussion, also referred to as chest physiotherapy, is an airway clearance technique that involves clapping on the chest and/or back to help loosen thick secretions. Doing this makes mucus easier to expel, or cough up. Chest percussion is often coupled with postural drainage and vibration and can be performed using either cupped hands or a mechanical airway clearance device.

Vibration

Vibration is an airway clearance technique that, coupled with chest percussion, is applied during postural drainage to help  clear mucus from the airways. Vibration helps to gently shake mucus and secretions into the large airways, making them easier to cough up. During vibration, place your flat hand firmly against the chest wall, atop the appropriate lung segment to be drained. Stiffen your arm and shoulder, apply light pressure and create a shaking movement, similar to that of a vibrator.

Ask service user  to breathe in deeply during vibration therapy, and exhale slowly and completely. Taking a deep breath and then exhaling slowly and forcefully without straining will hopefully stimulate a productive cough.

Upper lobes/Apical Segments

To drain mucus from the upper lobe apical segments, the patient sits in a comfortable position on a bed or flat surface and leans on a pillow against the headboard of the bed or the caregiver. The therapist percusses and vibrates over the muscular area between the collar bone and very top of the shoulder blades (shaded areas of the diagram) on both sides for 3 to 5 minutes. Encourage the service user to take a deep breath and cough during percussion in order to help clear the airways. Do not percuss over bare skin.

Upper Lobes /Posterior segments

The Patient sits comfortably in a chair or the side of the bed and leans over, arms dangling, against a pillow. The therapist percusses and vibrates with both hands over upper back on both the right and left sides.

Upper lobes/ anterior segments

The patient lies flat on the bed or table with a pillow for comfort under his or her head and legs. The therapist percusses and vibrates the right and left sides of the front of the chest, between the collar bone and nipple

Lingula

The patient lies with the head down toward the foot of the bed on the right side, hips and legs up on pillows. The body should be rotated about a quarter-turn towards the back. A pillow can also be placed behind the service user and their legs slightly bent with another pillow between the knees. The therapist percusses and vibrates just outside the nipple area.

  

Middle Lobe

The Patient lies head-down on his left side, a quarter-turn toward the back with the right arm up and out of the way. The legs and hips should be elevated as high as possible. A pillow may be placed in back of the service user and between slightly bent legs. The therapist percusses and vibrates just outside the right nipple area.

Lower Lobes/ Anterior basal segments

The Patient lies on his right side with his head facing the foot of the bed and a pillow behind his back. The hips and legs should be elevated as high as possible on pillows. The knees should be slightly bent and a pillow should be placed between them for comfort. The therapist percusses and vibrates over the lower ribs on the left side, as shown in the shaded part of the diagram. This should then be repeated on the opposite side, with percussion and vibration over the lower ribs on the right side of the chest.

  

Lower lobes/posterior basal segments

The Patient Lies on his or her stomach, with the hips and legs elevated by pillows. The therapist percusses and vibrates at the lower part of the back, over the left and right sides of the spine, careful to avoid the spine and lower ribs.

Lower lobes/Lateral basal segments

The patient lies on his right side, leaning forward about one-quarter of a turn with hips and legs elevated on pillows. The top leg may be flexed over a pillow for support and comfort. The therapist percusses and vibrates over the uppermost portion of the lower part of the left ribs, as shown in the shaded area. This should then be repeated on the opposite side, with percussion and vibration over the uppermost portion of the right side of the lower ribs.

Lower Lobes/ Superior Basal Segments

For this position, the patient lies on his stomach on a flat bed or table. Two pillows should be placed under the hips. The therapist percusses and vibrates over the bottom part of the shoulder blades, on both the right and left sides of the spine, avoiding direct percussion or vibration over the spine itself.

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Best Exercise for Diabetic people

Physical Activity and TypeII Diabetes

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What we need to know

q  It is now generally considered that

physical activity should play a key role

in the management of individuals with

diabetes 1,2.                   

q   However there are a

number of factors that people with type

II diabetes should be aware of prior to

beginning an exercise program or

increasing activity levels.

Contraindications

You should not begin an exercise program and you should seek medical advice if you have

v  Unstable angina

v  BP >200/100

v  Significant drop in BP during activity

v  Febrile illness

v  Uncontrolled glycaemia

v   

Recommendation One

A medical history and physical

examination should be performed

by your GP prior to commencement.

¨  Reasons: Different stages of Type II

¨    diabetes can present unique problems that may need to be highlighted prior to an exercise routine so that appropriate modifications can be made. For example peripheral and autonomic neuropathy.

Physical activity programs

        For those with type II diabetes without significant complications or limitations should include arrange of endurance and resistance exercises.The following recommendations will help you to decide

¨  how much exercise you need,

¨  how hard it should be,

¨  how often you should do it and

¨  what to expect as you become more physically active.

Frequency (How much is enough?)

¨  Research suggests at least three

Non consecutive days and up to five physical

activity sessions each week to improve

cardiovascular endurance

Intensity (How hard?)

¨  Research suggests low-to-moderate

intensity physical activity (RPE 10-12)

¨  Due to potential autonomic changes or

medications is may not be appropriate to use

heart rate as a guide of intensity therefore the

BORG rate of perceived exertion scale is

suggested as an easy means of self

assessment.

BORG Scale RPE

Example of exercise

Time (How long?)

¨  New to exercise or long lay off ?– start with

10-15mins. Gradually increase this over the

coming session until you can manage 30

minutes.

¨  If weight loss is a goal then gradually increase

the sessions to 60 mins of low-moderate

Exercise.

Type (what sort of exercise ?)

Should be enjoyable but allow for good control

over intensity.

¨  Combining with personal

hobbies/interests is better. E.g. bird watching –

may involve long varied walks at the weekend.

¨  Walking is the most popular activity but such

conditions as peripheral neuropathy or

degenerative arthritis may require alternatives.

¨  That are non-weight bearing such as swimming

and cycling Resistance training to improve muscle mass,

muscle strength and endurance also has been

shown to decrease risk factors for

cardiovascular disease

Guideline for exercise

¨  Guidelines suggest 2 days a week of 8-10

exercises involving major muscle groups.

one set of 10-15 repetitions to near fatigue is

suggested as a good place to begin.

¨  However as poor technique or unfamiliarity with

machines is common then appropriate screening

and supervision is recommended prior to

commencing. Particular caution should be taken

with retinal and cardiovascular complications

Recommendation Before and After Exercise

¨  Ensure you have proper fitting footwear that is suitable for the activity you are doing.

¨  Monitor your feet before and after exercise for signs of blisters or damage

¨  Get your feet checked regularly.

Awareness..

¨  If taking insulin you need to be aware of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), both of which have implications for exercise

¨  Factors affecting low blood sugar levels are the intensity and duration of the exercise, dose and timing of insulin , time of day and environment

¨  Make sure you monitor glucose levels before and after exercise and during exercise of greater than 60 mins. 1 You may need to alter insulin levels or increase carbohydrate.

¨  For high blood sugar (blood glucose levels above 15mmol/l) prior to activity it is suggested physical activity should be postponed until normal levels return.

¨  Don’t forget to adequately hydrate prior to, during and after exercise. D R I N K.

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Nerve Facial Palsy Tester Procedure

Traumatic head injury with facial palsy

Bismillahirhmanirahim

Introduction

·         Incidence of cranial nerve injury among head trauma patients ranges between 5 and 23 percent

·         The CNI (olfactory nerve), CNVII (facial nerve), and CNVIII (acoustic nerve) cranial nerves are the ones most frequently affected.

·         The facial nerve (CN VII) :most commonly damaged motor cranial nerve. [6]

·         Lower motor neuron facial palsy type.

Facial nerve (CNVII)

·         Primary motor cortex (above parietal lobe).

·         Emerges from brainstem between pons and medulla

·         Existing from stylomastoid foramen

·         Enters the parotid gland.

·         Two main divisions.

Traumatic injuries to the facial nerve

·         By site:

o   Extracranial

o   Intratemporal

o   Intracranial

·         By type of trauma:

o   Penetrating

o   Non-penetrating

o   Iatrogenic

Extracranial facial nerve injury

·         Injured at any point after its exit from temporal bone at the stylomastoid foramen.

·         Causes:

o   Laceration

o   stab wounds

o   gunshots

o   soft tissue avulsion

o   contusion

·         Temporal division:

o   Protect cornea from eyelid weakness

·         Mandibular division:

o   Prevent drooling resulting from lower lip weakness

o   If primary repair is not possible in first 3 days, the optimal time for repair may be at 21 days after injury

Intratemporal facial nerve injury

·         Disrupting

o   bony

o   membranous labyrinth

o   the inner ear

o   facial nerve

·         Non-penetrating injury

o   Transverse fracture (hearing loss)(20%)

o   Longitudinal fracture(50%)

o   Mixed fracture

·         Penetrating injury

o   Gunshot or stab wound

o   Suspicion of vascular injury of sigmoid or lateral sinus, jugular vein or carotid system.

·         Most commonly occurs during

o   Resection of an acoustic neuroma

o   Tumor of the cerebellopontine angle (CPA)

o   Iatrogenic

Facial Nerve lesion

·         Forehead muscle function receives bilateral innervations from the motor cortex

·         Lower face receives contralateral innervation from the motor cortex

Distinguish level of Facial Nerve lesion

·         Upper Motor Neuron (UMN) /Central type

o   Paresis over contralateral side, lower part of face.

o   Unless bilateral lesion, does not affect forehead

o   Mouth paralysis is overcome by emotional expression

·         Lower Motor Neuron (LMN) /peripheral type

o   Paresis over ipsilateral forehead and lower face

o   Bell’s palsy

Facial Motor Exam

·         Forehead and Upper lid innervations

o   Eyebrow elevation

§  Occipitofrontalis, frontalis part

o   Bridge of the nose wrinkling

§  Procerus

o   Frowning

§  Corrugator supercilii

o   Tight Closing of the eyes

§  Orbicularis oculi

·         Lower Face innervations

o   Lip closing

§  Orbicularis oris

o   Cheek compression

§   Buccinator

o   Natural smile

§  Levator anguli oris

·         General grading procedures:

o   F: functional; appears normal or only slight    impairment

o   WF: weak functional; moderate impairment that  

·         affects the degree of active motion

o   NF: nonfunctional; severe impairment

o   0: Absent

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