INSTABILITY / TRAUMATIC

SYNDROME

Outcomes Be familiar with the mechanism of a

instability / traumatic syndrome. To be familiar with the clinical presentation

of a typical patient with acute instability syndrome.

Be familiar with the most widely used medical as well as physiotherapy treatment protocols for a patient with a typical acute / sub-acute and chronic instability syndrome.

Be familiar with the possible pathological changes associated with an instability syndrome.

Outcomes Be familiar with the clinical presentation of

a typical patient with an instability syndrome.

Be familiar with the associated symptoms experienced by a patient with a typical instability syndrome.

Causes Trauma as a result of a motor-vehicle

accident or sport injury

Degenerative in the articular complex

Leads to irregular patterns of comparable signs and a variety of signs and symptoms

Hyperextension injuries Acceleration when a car is hit from behind

The seat with the lower body accelerates forwards

The neck is unstable and can not control the movement of the head

The neck moves into sudden extension – reflex contraction of the neck flexors causes the neck to go into flexion

Hyperflexion injuries Deceleration when a car is brought to a

stand still due to the collision

Head and neck continues to move forwards causing hyperflexion until the chin bumps against the chest

Reflex contraction of the extensors causes extension

General If the neck is rotated when the collusion

occurs an excessive amount of lateral flexion and rotation will take place

Normal physiological ranges is exceeded and this leads to damage and anatomical changes of the soft tissue

Structures that are damaged Ligaments

Intervertebral disc

Facet joints

Surrounding muscles

Haematoma of especially the m sternocleidomastoïd

Symptoms Pain during rest especially if the structures

are placed on stretch

Pain through entire range of movement

Muscles are painful during stretch and contraction

Ligaments are painful when placed on stretch (except the interspinal ligament which is painful during extension)

Treatment: Acute Total bed-rest for first 2-3 days Supportive, soft neck support (when patient is

in an upright position) Ice for first 24 hours Heat is contra-indicated for first 48 hours

(Afterwards damp heat) Anti-inflammatory medication and muscle

relaxants Careful, active non-weight bearing exercises

(except rotation and lateral flexion) Gentle massage

Treatment: Sub-Acute Symptoms become more specific Wean from neck support – still use support in a

vehicle of when neck feels tired Ultrasound and damp heat/ice Mobilisations – short of pain Cautious isometric exercises Increase active exercises (introduce flexion and

extension into exercise programme) Commence with PNF patterns if pain will allow Cautiously commence with distal neural

mobilisations

Treatment: Chronic Treat according to signs and symptoms Pain at end of range (6-8 weeks after injury) Totally wean from neck support Isometric exercises are progressed into

standing Evaluate for muscle imbalance and treat

accordingly Make use of combined movements and

neural mobilisation techniques for final rehabilitation

Possible pathological changes Ligament injuries: Anterior longitudinal Posterior

longitudinal Interspinal Disc herniation Fracture : Spinous process Vertebral bodies Tear of the capsule and facet joints with

acute synovitis Tear of the neck muscles

Possible pathological changes (cont)

Tempomandibular joint injuries Retropharingeal heamatoma Oesophageal haemorrhage Sympatic chain injuries Concussion and minor head injuries Vertebral artery damage Thoracic outlet syndrome

Clinical presentation Pain and tenderness over affected structures Referred pain – irritation of nerve root miofascial trigger points scleretome referral (deep

burning pain which feels like it is in the bone itself) Neck muscle spasm Headaches (experienced as a deep pressure

with pounding , nausea , vomiting and photophobia)

Normal range of movement restricted

Clinical presentation (cont) Dysphagia with hoarseness in the acute

phase

Sympathetic signs: Intermittent weak vision Headaches Horner’s syndrome Dizziness: Vertebral artery symptoms Middle ear injuries

Oedema

Horner’s syndrome Miosis (constriction of the pupil) Pytosis (drooping eye) Enophthalmia (sunken eye) Anidosis (loss of perspiration on the one

side of the face)

Clinical presentation (cont) Anterior chest pain: presents as angina becomes worse

with exercise

tender anterior nausea sleeps poorly becomes worse

with coughing and

sneezing Oedema

Associated symptoms Thoracic outlet syndrome Lower backache Head injuries such as concussion Tempromandibular joint injuries Fibromialgia (chronic pain and stiffness in

muscles with local tenderness) Psychosis Depression Difficulty with acceptance

Associated symptoms (cont)

Anxiety Rage Frustration (financial and family) Personality changes and interference in

daily living Post-traumatic stress syndrome

Treatment Analgesics Anti-depressants Surgery Psychiatric treatment