Management of Whiplash Associated Disorders - International Chiropractors Association of California
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Management of
Whiplash Associated Disorders
International Chiropractors Association of California
The participants in the guidelines development process undertaken by the ICAC are: Charles G. Davis, DC – Editor Joe Betz, DC Art Croft, DC, MS, MPH, FACO Ed Cremata, DC Deed Harrison, DC Hugh Lubkin, DC John Maltby. DC Dan Murphy, DC, DABCO James Musick, DC Bryan Gatterman, DC, DACBR Shad Groves, DC, DACNB Management of Whiplash Associated Disorders Copyright © 2009 by International Chiropractors Association of California All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means without written permission from the author. Printed in USA ICA of California 9700 Business Park Drive #305 Sacramento, CA 95827 800-275-3515
Table of Contents Introduction. ................................................................................................................ 1 Assessment and Treatment of WAD First 12 Weeks..........................................14 Range of Possible Symptoms In Whiplash Disorders ........................................16 Examination ...................................................................................................................18 RED Flags .................................................................................................................... 28 Prognosis..................................................................................................................... 30 Criteria for Discharge ............................................................................................. 32 Treatment of Acute Whiplash-Associated Disorders ...................................... 33 Stages of Injury ......................................................................................................... 41 Grades Severity of Injury ........................................................................................ 42 Frequency and Duration .......................................................................................... 43 Complicating Factors .............................................................................................. 45 Treatment Adjuncts .................................................................................................. 46 Chronic Whiplash Pathway> 12 Weeks ................................................................ 47 Course of Recovery .................................................................................................. 48 Mild Traumatic Brain Injury..................................................................................... 49 Outcome Assessments .............................................................................................. 50
Introduction
Injuries from whiplash may give rise to an array of symptoms and complaints. This document is
a combination of research and clinical experience for the primary practitioner in a whiplash
case.
This document provides a structure for the assessment and treatment of people with WAD
during the first 12 weeks following injury and additional care in chronic cases. This document
offers a summary of how to apply the recommendations.
As an individual patient can be considered a case study, all levels of evidence were considered,
not just randomized control trials.
The Institute of Medicine defines clinical practice guidelines as “Systematically developed
statements to assist practitioners’ and patient decisions about appropriate health care for
specific clinical circumstances”. Guidelines are also known as “parameters, practice protocols,
practice standards, review criteria and preferred practice patterns”
Field M and Lohr K. Clinical practice guidelines: Directions for a new program. Institute of Medicine.
Washington, D.C. National Academy Press; 1990.
Medicare utilization review (UR) protocols, which were statutorily required to be based upon
“Professionally developed norms of care, diagnosis, and treatment based upon typical patterns
of practice.” (Public Law 92-603, Section 249f, 42 United States Code, Section 1301).
In this document the maxima guidelines are that considered in a
complicated case.
Most injuries should not require the maxing out of these guidelines.
Guidelinesaredesignedtosupportthedecisionmakingprocessesinpatientcare.Thecontentofaguideline
isbasedonasystematicreviewofclinicalevidencethemainsourceforevidencebasedcare.
Purposesofguidelines
x To describe appropriate care based on the best available scientific evidence and broad
consensus;
x To reduce inappropriate variation in practice;
x To provide a more rational basis for referral;
x To provide a focus for continuing education;
x To promote efficient use of resources;
x To Act as focus for quality control, including audit.
It is a guide only and there will always be individual variations.
1
Management of Whiplash Associated Disorders
“Randomizedtrial I.Introduction
informationisrarely
availabletoanswer EachpatientisanNof1clinicaltrial.AnNof1isaclinicaltrialinwhich
questionsofetiology, asinglepatientistheentiretrial,asinglecasestudy.
diagnosis,andprognosis,
We found little evidence that estimates of treatment effects in
andthatonlyaportionof
observationalstudiesreportedafter1984areeitherconsistentlylarger
theclinicalissuesis
than or qualitatively different from those obtained in randomized,
appropriateinformation
controlledtrials.
available.” BensonK,HartzAJ.Acomparisonofobservationalstudiesandrandomized,
SnidermanAD.Clinicaltrials,
controlledtrials.NEnglJMed.2000Jun22;342(25):187886.
consensusconferences,and
clinicalpractice.Lancet.1999 Theresultsofwelldesignedobservationalstudies(witheitheracohort
Jul24;354(9175):32730. or a casecontrol design) do not systematically overestimate the
magnitude of the effects of treatment as compared with those in
randomized,controlledtrialsonthesametopic.
You must answer 5 ConcatoJ,ShahN,HorwitzRI.Randomized,controlledtrials,observational
questions to successfully studies,andthehierarchyofresearchdesigns.NEnglJMed.2000Jun
apply information to your 22;342(25):188792.
individual patient.
The outcomes of the 12 large randomized, controlled trials that we
1. Are the patients in studied were not predicted accurately 35 percent of the time by the
these trials metaanalysespublishedpreviouslyonthesametopics.
sufficiently similar to LeLorierJ,GrégoireG,BenhaddadA,LapierreJ,DerderianF.Discrepancies
mine? betweenmetaanalysesandsubsequentlargerandomized,controlledtrials.N
EnglJMed.1997Aug21;337(8):53642.
2. Do the outcomes make
clinical sense to me? As with many interventions intended to prevent ill health, the
3. Is the magnitude of effectiveness of parachutes has not been subjected to rigorous
benefit likely to be evaluationbyusingrandomizedcontrolledtrials.Advocatesofevidence
worthwhile for my basedmedicinehavecriticizedtheadoptionofinterventionsevaluated
patient? byusingonlyobservationaldata.Wethinkthateveryonemightbenefit
if the most radical protagonists of evidence based medicine organized
4. What are the adverse and participated in a double blind, randomized, placebo controlled,
effects? crossovertrialoftheparachute.
5. Does the treatment fit Individuals who insist that all interventions need to be validated by a
in with my patient’s randomizedcontrolledtrialneedtocomedowntoearthwithabump.
values and beliefs? SmithGC,PellJP.Parachuteusetopreventdeathandmajortraumarelatedto
gravitationalchallenge:systematicreviewofrandomisedcontrolledtrials.BMJ.
WilliamsHC.Applyingtrial
2003Dec20;327(7429):145961.
evidencebacktothepatient.
ArchDermatol.2003 Thereareperhaps30,000biomedicaljournalsintheworld,andthey
Sep;139(9):1195200. havegrownsteadilyby7%ayearsincetheseventeenthcentury.Yet
onlyabout15%ofmedicalinterventionsaresupportedbysolid
scientificevidence.
SmithR.Whereisthewisdom...?BMJ.1991Oct5;303(6806):7989.
2Whiplash Injury No significant correlation was found between deltaV
andtheQTFgradeforanyofthecollisiontypes.There
was no deltaV threshold associated with acceptable
Evidence supports an organic basis for acute and
sensitivityandspecificityfortheprognosisofacervical
chronicwhiplashinjuries.Areviewtheanatomicalsites
spineinjury.
withintheneckthatarepotentiallyinjuredduringthese
ElbelM,KramerM,HuberLangM,HartwigE,DehnerC.
collisions. Include — facet joints, spinal ligaments, Decelerationduring'reallife'motorvehiclecollisionsa
intervertebral discs, vertebral arteries, dorsal root sensitivepredictorfortheriskofsustainingacervicalspine
ganglia,andneckmuscles, injury?PatientSafSurg.2009Mar8;3(1):5.
Clinically, whiplash patients present with neck, Analysis of data revealed that the rear impact vector
shoulder, or back pain; headaches; dizziness; crash resulted in 2.8 times greater head linear
paresthesias; vertigo; or cognitive/ psychological acceleration than frontal crashes. Rear impact crashes
symptoms. resulted in biphasic, complex kinematics compared to
the monophasic, less complex frontal crashes. Rear
Thecervicalfacetjointsarethemostcommonsourceof impactcrasheswereratedmarkedlylesstolerable.Croft
neckpain. AC, Haneline MT, Freeman MD. Low speed frontal crashes
Therearetwofacetjointsbetweeneachpairofcervical and low speed rear crashes: is there a differential risk for
vertebrafromC2toC7.Thefacetjointisasynovialjoint injury?AnnuProcAssocAdvAutomotMed.2002;46:7991.
enclosed by a thin, loose ligament known as the facet Asubstantialnumberofinjuriesarereportedincrashes
capsule. A synovial fold on the inner capsule extends oflittleornopropertydamage.Propertydamageisan
betweenthemarginsofthearticulatingbonysurfaces. unreliable predictor of injury risk or outcome in low
Cervical facet joints are innervated by the medial velocity crashes. Croft AC, Freeman MD. Correlating crash
branches of the dorsal primary ramus from the two severity with injury risk, injury severity, and longterm
levels surrounding each joint. Several histologic and symptoms in low velocity motor vehicle collisions. Med Sci
anatomicstudieshaveidentifiedmechanoreceptorsand Monit.2005Oct;11(10):RA31621.
unmyelinatednociceptorsinthecervicalfacetjoint.
ThefacetcapsulealsocontainsAandCfibers,bothof Healing
whichtransmitnociceptivesingals;i.e.,pain. PhaseI(acuteinflammation)occursduringthefirst72
Nociceptors reactive for substance P and calcitonin hours. There is hematoma formation and acute
generelated peptide have also been identified in the inflammationmanifestedbyswelling,redness,warmth,
cervicalfacetcapsules. andpain.
Phase II (repair and regeneration) lasts from 48 to 72
Magentic resonance and autopsy studies of whiplash hours after the injury until approximately six weeks
patients have documented injuries to the neck after the injury. It is characterized by subsidence of
ligaments and intervertebral discs in addition to the inflammationandthebeginningofhealing.
facetjoints. Phase III (remodeling) requires 12 months or more to
Whiplashrelated symptoms may be due, in part, to become maximal. The healing ligament becomes
injuries of cervical ligaments and discs and their increasingly contracted, and demonstrates increasing
embedded mechanoreceptive and nociceptive nerve tensile strength. The exact timing is unknown in
endings. Ligament injuries may cause acute neck pain humans but laboratory studies (including some in
and lead to chronic spinal instability, and injured primates) indicate that maximum ligament scar
echanoreceptors may corrupt normal sensory signals maturation is not achieved before 12 months. Even
and could lead to abnormal muscle response patterns then,theoriginaltensilestrengthisnotregained(50%
anddecreasedneckmobilityandproprioception. to70%istheprobablerange).
WooSLY,BuckwalterJA.InjuryandRepairofMusculoskeletal
SoftTissues.AmericanAcademyofOrthopedicSurgeons,
1988.pg.106.
3Range of Symptoms from Whiplash
Generalized
hypersensitivity Hypersensitivity
Those with whiplash symptoms may have a
Centralhypersensitivitymayexplainexaggeratedpainin
generalizedhypersensitivity,extendingasfaras thepresenceofminimalnociceptiveinputarisingfrom
minimallydamagedtissues.
the lower limbs, when compared with healthy
CuratoloM,ArendtNielsenL,PetersenFelixS.Evidence,
volunteers.
mechanisms,andclinicalimplicationsofcentral
hypersensitivityinchronicpainafterwhiplashinjury.ClinJ
ItwassuggestedthatWADmightleadtospinal
Pain.2004NovDec;20(6):46976.
cordhyperexcitabilitycausingexaggeratedpain
onperipheralstimulation. There is evidence for spinal cord hyperexcitability in
patients with chronic pain after whiplash injury and in
fibromyalgia patients. This can cause exaggerated pain
following low intensity nociceptive or innocuous
Injury may lead to increases in peripheral stimulation. Spinal hypersensitivity may
neuronal activity and explain, at least in part, pain in the absence of
prolonged changes in the detectabletissuedamage.
nervous system. BanicB,PetersenFelixS,AndersenOK,RadanovBP,Villiger
PM,ArendtNielsenL,CuratoloM.Evidenceforspinalcord
Chronic pain may be seen as hypersensitivityinchronicpainafterwhiplashinjuryandin
part of a central disturbance fibromyalgia.Pain.2004Jan;107(12):715.
accompanied by disinhibition
or sensitization of central pain Findingsdemonstrategeneralizedhypoesthesiainacute
modulation, mirrored in the whiplash associated disorders suggesting adaptive
immune and endocrine central nervous system processing mechanisms are
systems. involved,regardlessofpainanddisability.
ChienA,EliavE,SterlingM.Hypoesthesiaoccursinacute
DavisC,JMPT2001 whiplashirrespectiveofpainanddisabilitylevelsandthe
presenceofsensoryhypersensitivity.ClinJPain.2008Nov
Dec;24(9):75966.
Sensory hypoaesthesia and hypersensitivity coexist in
the chronic whiplash condition. These findings may
indicateperipheralafferentnervefiberinvolvementbut
could be a further manifestation of disordered central
painprocessing.
ChienA,EliavE,SterlingM.Hypoaesthesiaoccurswith
sensoryhypersensitivityinchronicwhiplashfurtherevidence
ofaneuropathiccondition.ManTher.2009Apr;14(2):13846.
Diagramofthe‘GateTheoryofPain.’
Patientswithchronicwhiplashsyndromemayhavea
Melzack,R.andWall,P.D.1965.Pain
generalizedcentralhyperexcitabilityfromalossoftonic
mechanisms:anewtheory.Science150, inhibitoryinput(disinhibition)and/orongoingexcitatory
971–979. inputcontributingtodorsalhornhyperexcitability.
DavisC.Chronicpain/dysfunctioninwhiplashassociated
disorders.JManipulativePhysiolTher.2001Jan;24(1):4451.
4Range of Symptoms from Whiplash
Neck pain
Neck pain is the most commonly reported symptom of WAD.
Furthermore specific segmental zygapophyseal (facet) joint blocks
have demonstrated that the neck and surrounding tissues are the
mostcommonsourceofchronicpainforpeoplewithWAD.People
involved in a rear end motor vehicle accident found the most
commonly reported symptom was neck pain, followed by
headache, neck stiffness, low back pain, upper limb symptoms,
dizziness, nausea and visual problems. Tinnitus,
temporomandibular joint pain, paraesthesia and concentration or
memorydisturbancemayalsobeexperienced.
Radiating pains to the head, shoulder, arms or
Normal referred pain from cervical facets.
interscapular area
Radiating pains to the head, shoulder, arms or interscapular area
are often reported at some time post injury. These patterns of Referred pain is
somatic referral do not necessarily indicate which structure is the perceived in a region
primary source of the pain but rather suggest a referred type of topographically displaced
painfromthefacetsordiscsinthecervicalspine. from the region of the
source of the pain.
Referred pain
LiteratureonreferredpaingoesbacktoHenryHeadin1894.More
recent studies have investigated referred pain from spinal
structuresincludingthefacetsanddiscs. Radicular pain is
HeadH.Ondisturbancesofsensationwithspecialreferencetothepainof produced in the
visceraldisease.Brain1894;17:339–480. distribution of a nerve
KellgrenJH.Onthedistributionofpainarisingfromdeepsomaticstructure root as a result of some
withchartsofsegmentalpainareas.ClinSci.1939;4:3546. sort of mechanical
ClowardRB.Theclinicalsignificanceofthesinuvertebralnerveofthe
compression or irritation
cervicalspineinrelationtothecervicaldisksyndrome.JNeurolNeurosurg
Psychiatry.1960Nov;23:3216. of that root.
HockadayJM,WhittyCW.Patternsofreferredpaininthenormalsubject.
Brain.1967Sep;90(3):48196.
KellgrenJH.Theanatomicalsourceofbackpain.RheumatolRehabil.1977
Feb;16(1):312.
BogdukN,MarslandA.Thecervicalzygapophysialjointsasasourceof
neckpain.Spine.1988Jun;13(6):6107.
O'NeillCW,KurganskyME,DerbyR,RyanDP.Discstimulationand
patternsofreferredpain.Spine.2002Dec15;27(24):277681.
JinkinsRJ.Theanatomicandphysiologicbasisoflocal,referredand
radiatinglumbosacralpainsyndromesrelatedtodiseaseofthespine.J
Neuroradiol.2004Jun;31(3):16380.
SlipmanCW,PlastarasC,PatelR,IsaacZ,ChowD,GarvanC,PauzaK,
FurmanM.Provocativecervicaldiscographysymptommapping.SpineJ.
2005JulAug;5(4):3818.
5Range of Symptoms from Whiplash
Headache Headache
Headache is the second most common
symptom,ofteninthesuboccipitalregionwith Uppercervicalpainand/orheadachesoriginatingfrom
referral to the temporal area. These areas are theC0toC3segmentsarepainstatesthatare
innervatedfromtheuppercervicallevelsandit commonlyencounteredintheclinic.Theuppercervical
was found that 50% of people complaining of spineanatomicallyandbiomechanicallydiffersfrom
headaches had pain arising from the C2/C3 thelowercervicalspine.Patientswithuppercervical
segmentallevel. disordersfallintotwoclinicalgroups:(1)localcervical
syndrome;and(2)cervicocephalicsyndrome.
Chronic daily headache (CDH) is defined by Symptomsassociatedwithvariousformsofboth
headacheon15ormoredayspermonth. disordersoftenoverlap,makingdiagnosisagreat
challenge.Therecognitionandcategorizationof
specificprovocationandlimitationpatternslendto
Trauma to the cervical spine is probably the
effectiveandaccuratediagnosisoflocalcervicaland
mostimportantsinglefactorinthecausationof
cervicocephalicconditions.
chronic headaches. Trauma produces a SizerPSJr,PhelpsV,AzevedoE,HayeA,VaughtM.Diagnosis
mechanical derangement of the structures of andmanagementofcervicogenicheadache.PainPract.2005
the cervical spine which may involve the Sep;5(3):25574.
cervical nerve roots, the cervicocranial
autonomic system, and/or the vertebral This prospective study shows an association of low
vessels.Chronicheadachecanbepreventedby cervical prolapse with cervicogenic headache:
early recognition of the cervical lesion as the headacheandneckpainimprovesordisappearsin80%
cause of the headache followed by adequate ofpatientsaftersurgeryforthe cervicaldiscprolapse.
treatmentdirectedtowardsthecervicalspine. These results indicate that pain afferents from the
BraafMM,RosneRS.Traumaofcervicalspineas lower cervical roots can converge on the cervical
causeofchronicheadache.JTrauma.1975 trigeminalnucleusandthenucleuscaudalis.
May;15(5):4416. DienerHC,KaminskiM,StappertG,StolkeD,SchochB.Lower
cervicaldiscprolapsemaycausecervicogenicheadache:
prospectivestudyinpatientsundergoingsurgery.
Cephalalgia.2007Sep;27(9):10504.
Head or neck injury increases the
risk of chronic daily headache.
Anterior cervical discectomy and fusion appears to be
CouchJR,etal.Headorneckinjury quite effective for discogenic cervical headache, but
increasestheriskofchronicdaily should be reserved for patients who are extremely
headache:apopulationbasedstudy. impairedandrefractorytoallothertreatments.
Neurology.2007Sep11;69(11):116977. SchoffermanJ,GargesK,GoldthwaiteN,KoestlerM,LibbyE.
Uppercervicalanteriordiskectomyandfusionimproves
discogeniccervicalheadaches.Spine.2002Oct
15;27(20):22404.
The risk of developing post-
traumatic chronic daily
headache is greater for less
severe head injury compared
with moderate/severe head
injury.
CouchJR.Headache2001
6Visual disturbances
Injuries to the neck due to whiplash can cause
Visual disturbances are mentioned in the literature. distortionoftheposturecontrolsystemasaresultof
Whiplash was associated with defective disorganizedneckproprioceptiveactivity.
accommodation in the present select group of GimseR,TjellC,BjørgenIA,SaunteC.Disturbedeye
whiplash subjects. Oculomotor function seems to be movementsafterwhiplashduetoinjuriestotheposture
impaired in patients with chronic symptoms of controlsystem.JClinExpNeuropsychol.1996
whiplash injury of the cervical spine. The smooth Apr;18(2):17886.
pursuit neck torsion test to identify eye movement HeikkiläHV,WenngrenBI.Cervicocephalickinesthetic
disturbancesinpatientswithwhiplasharelikelytobe sensibility,activerangeofcervicalmotion,andoculomotor
duetodisturbedcervicalafferentation. functioninpatientswithwhiplashinjury.ArchPhysMed
Visual disturbances occur in 10 to 30% of whiplash Rehabil.1998Sep;79(9):108994.
patients with blurred vision the most common
Theproprioceptivedeficitcausedbyaligamentinjury
symptom.
rarely is due only to sensory and mechanical
Proprioceptive control of head and neck dysfunctionoftheligament.
position
Aligamentinjuryisoftenaccompaniedbydamagesto
Proprioceptive control of head and neck position has other joint structures, e.g. the joint capsule and
been found to be reduced in people after whiplash menisci,implyingthatthedisturbedsensoryfeedback
injury. Individuals who have sustained a whiplash from these structures are likely to contribute to the
injury may have proprioceptive deficits that do not reportedproprioceptivedeficits.
allow them accurately or reliably to calculate head
position. This may be detrimental to their everyday Even in the cases of an isolated ligament injury,
function. The central nervous system (CNS) uses the contributing effects from the surrounding tissue
information provided by the proprioceptors to build
cannot be excluded since the sprained or ruptured
upaninternalreferenceframeofourmusculoskeletal
system and to recalibrate it. Rehabilitation after ligaments induce alterations of the normal
whiplash injury should focus not only on range of biomechanicsofthejoint.
motionandstrengthbutonposturalawareness.
Thereby the loads imposed on different joint
Vertigo/Dizziness structures and muscles will change, causing altered
sensory feedback from mechanoreceptors within and
Posttraumaticvertigorefers todizzinessthatfollows aroundthejoints.
a neck or head injury. There are many potential SjolanderP,JohanssonH,DjupsjobackaM.Spinaland
causesofposttraumaticvertigo.Whiplashclinicallyis supraspinaleffectsofactivityinligamentafferents.J
ElectromyogrKinesiol.2002Jun;12(3):16776.
similar to post concussion syndrome, but with the
addition of neck complaints. Dizziness occurs in 20
60%. Thedatasupporttothenotionofacausalconnection
between the disturbed posture control system and
somecognitivemalfunctions.
Impaired cognitive function
GimseR,BjörgenIA,TjellC,TyssedalJS,BøK.Reduced
Cognitive function may be impaired in WAD with cognitivefunctionsinagroupofwhiplashpatientswith
symptoms as a result of mild traumatic brain injury, demonstrateddisturbancesintheposturecontrolsystem.J
chronic pain, chronic fatigue or depression. The ClinExpNeuropsychol.1997Dec;19(6):83849.
cervicoenchephalic syndrome is characterized by
headache, fatigue, dizziness, poor concentration,
disturbed accommodation (eye movements), and
impairedadaptationtolightsensitivity.
7Thoracic outlet syndrome
Complex Regional Pain Syndrome 1
(Reflex sympathetic dystrophy)
Therearevariousnamesforthoracicoutletsyndrome
Pain 93%
(TOS) including: cervical rib, scalenus anticus,
Hyperesthesia 75%
costoclavicular, hyperabduction, pectoralis minor,
Hypesthesia 69%
bachiocephalic, and fractured claviclerib syndromes, Muscular incoordination 54%
nocturnal paresthetic brachialgia, and effort vein Tremor 49%
thrombosis. Common whiplash TOS symptoms VeldmanPH,ReynenHM,ArntzIE,GorisRJ.Signsand
include: nausea, dizziness, numbness, aching pain, symptomsofreflexsympatheticdystrophy:prospectivestudy
of829patients.Lancet.1993Oct23;342(8878):1012–6.
disorientation, neck stiffness, arm heaviness,
incapacitating headache, easy fatigability of the arm, Double Crush Syndrome
tinglingandnumbnessintheulnaraspectofthehand.
Double crush syndrome means that nerves being
Neck pain 90% irritatedupintheneckoratsomeproximallocationlike
Paresthesia 90% the thoracic outlet (in the shoulder) are causing a
Arm pain 84% peripheral nerve entrapment like carpal tunnel or ulnar
Headaches 80% entrapmentattheelbow.
Shoulder pain 75% The hypothesis was that neural function could be
impairedwhensingleaxons,havingbeencompressedin
Arm weakness 47%
oneregion,becomeespeciallysusceptibletodamagein
Chest pain 10%
another. They postulated that nonsymptomatic
Raynaud's Phenomenon 1–3%
impairment of axoplasmic flow at more than one site
Swelling 1–4% along a nerve might summate to cause a symptomatic
SandersRJ,PearceWH.Thetreatmentofthoracicoutlet
neuropathy. This was suggested by their clinical
syndrome:acomparisonofdifferentoperations.JVasc
Surg.1989Dec;10(6):626–34.
observation that the majority of their patients had a
medianorulnarneuropathyassociatedwithevidenceof
Carpal Tunnel Syndrome cervicothoracicrootlesions.
UptonARM,McComasAJ.Thedoublecrushinnerve
entrapmentsyndromes.Lancet2:359361,1973.
Carpal tunnel syndrome due to compression of the
median nerve in the carpal tunnel syndrome,
commonlypresentswithsensorydisturbanceandpain
Cervical spondylosis and disc prolapsed
in the hand. The most useful diagnostic clues is the
in patients with C5-C6 and C6-C7 were
presence of sensory symptoms at night time relieved
on the same side as the symptoms in the
by changing hand posture. It is also worth
wrists in 50% of the cases.
remembering that carpal tunnel syndrome can
sometimes present with symptoms in an ulnar or The higher incidence of narrowed
radial nerve distribution. There are as many ways of cervical foramens in the patient patients
testing electrophysiogically for carpal tunnel and the concordance with affected nerve
syndrome. A common way is to compare median roots on the same side of CTS, supports
sensory conduction velocity across wrist with ulnar the hypothesis of a double crush
velocity.Thisshouldbesupportedbymeasurementof phenomenon.
motor conduction across the wrist and motor PierreJeromeC,BekkelundSI.Magnetic
conductionintheforearmsegment. resonanceassessmentofthedoublecrush
D’ArcyCA.DoesthispatienthaveCarpalTunnelSyndrome?
phenomenoninpatientswithcarpaltunnel
JAMA2000;283:31103117.
syndrome:abilateralquantitativestudy.ScanJ
PalstReconstrHandSurg.2003;37:4653.
8Structures Injured
Cervical Facets
Cervical Facets
Diagnostic blocks are a valid technique in the
The high yield of positive responders in this study identificationofpainfulzygapophysialjoints.
probably reflects the propensity of patients with BarnsleyL,LordS,BogdukN.Comparativelocal
facet joint syndromes to gravitate to a pain clinic anaestheticblocksinthediagnosisofcervical
when this condition is not recognized in zygapophysialjointpain.Pain.1993Oct;55(1):99106.
conventionalclinicalpractice.
BogdukN,MarslandA.Thecervicalzygapophysialjoints The evidence obtained from literature review
asasourceofneckpain.Spine.1988Jun;13(6):6107. suggests that controlled comparative local
anestheticblocksoffacetjoints(medialbranchor
Both a symptomatic disc and a symptomatic dorsal ramus) are reproducible, reasonably
zygapophysial joint were identified in the same accurate and safe. The sensitivity, specificity,
segmentin41%ofthepatients. falsepositiverates,andpredictivevaluesofthese
BogdukN,AprillC.Onthenatureofneckpain, diagnostic tests for neck and low back pain have
discographyandcervicalzygapophysialjointblocks.Pain.
been validated and reproduced in multiple
1993Aug;54(2):2137.
studies.
SehgalN,DunbarEE,ShahRV,ColsonJ.Systematic
Painfuljointswereidentifiedin54%ofthepatients reviewofdiagnosticutilityoffacet(zygapophysial)
(95% confidence interval, 40% to 68%). In this jointinjectionsinchronicspinalpain:anupdate.Pain
population, cervical zygapophysial joint pain was Physician.2007Jan;10(1):21328.
themostcommonsourceofchronicneckpainafter
whiplash. Manual diagnosis by a trained manipulative
BarnsleyL,LordSM,WallisBJ,BogdukN.Theprevalence therapistcanbeasaccurateascanradiologically
ofchroniccervicalzygapophysialjointpainafter controlled diagnostic blocks in the diagnosis of
whiplash.Spine.1995Jan1;20(1):205;discussion26.
cervicalzygapophysialsyndromes.
JullG,BogdukN,MarslandA.Theaccuracyofmanual
Comparedtoaneutralheadposture,themaximum diagnosisforcervicalzygapophysialjointpain
syndromes.MedJAust.1988Mar7;148(5):2336.
principal strain in the facet capsule doubles on the
sidetowardwhichtheheadisturned.
Stretching the facet joint capsule beyond
Excessive capsular strains experienced by some
physiological range could result in altered axonal
individualsduringsomewhiplashconditionsmaybe
morphologythatmayberelatedtosecondaryor
responsibleforpainfulcapsularwhiplashinjury.
delayedaxotomychangessimilartothoseseenin
SiegmundGP,DavisMB,QuinnKP,HinesE,MyersBS,
EjimaS,OnoK,KamijiK,YasukiT,WinkelsteinBA.Head central nervous system injuries where axons are
turnedposturesincreasetheriskofcervicalfacetcapsule subjected to stretching and shearing. These may
injuryduringwhiplash.Spine.2008Jul1;33(15):16439. contributetoneuropathicpainandarepotentially
relatedtoneckpainafterwhiplashevents.
Facetjointcomponentsmaybeatriskforinjurydue KallakuriS,SinghA,LuY,ChenC,PatwardhanA,
to facet joint compression during rearimpact CavanaughJM.Tensilestretchingofcervicalfacetjoint
accelerationsof3.5gandabove.Capsularligaments capsuleandrelatedaxonalchanges.EurSpineJ.2008
areatriskforinjuryathigheraccelerations. Apr;17(4):55663.
PearsonAM,IvancicPC,ItoS,PanjabiMM.Facetjoint
kinematicsandinjurymechanismsduringsimulated
whiplash.Spine.2004Feb15;29(4):3907.
9Structures Injured
Cervical Discs
Clinical evidence suggests that disc
injury and accelerated degeneration are The results of recent experimental studies suggest
common in whiplash patients. that an injury to the anulus causes secondary
cellularreactioninthenucleuspulposus,similarto
theprocessobservedinhumandiscdegeneration.
Cervical Discs PetterssonK,HildingssonC,ToolanenG,FagerlundM,
Microdissection and histologic studies were BjörnebrinkJ.Discpathologyafterwhiplashinjury.A
undertaken to determine the innervation of the prospectivemagneticresonanceimagingandclinical
cervical intervertebral discs. The cervical investigation.Spine.1997Feb1;22(3):2837;discussion
sinuvertebralnerveswerefoundtohaveanupward 288.
course in the vertebral canal, supplying the disc at
theirlevelofentryandthediscabove.Branchesof A high incidence of discoligamentous injuries was
the vertebral nerve supplied the lateral aspects of found in whiplashtype distortions. Most patients
the cervical discs. Histologic studies of discs withsevere persistingradiatingpain hadlarge disc
obtained at operation showed the presence of protrusions on MRI that were confirmed as
nerve fibers as deeply as the outer third of the herniationsatsurgery.
anulusfibrosus. JónssonHJr,CesariniK,SahlstedtB,RauschningW.
BogdukN,WindsorM,InglisA.Theinnervationofthe Findingsandoutcomeinwhiplashtypeneckdistortions.
cervicalintervertebraldiscs.Spine.1988Jan;13(1):28. Spine.1994Dec15;19(24):273343.
Nerve fibers appeared to enter the disc in the Excessive 150° fiber and disc shear strain occurred
posterolateral direction and course both parallel during simulated whiplash. These strains were
and perpendicular to the bundles of the anulus greatest at the posterior region of the C56, and
fibrosus. Nerves were seen throughout the anulus clinicaldatesuggeststhatthisisthemostcommon
butweremostnumerousinthemiddlethirdofthe location for disc herniation in whiplash patients.
disc.ReceptorsresemblingPaciniancorpusclesand Disc injury may be the cause of acute pain and
Golgitendonorganswereseenintheposterolateral musclespasmduringthetrauma,itcouldalsolead
region of the upper third of the disc. These results to disc degeneration, facet osteoarthritis, and
provide further evidence that human cervical chronicneckpain.
intervertebral discs are supplied with both nerve PanjabiMM,ItoS,PearsonAM,IvancicPC.Injury
fibersandmechanoreceptors. mechanismsofthecervicalintervertebraldiscduring
MendelT,WinkCS,ZimnyML.Neuralelementsinhuman simulatedwhiplash.Spine.2004Jun1;29(11):121725.
cervicalintervertebraldiscs.Spine.1992Feb;17(2):1325.
The disc injuries occurred at lower impact
accelerationsduringrearimpactascomparedwith
frontalimpact.Thesubfailureinjuriesofthecervical
intervertebraldiscthatoccurduringfrontalimpact
may lead to the chronic symptoms reported by
patients,suchasheadandneckpain.
ItoS,IvancicPC,PearsonAM,TominagaY,GimenezSE,
RubinW,PanjabiMM.Cervicalintervertebraldiscinjury
duringsimulatedfrontalimpact.EurSpineJ.2005
May;14(4):35665.
10Upper Cervical Structures Reliableassessmentoftheanatomyandfunction
of the alar ligament can be achieved with MR
MRI shows structural changes in ligaments and imaging,preferablyincoronalplanes.MRimaging
membranes after whiplash injury, and such with the aid of a functional study may be a
lesions can be assessed with reasonable valuable imaging modality in the evaluation of
reliability. Lesions to specific structures can be alarligamentfailure.
linkedwithspecifictraumamechanisms.Thereis KimHJ,JunBY,KimWH,ChoYK,LimMK,SuhCH.MR
a correlation between clinical impairment and imagingofthealarligament:morphologicchanges
morphologicfindings. duringaxialrotationoftheheadinasymptomatic
Whiplash trauma can damage soft tissue youngadults.SkeletalRadiol.2002Nov;31(11):63742.
structuresoftheuppercervicalspine,particularly
thealarligaments. Highsignal changes of the alar and transverse
KrakenesJ,KaaleBR.Magneticresonanceimaging ligamentsarecommoninWAD12andunlikelyto
assessmentofcraniovertebralligamentsand representagedependentdegeneration.
membranesafterwhiplashtrauma.Spine.2006Nov VettiN,KråkenesJ,EideGE,RørvikJ,GilhusNE,
15;31(24):28206. EspelandA.MRIofthealarandtransverseligamentsin
whiplashassociateddisorders(WAD)grades12:high
Whiplashpatientswhohadbeensittingwiththeir signalchangesbyage,gender,eventandtimesince
head/neck turned to one side at the moment of trauma.Neuroradiology.2009Apr;51(4):22735.
collisionmoreoftenhadhighgradelesionsofthe
Whiplash trauma can damage the transverse
alar and transverse ligaments. Severe injuries to
ligament. By use of highresolution proton
thetransverseligamentandtheposterioratlanto
weightedMRimagessuchlesionscanbedetected
occipitalmembraneweremorecommoninfront
andclassified.
thaninrearendcollisions.Thepatientswhohad KrakenesJ,KaaleBR,NordliH,MoenG,RorvikJ,Gilhus
the head rotated at the instant of collision had NE.MRanalysisofthetransverseligamentinthelate
more often highgrade MRI changes of the alar stageofwhiplashinjury.ActaRadiol.2003
ligaments than those with the head in a neutral Nov;44(6):63744.
position. A total of 61.7% of the patients with
rotated neck position had alar ligament grade 3 The results for the membranes appeared
lesions, as opposed to only 4.4% in the patient somewhat better than for the ligaments. When
groupwithneutralneckposition. there was disagreement, the classifications
KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Head obtained by the clinical test were significantly
positionandimpactdirectioninwhiplashinjuries: lower than the MRI grading, but mainly within
associationswithMRIverifiedlesionsofligamentsand onegradedifference.Whencombininggrade01
membranesintheuppercervicalspine.JNeurotrauma. (normal) and 23 (abnormal), the agreement
2005Nov;22(11):1294302. improved considerably (range 0.700.90).
Althoughresultsfromtheclinicaltestseemtobe
slightly more conservative than the MRI
assessment, we believe that a clinical test can
serveasvaluableclinicaltoolintheassessmentof
WADpatients.
KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Clinical
assessmenttechniquesfordetectingligamentand
membraneinjuriesintheuppercervicalspineregiona
comparisonwithMRIresults.ManTher.2008
Oct;13(5):397403.
11Structures Injured
Symptoms from the temporomandibular joint
Shoulder Pain
Symptoms from the temporomandibular joint have
52.6%ofsubjectswithlatewhiplashsyndromehad been reported in the literature related to WAD.
periarticular disorders of the shoulder joint and Symptoms of TMJ induced by whiplash may include
shoulder pain that was exaggerated by shoulder headache, dizziness, and deep ear pain, pressure
movement and tenderness in the tendons of the behind the eyes, earaches and stiff neck. TMJ
rotatorcufforthebicepstendon. symptomswillappearasaninabilitytoopenthejaw
MagnussonT.Extracervicalsymptomsafterwhiplash
fully,aclickingorsnappingofthejawandchangesin
trauma.Cephalalgia.1994Jun;14(3):2237;discussion
1812.
alignmentwhenthejawisopenedorclosed.
The shoulder is affected by irritation of a cervical Observations suggest an association between neck
nerve root or referred pain. The anteroposterior injury and disturbed jaw function and therefore
diameter of the spinal canal at C5 and C6 in the impairedeatingbehavior.
painfulshoulder group was significantly narrower GrönqvistJ,HäggmanHenriksonB,ErikssonPO.Impaired
jawfunctionandeatingdifficultiesinwhiplashassociated
thaninthecontrolgroup.
disorders.SwedDentJ.2008;32(4):1717.
MimoriK,MunetaT,KomoriH,OkawaA,ShinomiyaK.
Relationbetweenthepainfulshoulderandthecervical
spinewithnarrowcanalinpatientswithoutobvious The TMJ and surrounding musculature should be
radiculopathy.JShoulderElbowSurg.1999JulAug; examined similarly to other joints, with no
8(4):3036. preconceived notion that TMD pathology after
whiplashisunlikely.
Thereisevidencethattheacromioclavicularjointof FriedmanMH,WeisbergJ.Thecraniocervicalconnection:
the seatbelt shoulder may be injured during an aretrospectiveanalysisof300whiplashpatientswith
road traffic accidents. The joint involved was cervicalandtemporomandibulardisorders.Cranio.2000
significantlymorelikelytobeonthesiderestrained Jul;18(3):1637.
bytheseatbelt.Theacromioclavicularjointsshould
be checked for involvement following whiplash
injuries,particularlyinwomen.
SaundersL.Acromioclavicularjointsprainandits
prevalencewithwhiplashinjuries.Physiotherapy2001;
87(11);587592.
Whiplash injuries can result in indirect acute
shoulder trauma, possibly through an acceleration
deceleration mechanism, and may be a distinct
entity.
Mudduen,etal.Whiplashinjuryoftheshoulder:Isita
distinctclinicalentity?ActaOrthop.Belg.,2005,71,385
387.
Thisstudyshowedanincidenceof22%ofshoulder
pain after whiplash injury and is comparable with
otherstudies.
ChauhanSK,PeckhamT,TurnerR.Impingement
syndromeassociatedwithwhiplashinjury.JBoneJoint
Surg[Br]2003;85B:40810.
12Structures Injured Low Back Pain in Acceleration/Deceleration
Low back pain Collisions
Low back pain occurs in approximately 50% of these Lumbar spine injury mechanisms
cases.Compressionwithbiphasiclumbarspinalmotions
(increased/decreasedlordosis)maycauseinjuriesinthe LumbarSpinalStrainsAssociatedwithWhiplashInjury,
lumbarspine. reported that up to half of the persons involved in
theseaccidents(rearendcollisions)maydeveloplow
Lower back pain is associated with whiplash back pain but the mechanisms leading to and
trauma sustaining the low back pain still remain unclear as
Author Year %withLowBackComplaints thereisscantbiomechanicaldatadealingwiththelow
Cassidy et al 2003 61 backafterwhiplashinjuries.
Berglund et al 2001 20
Following a rearend collision injury mechanisms
Sqiures 1996 48
include traction (tensile stretching) and compression
Sturzenegger 1995 46 togetherwithshearforcesaffectinglumbarvertebrae,
Radanov et al 1994 39 and that the forces could produce soft tissue injuries
Magnusson 1994 47 tomuscles,ligaments,capsules.
Teasel 1993 40 FastA,SosnerJ,BegemanP,ThomasMA,ChiuT.Lumbar
Hildingson 1990 25 SpinalStrainsAssociatedwithWhiplashInjury:ACadaveric
Hohl 1974 35 Study.AmJPhysMedRehabil.2002Sep;81(9):645650.
Supine Seated
NachemsonA.Invivodiscometryinlumbar
discswithirregularnucleograms.
ActaOrthopScand.1965;36(4):41834.
From a standing to sitting position, the lumbar lordosis decreases by on average 38°
AnderssonGetal.Theinfluenceofbackrestinclinationandlumbarsupportonlumbarlordosis.Spine,1981;4(1):5258.
13Evaluation - Initial
History & Physical Examination
Diagnostics & Imaging
Classify WAD grade
Assess Pain – Pain Scale (VAS/NPS) and
Disability – Neck Disability Index (NDI)
Pain Drawing
Define WAD grade
WAD I WAD II WAD III
Apply recommended treatments
• Mobilization/Manipulation
• Modalities/ Exercise/Nutrition
• Prescribed Functional Activities
7 Days
Improving Not Improving
Continue recommended treatments (VAS/NPS and NDI still high)
Consider more concerted treatment.
Other treatments therapies may be
considered
3 Weeks
Reassess
(Should include VAS/NPS and NDI, may include a psychological measure (for e.g., IES)
Improving Not Improving
Continue recommended treatments (e.g., VAS and NDI still high/unchanged)
Consider refer to Specialist: Specialist exam
should include specialized physical examination
6 Weeks
Reassess
(Should include VAS/NPS and NDI, may include IES)
Resolving Not Resolving
Reduce treatment VAS/NPS and NDI still high/unchanged)
Refer to Specialist: Specialist exam should
Resolved – cease treatment include specialized physical examination
3 Months
Resolution expected ( 50%) Not Resolving ( 50%)
Discharge from care Follow recommendation from whiplash
or specialist and ensure coordinated care.
Treatment as needed Special studies (VF, MRI ect.)
14Initial Assessment
Classify the injury Whiplash (WAD) injury. Although higher WAD grades indicate greater severity,
poor prognosis is most likely associated with a high Visual Analogue Scale (VAS)/numeric pain
score (NPS) >7/10) or high Neck Disability Index (NDI) score (>20/50). The SF-36 may be also be
used. Orthopedic & neurological examination. Clinician determines imaging necessity.
Apply recommended treatments.
Seven Day Reassessment
Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are high or unchanged,
treatment type and intensity should be reviewed. Other treatments may be considered.
The effectiveness of such treatments should be closely monitored and only continued if there is
evidence of benefit (at least 10% change on VAS and NDI).
Three Week Reassessment
Reassess, including the VAS/NPS and NDI. If the VAS/NPS and NDI are unchanged, a more
complex assessment may need to be considered and treatment type and intensity should again be
reviewed. The Impact of Event Scale (IES) may be used as a baseline for psychological
assessment. Other recommended scales can be used. If pain and disability are still high (VAS, NPS
>5.5) and NDI (>20/50) or unchanged, consider referral to a specialist in Whiplash Associated
Disorders (WAD).
A specialist is considered a practitioner with specialized expertise in the management of WAD.
These may include chiropractors, medical physicians, pain medicine specialists and other
physicians who specialize in WAD. Among other things, if the VAS/NPS and NDI are unchanged,
the specialist should undertake a more complex physical and/or psychological examination. They
should direct more appropriate care and liaise with the treating practitioner to ensure this is
implemented.
Six Week Reassessment
Reassess again at this point. In at least 30% of cases resolution should be occurring, and the
process of reducing treatment in these cases should commence or continue. If resolution is not
occurring and the VAS/NPS and NDI have not changed by at least 10% from the last review,
specialist care should still be followed, or a specialist should be referred to if this has not already
been done. Prescribe home programs for functional improvement. Consultation with a whiplash
specialist may be needed if pain or disability are still high (VAS, NPS > 5.5, NDI > 20/50) or
unchanged.
Three Month Reassessment
Assessment should Include VAS/NPS and NDI. Resolution usually occurs in approximately 50% of
cases. If the patient is still improving, continue treatment; independence should be promoted (e.g.,
focus on active exercise). In these resolving cases, the patient should be reviewed intermittently
over the next six to 12 months until resolution. Prescribe home programs to maintain improvement.
Consultation with a whiplash specialist is usually required. At this point, referral to a clinical
psychologist may also be considered if the psychological assessment data is markedly below
norms (for the IES this means a score of > 26 at six weeks after injury).
Coordinated Care
Patients whose VAS/ NPS and/or NDI scores are not improving at this point are likely to require
coordinated care that is multidisciplinary. It is likely that a combination of physical, psychological
and medical care is required. The primary practitioner should facilitate this process.
15Range of Possible Symptoms in Whiplash Disorders
Neck Pain
Neck pain is the most commonly reported symptom of WAD. Furthermore specific segmental
zygapophyseal (facet) joint blocks have demonstrated that the neck and surrounding tissues are
the most common source of chronic pain for people with WAD. People involved in a rear end
motor vehicle accident found the most commonly reported symptom was neck pain, followed by
headache, neck stiffness, low back pain, upper limb symptoms, dizziness, nausea and visual
problems. Tinnitus, temporomandibular joint pain, paraesthesia and concentration or memory
disturbance may also be experienced.
Headache
Headache is the second most common symptom, often in the sub-occipital region with referral
to the temporal area. These areas are innervated from the upper cervical levels and it was
found that 50% of people complaining of headaches had pain arising from the C2/C3
segmental level.
Radiating Pains to the Head, Shoulder, Arms or Interscapular area
Radiating pains to the head, shoulder, arms or interscapular area are often reported at some
time post injury. These patterns of somatic referral do not necessarily indicate which structure is
the primary source of the pain but rather suggest a referred type of pain from the facets or discs
in the cervical spine.
Generalized Hypersensitivity
Those with whiplash symptoms may have a generalized hypersensitivity, extending as far as the
lower limbs, when compared with healthy volunteers. It was suggested that WAD might lead to
spinal cord hyperexcitability causing exaggerated pain on peripheral stimulation.
Paresthesia and Muscle Weakness
Paresthesia and muscle weakness may be caused by cervical radiculopathy, thoracic outlet
syndrome and spinal cord compression.
Symptoms from the Temporomandibular joint
Symptoms from the temporomandibular joint have been reported in the literature related to
WAD. Symptoms of TMJ induced by whiplash may include headache, dizziness, deep ear pain,
pressure behind the eyes, earaches and stiff neck. TMJ symptoms will appear as an inability to
open the jaw fully, a clicking or snapping of the jaw and changes in alignment when the jaw is
opened or closed.
Visual Disturbances
Visual disturbances are mentioned in the literature. Whiplash was associated with defective
accommodation in the present select group of whiplash subjects. Oculomotor function seems to
be impaired in patients with chronic symptoms of whiplash injury of the cervical spine. The
smooth pursuit neck torsion test to identify eye movement disturbances in patients with
whiplash are likely to be due to disturbed cervical afferentation.
16Proprioceptive Control of Head and Neck Position
Proprioceptive control of head and neck position has been found to be reduced in people after
whiplash injury. Individuals who have sustained a whiplash injury may have proprioceptive
deficits that do not allow them accurately or reliably to calculate head position. This may be
detrimental to their everyday function. The central nervous system (CNS) uses the information
provided by the proprioceptors to build up an internal reference frame of our musculoskeletal
system and to recalibrate it. Rehabilitation after whiplash injury should focus not only on range
of motion and strength but on postural awareness.
Vertigo/Dizziness
Post-traumatic vertigo refers to dizziness that follows a neck or head injury. There are many
potential causes of post-traumatic vertigo. Peripheral vertigo may be either a lesion of the inner
ear via the vestibular nerve or afferents from the cervical spine: major differential would be
dizziness with turning the head but not with rotation of head and body together.
Whiplash clinically is similar to post concussion syndrome, but with the addition of neck
complaints. Dizziness occurs in 20-60%.
Impaired Cognitive Function
Cognitive function may be impaired in WAD with symptoms as a result of mild traumatic brain
injury, chronic pain, chronic fatigue or depression. The cervicoenchephalic syndrome is
characterized by headache, fatigue, dizziness, poor concentration, disturbed accommodation
(eye movements), and impaired adaptation to light sensitivity.
Low Back Pain
Low back pain occurs in approximately 50% of these cases. Compression with biphasic lumbar
spinal motions (increased/decreased lordosis) may cause injuries in the lumbar spine.
Carpal Tunnel Syndrome
The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the
wrist on one side and the transverse carpal ligament on the other. This opening forms the
carpal tunnel.
The median nerve passes through the carpal tunnel into the hand. It gives sensation to the
thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to
control the thenar muscles of the thumb. Any condition that causes abnormal pressure in the
tunnel can produce symptoms of CTS.
Double Crush Syndrome
Double crush syndrome means that nerves being irritated up in the neck or at some proximal
location like the thoracic outlet (in the shoulder) are causing a peripheral nerve entrapment like
carpal tunnel or ulnar entrapment at the elbow.
Delay in Symptoms
Delay in symptoms is not uncommon. Symptoms may be delayed for hours, days, or longer.
17You can also read
