2.  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.

3.  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.

4.  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

5.  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

6.  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

8.  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

9.  Ligaments  Intervertebral disc  Facet joints  Surrounding muscles  Haematoma of especially the m sternocleidomastoïd

10.  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)

11.  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

12.  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

13.  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

14.  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

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

16.  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

17.  Dysphagia with hoarseness in the acute phase  Sympathetic signs: Intermittent weak vision Headaches Horner’s syndrome  Dizziness: Vertebral artery symptoms Middle ear injuries  Oedema

18.  Miosis (constriction of the pupil)  Pytosis (drooping eye)  Enophthalmia (sunken eye)  Anidosis (loss of perspiration on the one side of the face)

19.  Anterior chest pain: presents as angina becomes worse with exercise tender anterior nausea sleeps poorly becomes worse with coughing and sneezing  Oedema

20.  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

21.  Anxiety  Rage  Frustration (financial and family)  Personality changes and interference in daily living  Post-traumatic stress syndrome

22.  Analgesics  Anti-depressants  Surgery  Psychiatric treatment