Management of whiplash-associated disorder in the Italian emergency department: the feasibility of an evidence-based continuous professional development course provided by physiotherapists.

PURPOSE: The management of whiplash and associated disorders (WAD) in the Italian Health System is still empirical and influenced by a single professional's expertise. Therefore, the purpose of our study is to describe a structured management changes in an Italian emergency department (ED) after an evidence based continuous professional development (CPD) course. METHODS: A CPD course was organized by Orthopedic Manipulative Physical Therapists (OMPT) for personnel of ED in the hospital Girolamo Fracastoro (San Bonifacio, Verona, Italy), based on latest scientific evidence. Data regarding the number of X-Rays, computed tomography (CT) scan, orthopaedic referrals, neck collars and WAD IV (i.e., severe diagnosis) before and after the course were compared. RESULTS: 3066 cases of WAD have been analyzed in 2016 and 2185 in 2017/2018. The number of X-Rays dropped down from 15.1% to 13.5%; the CT scans increased from 1.3% to 1.9%; the WAD IV diagnosis increased from 0.7% to 1.6%; the orthopaedic referrals dropped from 1.5% to 1.1%; the collars prescription dropped from 8.8% to 2.5%. CONCLUSION: An updated framework increased the efficiency of ED's maintaining the same level of safety (i.e., WAD IV diagnosis). Given that, it can also be argued that, in line with other countries, the implementation of an OMPT role within the ED multidisciplinary team is advised also in Italy.Implications for rehabilitationPhysiotherapists were commissioned to organize a management change of patients in an Italian Emergency Department clinical setting for the management of whiplash;Guidelines and other appropriate clinical rules facilitate the delivery of an evidence-based and more appropriate management and care plan;An inter-disciplinary continuous professional development course has the potential to positively influence patients' journey and to optimize the use of departmental resources;The involvement of other health professionals (e.g., Physiotherapists) within the Italian Emergency Department organizational chart might lead to further improvement of service provided.

Use of Soft Cervical Collar among Whiplash Patients in Two Italian Emergency Departments Is Associated with Persistence of Symptoms: A Propensity Score Matching Analysis.

PURPOSE: Although the use of soft cervical collars in the emergency department (ED), for whiplash-associated disorders (WAD), is controversial, it is still widely adopted. The purpose of our study was to investigate the impact of the early use of soft cervical collars on the return to the ED, within three months of a road traffic collision. METHODS: We conducted a retrospective observational study on WAD patients from two EDs in Verona (Italy). Patients in the earlier acute phase of WAD (within 48 h from the trauma) were included; those with serious conditions (WAD IV) were excluded. As an end point, we considered patients who returned to the ED complaining of WAD symptoms within three months as positive outcome for WAD persistence. RESULTS: 2162 patients were included; of those, 85.4% (n = 1847/2162) received a soft cervical collar prescription. Further, 8.4% (n = 156/1847) of those with a soft cervical collar prescription, and 2.5% (n = 8/315) of those without a soft cervical collar (p < 0.001) returned to the ED within three months. The use of the soft cervical collar was an independent risk factor for ED return within three months, with an OR, adjusted for possible clinical confounders, equal to 3.418 (95% CI 1.653-7.069; p < 0.001). After the propensity score matching, 25.5% of the patients (n = 25/98) using the soft cervical collar returned to the ED at three months, compared to the 6.1% (n = 6/98) that did not adopt the soft cervical collar. The use of a soft cervical collar was associated with ED return with an OR = 4.314 (95% CI 2.066-11.668; p = 0.001). CONCLUSIONS: Our study shows that the positioning of the soft collar in a cohort of patients with acute WAD, following a rear-end car collision, is an independent potential risk factor to the return to the ED. Clinically, the use of the collar is a non-recommended practice and seems to be related to an increased risk of delayed recovery. There is a need to inform healthcare providers involved in the ED of the aim to limit the use of the soft cervical collar. A closer collaboration between clinicians (e.g., physicians, physical therapists, nurses) is suggested in the ED. Future primary studies should determine differences between having used or not having used the collar, and compare early physical therapy in the ED compared with the utilization of the collar.

Craniopharyngioma in a young woman with symptoms presenting as mechanical neck pain associated with cervicogenic headache: a case report.

Background: Craniopharyngioma is benign neoplasm thought to be caused by mal-development, which occurs in both children and adults in the sellar and suprasellar regions of the brain. Typical manifestations in adults are visual and endocrine system symptoms followed by signs and symptoms of increased intracranial pressure (i.e., headache). The management of this rare condition is complex and requires life-long surveillance by a multidisciplinary team of health-care professionals.Objective: To present a rare clinical presentation of craniopharyngioma mimicking nonspecific neck pain usually associated with cervicogenic headache recognized by a physiotherapist in a direct access setting as a condition requiring medical referral.Case Presentation: This case report describes the history, examination findings, and clinical reasoning used in the initial examination of a 33-year-old female with neck pain and cervicogenic headache as chief complaints. Several key indicators in the patient presentation warranted further and urgent investigation: 1) the recent onset of a "new-type" headache; 2) the phenotype headaches change; 3) the rapid progression of the symptoms; 4) the presence of associated neurological signs and symptoms; and 5) the worsening of the symptoms during Valsalva-like activities. The decision was made to refer the patient for further evaluation. An MRI revealed a craniopharyngioma. After a surgical removal of the tumor mass, the patient participated in a rehabilitation program and reached a full recovery after 6 months.Conclusion: This case report highlights the need of more research regarding red flags and warning signs during examination of in the head-neck region, and the central role of primary care clinicians such as physiotherapists in differential diagnosis of life-threatening conditions.

OSTEOCHONDRITIS DISSECANS OF THE RADIAL HEAD IN A YOUNG ATHLETE: A CASE REPORT.

BACKGROUND AND PURPOSE: Elbow pain is common in young gymnasts and is frequently encountered by physical therapists working in direct access outpatient clinics. Most elbow pain is benign; however, non-specific symptoms can mask serious medical pathologies, as is the case with osteochondritis dissecans (OCD). OCD is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. Risk factor analysis, palpable joint tenderness and swelling, joint locking, and a history of high intensity repetitive activities may inform the clinical reasoning; however, the diagnosis of OCD is best made using magnetic resonance imaging (MRI). The purpose of this case report is to describe the main components of the history and physical examination that led to OCD differential diagnosis. CASE DESCRIPTION: A 12-year-old female gymnast presented to an outpatient physical therapy clinic with right elbow pain following a compressive trauma. The decision was made to refer the patient for diagnostic imaging evaluation due to localized joint swelling and point tenderness over the radial head, elbow pain with compressive loading, the presence of demographic risk factors, and a recent worsening in her symptoms after a second trauma. MRI subsequently revealed OCD associated with external humeral condyle bone marrow edema. The patient underwent surgical repair. OUTCOMES: The follow-up MRI at five months post-surgically reported a "excellent graft integration". A post-operative progressive load management program was initiated, with full return to sport achieved at 10 months after surgery. DISCUSSION: This case report highlights the central role of primary care clinicians, such as physical therapists, in identifying patients with suspected pathologic conditions that may need referral for imaging, medical assessment, or surgical intervention. Physical therapists working in direct access environments should be aware of subtle signs/symptoms and specific risk factors that may be indicative of serious pathologies. LEVEL OF EVIDENCE: Level 4.