Neck Solutions

Neck injury during whiplash increased with head turned postures

Head-turned postures increase the risk of cervical facet capsule injury during whiplash

From: Spine. 2008 Jul 1;33(15):1643-9

Injury to the cervical facet capsular ligaments is a potential mechanism for chronic neck pain after acute whiplash injury. Distending the facet capsule by injecting contrast media has produced whiplash like pain patterns in normal individuals, and anesthetic blocks have isolated the cervical facet joints as the source of pain in about half of a chronic whiplash population. More recently, in vivo animal models of facet capsule loading have shown that group III and IV afferents (thought to mediate pain) from the facet capsule have a graded electrical response to mechanical loading of the facet joint in the goat and have suggested that a capsular ligament strain threshold exists above which allodynia pain in response to a normally nonnoxious stimulus is produced. These data support a facet capsule based mechanism for whiplash injury, but do not establish whether human capsular ligaments are injured in the low speed rear end collisions to which many whiplash injuries are attributed.

Whiplash patients who had their head turned at impact have more severe and persistent symptoms than patients who were facing forward. These findings have prompted biomechanical studies using human cadaveric necks to investigate why a head turned posture increases injury potential. Dynamic rear impact tests of prerotated ligamentous spines (occiput-T1) produce increased neck flexibility (interpreted as injury) in extension, lateral bending and axial rotation. Though concentrated in the lower cervical spine, these injuries were not isolated to particular spinal ligaments. Detailed measurements of the strain field in the facet capsule have also shown that a head-turned posture generates higher capsular strains than a neutral head posture, but the quasi static loads applied during those tests were limited to pure neck flexion/extension moments and did not include the axial compression or posterior shear present during whiplash loading. Thus the question of how a head turned posture combined with multiaxial whiplash loads affects facet capsular ligament strain has yet to be answered.

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Disability in subacute whiplash and the Neck Disability Index

Disability in subacute whiplash patients: Usefulness of the Neck Disability Index

From: Spine J. 2008 August ;33(18)630-635

Whiplash describes a process of hyperextension and hyperflexion of the cervical musculature that may result from motor vehicle collisions. The incidence of whiplash has been estimated to be of 1 case per 1000 habitants per year in Western societies, nevertheless available studies report conflicting rates. Symptoms associated with whiplash problems typically resolve in a relatively brief time (days or weeks), but chronic pain, and long-term disability may occur in 10% to 40% of the cases.

The prevention and treatment of chronic disabling pain in whiplash patients has shown to be elusive. On the one hand, predictive factors of chronic disabling problems in whiplash patients are far from being completely elucidated. Although one can hypothesize that factors from different levels (i.e., physiology, thoughts, feelings, and behavior) and units (i.e., individual, dyad, and context) of analysis play a role, very few and inconsistent findings are available. On the other hand, there is limited evidence about what is the most beneficial treatment for whom and under what circumstances. The use of many different outcome variables and assessment instruments may be responsible, in part at least, of the problems encountered in this area of research to compare results across studies and extract definitive conclusions.

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Whiplash injuries can be visible by functional magnetic resonance imaging

Whiplash injuries can be visible by functional magnetic resonance imaging

From: Pain Res Manag. 2006 Autumn;11(3):197-9

Whiplash trauma can result in injuries that are difficult to diagnose. Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint complex). Studies indicate that neck injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headache, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light and pronounced fatigue. Consequently, diagnosis of lesions in the craniocervical joint region is important.

Functional magnetic resonance imaging is a radiological technique that can visualize injuries of the ligaments and the joint capsules, and accompanying pathological movement patterns. Three severely injured patients that had been extensively examined without any findings of structural lesions were diagnosed by functional magnetic resonance imaging to have injuries in the craniocervical joint region. These injuries were confirmed at surgery, and after surgical stabilization the medical condition was highly improved. It is important to draw attention to the urgent need to diagnose lesions and dysfunction in the craniocervical joint complex and also improve diagnostic methods in whiplash injuires.

Factors related with clinical evolution in whiplash

Factors related with clinical evolution in whiplash

From: Med Clin (Barc). 2008 Jul 12;131(6):211-5

Factors of poor clinical recovery in acute whiplash are not conclusive. The goal of this prospective longitudinal study was to identify factors with influence in clinical evolution allowing identification of patients with risk for developing chronic symptoms and disabilities after an acute whiplash. Included were 226 patients who suffered acute whiplash after road traffic accident and met the Department of Physical Medicine and Rehabilitation for medical evaluation and physiotherapy treatment. Variables were collected following a protocol designed for the study. All patients were assessed through the visual analogue scale for the intensity of neck pain, the Goldberg Depression and Anxiety Scale and the Northwick Park Neck Pain Questionnaire for neck functionality, at initial evaluation and at discharge of treatment.

Factors related with poor recovery of Northwick Park Neck Pain Questionnaire at discharge were: number of days of neck immobilization with collar, presence of headache, dizziness, and dorsal pain at initial evaluation and initial evaluation of visual analogue scale score and Goldberg Depression and Anxiety Scale. In the multivaried analysis it was found that variables with influence on Northwick Park Neck Pain Questionnaire at discharge were statistically significant for visual analogue scale, Goldberg depression subscale and Northwick Park Neck Pain Questionnaire scores at initial evaluation. The most important factors that determine the evolution of patients with acute whiplash are the initial evaluation of the neck pain with the Visual Analogue Scale, the neck functionality with Northwick Park Neck Pain Questionnaire and Goldberg Depression subscale.

Acute whiplash daily pain and disability

The influence of fear of movement and pain catastrophizing on daily pain and disability in individuals with acute whiplash injury: A daily diary study

From: Pain. 2008 Jul 30; [Epub ahead of print]

Previous research supports the fear avoidance model in explaining the transition from acute to chronic non specific musculoskeletal pain. However, there is still little knowledge on when this vicious circle of pain, disability, pain catastrophizing and fear of movement starts. A daily diary study in 42 patients with acute whiplash injury was performed. Pain, disability, pain catastrophizing and fear of movement were measured on a daily basis with paper diaries for 21 consecutive days. Most participants showed a decline in pain and disability from day 1 to day 21 and this was paralleled by a decline in the fear of movement and pain catastrophizing in their whiplash injury. Multilevel analyses showed that both between and within persons, high levels of pain catastrophizing and fear of movement are associated with more pain and disability in whiplash. Moreover, the fear of movement was also predictive of pain and disability on the following day. We also examined the reverse association, that is, whether the changes in pain predict changes in the next day’s fear of movement and pain catastrophizing. Although for the fear of movement the model reached significance, the amount of explained variance was negligible in this whiplash study.

This study provides evidence that already in the early stages of whiplash related complaints, significant associations between fear of movement and pain intensity and disability occur, and that this association may be predictive of the persistence of pain.

Impairment of the cervical flexors in whiplash and insidious neck pain

Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients

From: Man Ther. 2004 May;9(2):89-94

Neck pain is a common condition causing substantial personal and financial costs. Broadly, onset may be insidious or may follow trauma. Pain is often persistent or recurrent in nature. Neck pain of traumatic origin following a motor vehicle crash (whiplash) often poses a particular challenge in management. There are several influences that may impact on the perception of neck pain and disability in persons with whiplash associated disorders compared to those with an insidious onset of neck pain. These include the magnitude of the injury, psychological responses to injury and pain, social factors and litigation. There has been little investigation into whether or not differences exist in the nature of physical impairment associated with neck pain of whiplash and insidious origins which may contribute to the greater difficulty often encountered in the rehabilitation of patients with whiplash associated disorders.

Changes in cervical flexor muscle function have been investigated in neck disorders of both whiplash and insidious origins. Vernon et al. in an initial comparative study of neck isometric strength and flexor/extensor strength ratios, found that subjects with both whiplash associated disorders and insidious onset neck pain had lesser strength than asymptomatic subjects. There was a progressive anterior-to-posterior muscle imbalance in the neck pain subjects, with the cervical flexors becoming relatively weaker as compared to the extensors. This was more apparent in subjects with whiplash associated disorders, suggesting that there could be a difference in the degree of impairment between these subject groups.

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The fear avoidance model in whiplash injuries

The fear avoidance model in whiplash injuries

From: Eur J Pain. 2008 Jul 18; [Epub ahead of print]

The aim of this work was to study whether fear of movement, and pain catastrophizing predict pain related disability and depression in subacute whiplash patients. Moreover, we wanted to test if fear of movement is a mediator in the relation between catastrophizing and pain related disability and/or depression as has been suggested by the fear avoidance model. Fear of movement and/or re-injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62:363-72]. The convenience sample used was of 147 subacute whiplash patients (pain duration less than 3 months). Two stepwise regression analyses were performed using fear of movement and catastrophizing as the independent variables, and disability and depression as the dependent variables. After controlling for descriptive variables and pain characteristics, catastrophizing and fear of movement were found to be predictors of disability and depression. Pain intensity was a predictor of disability but not of depression. The mediation effect of fear of movement in the relationships between catastrophizing and disability, and between catastrophizing and depression was also supported. The results of this study are in accordance with the fear avoidance model, and support a biopsychosocial perspective for whiplash disorders.

Postural sway and cervical vertigo after whiplash injury

Consciously postural sway and cervical vertigo after whiplash injury

From: Spine. 2008 Jul 15;33(16):E539-42.

Cross-sectional study of whiplash injury patients with vertigo and healthy volunteers consciously pretending to have postural sway as in malingering. The aim of this study was to evaluate the postural sway in malingerers by posturography. Malingering is not a problem in the majority of cases with whiplash injury and diagnosis should be made carefully. However, some patients with whiplash injury might exaggerate their symptoms or be malingerers because of the potential gain associated with insurance claims. We designed a diagnostic study to screen putative malingerers.

Subjects were 20 healthy volunteers who were tested under standing condition (normal group), consciously swaying the body under standing condition like malingerers (pseudomalingering group) and 32 patients who complained of neck pain with vertigo or dizziness after whiplash injury with whiplash associated disorders grade I and II . The movement of the center of pressure (COP) was measured using a force platform to quantify postural sway. Static posturography was performed under open and closed eyes. We analyzed (1) total envelop area per unit of time, (2) shifting length per second, (3) sway pattern, and (4) Romberg rate representing total shifting length under eyes-closed/eyes-open.

In open eyes condition, the values of envelop area and length per second were significant higher under pseudomalingering than both of the control and whiplash associated disorders groups. The Romberg rate was 1.30 +/- 0.17, 1.13 +/- 0.19, and 1.83 +/- 0.94 in control, pseudomalingering, and whiplash associated disorders group, respectively, and was less than 1.0 in 45% of pseudomalingering. There were significant differences in the envelop area, length per second, and Romberg rate between pseudomalingering and the other 2 groups.

Results suggest that compared with normal subjects and whiplash associated disorder patients, malingerers are more likely to exhibit a wide envelop area, a long sway length per second, and a low Romberg rate. Malingering must be diagnosed carefully and posturography could be a helpful supplementary tool for differentiating whiplash associated vertigo from malingering.

Chronic whiplash related to size and shape of the oropharynx

MRI analysis of the size and shape of the oropharynx in chronic whiplash

From: Otolaryngol Head Neck Surg. 2008 Jun;138(6):747-51

To quantify differences in the size/shape of the oropharynx between female subjects with whiplash and controls. A total of 113 subjects (79 whiplash, 34 controls) were included. T1-weighted MRI was used to measure 1) cross-sectional area and 2) shape ratios for the oropharynx. Reliability data were established. Whiplash subjects had significantly smaller oropharynx and shape ratios compared with healthy controls. Self-reported levels of pain and disability and duration of symptoms were not associated with size and shape of the oropharynx in whiplash subjects. Age and BMI did influence the size and shape of the oropharynx in the whiplash subjects, but only 20 to 30 percent of the variance could be explained by these factors. Significant difference in the size and shape of the oropharynx was noted in subjects with chronic whiplash compared with controls. Future studies are required to investigate the relationships between oropharynx morphometry and symptoms in patients with chronic whiplash.

Chronic pain and whiplash treated with cognitive behaviour therapy

Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash-Associated Disorders?

From: Cogn Behav Ther. 2008 Jun 13;:1-14 [Epub ahead of print]

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash associated disorders were recruited from a patient organization and randomized to either a treatment or a wait-list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10-session protocol emphasizing values-based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants’ abilities to behave in accordance with values in the presence of interfering pain and distress - psychological flexibility. After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the chronic pain and whiplash groups was seen in pain intensity. Improvements in the treatment group were maintained at 7-month follow-up. The authors discuss implications of these findings and offer suggestions for further research in chronic pain and whiplash with cognitive behaviour therapy.