Neck Solutions

Deep muscle pain, tender points and recovery in acute whiplash patients: A 1-year follow-up study

From: Pain. 2008 Sep 1; [Epub ahead of print]

Local sensitization to noxious stimuli has been previously described in acute whiplash injury and has been suggested to be a risk factor for chronic sequelae following acute whiplash injury. In this study, we prospectively examined the development of tender points and mechano-sensitivity in 157 acute whiplash injured patients, who fulfilled criteria for whiplash associated disorders grade 2 (n=153) or grade 3 (n=4) seen about 5 days after injury and who subsequently had or had not recovered 1 year after a neck sprain. Tender point scores and stimulus response function for mechanical pressure were determined in injured and non-injured body regions at specific time points after injury. Thirty six of 157 whiplash associated disorder grade 2 patients (22.9%) had not recovered, defined as reduced work capacity after 1 year. Non recovered patients had higher total tender point scores after 12, 107 and 384 days relative to those who recovered. Tenderness was found in the neck region and in remote areas in non-recovered patients. The stimulus response curves for recovered and non recovered patients were similar after 12 days and 107 days after the injury, but non recovered patients had steeper stimulus response curves for the masseter and trapezius muscles after 384 days. This study shows early mechano-sensitization after an acute whiplash injury and the development of further sensitization in patients with long term disability.

Catastrophizing, depression, and pain: Correlation with and influence on quality of life and health - A study of chronic whiplash-associated disorders

From: J Rehabil Med. 2008 Jul;40(7):562-9

The aims of this study were: (1) to classify subgroups according to the degree of pain intensity, depression, and catastrophizing, and investigate distribution in a group of patients with chronic whiplash associated disorders; and (2) to investigate how these subgroups were distributed and inter-related multivariately with respect to consequences such as health and quality of life outcome measures. DESIGN: Descriptive cross-sectional study. A total of 275 consecutive chronic pain patients with whiplash associated disorders who were referred to a university hospital. The following data were obtained by means of self-report questionnaires: pain intensity in neck and shoulders, background history, Beck Depression Inventory, the catastrophizing scale of Coping Strategy Questionnaire, Life Satisfaction Checklist, the SF-36 Health Survey, and the EuroQol.

Principal component analysis was used to recognize subgroups according to the degree of pain intensity, depression, and catastrophizing. These subgroups have specific characteristics according to perceived health and quality of life, and the degree of depression appears to be the most important influencing factor. From a clinical point of view, these findings indicate that it is important to assess patients for intensity of pain, depression, and catastrophizing when planning a rehabilitation programme. Such an evaluation will help individualize therapy and intervention techniques so as to optimize the efficiency of the programme.

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Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association

From: J Orthop Sports Phys Ther 2008;38(9):A1-A34

Although the natural history of neck pain appears to be favorable, rates of recurrence and chronicity are high. One study reported that 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater than 6 months duration affecting 14% of all individuals who experience an episode of neck pain. Additionally, a recent survey demonstrated that 37% of individuals who experience neck pain will report persistent problems for at least 12 months. Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern. In a survey of workers with injuries to the neck and upper extremity, it was reported that 42% missed more than 1 week of work and 26% experienced recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures. Neck pain is second only to low back pain in annual workers’ compensation costs in the United States. In Sweden, neck and shoulder problems account for 18% of all disability payments. It is reported that patients with neck pain make up approximately 25% of patients receiving outpatient physical therapy. Additionally, patients with neck pain frequently are treated without surgery by primary care and physical therapy providers.

A variety of causes of neck pain have been described and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and whiplash. Unfortunately, clearly defined diagnostic criteria have not been established for many of these entities. Similar to low back pain, a pathoanatomical cause is not identifiable in the majority of patients who present with complaints of neck pain and neck related symptoms of the upper quarter. Therefore, once serious medical pathology (such as cervical fracture or myelopathy) has been ruled out, patients with neck pain are often classified as having either a nerve root compromise or a “mechanical neck disorder”.

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Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious onset neck pain

From: Clin Radiol. 2008 Jun;63(6):681-7. Epub 2008 Jan 31

To investigate the presence of fatty infiltrate in the cervical extensor musculature in patients with insidious-onset neck pain to better understand the possible pathophysiology underlying such changes in chronic whiplash associated disorders. A sample of convenience of 23 women with persistent insidious onset neck pain (mean age 29.2+/-6.9 years) was recruited for the study. Magnetic resonance imaging (MRI) was used to quantify fatty infiltration in the cervical extensor musculature. Quantitative Sensory Testing (QST; pressure and thermal pain thresholds) was performed as sensory features are present in chronic whiplash. Self-reported pain and disability, as well as psychological distress, were measured using the Neck Disability Index and the General Health Questionnaire-28 (GHQ-28), respectively. Measures were compared with those of a previous dataset of chronic whiplash patients (n=79, mean age 29.7+/-7.8 years). Using a classification tree, insidious onset neck pain was clearly identified from whiplash, based on the presence of MRI fatty infiltrate in the cervical extensor musculature (0/102 individuals) and altered temperature thresholds (cold; 3/102 individuals).

Fatty infiltrates in the cervical extensor musculature and widespread hyperalgesia were not features of the insidious onset neck pain group in this study; whereas these features have been identified in patients with chronic whiplash associated disorders. This novel finding may enable a better understanding of the underlying pathophysiological processes in patients with chronic whiplash.

Is it time for a population health approach to neck pain?

From: J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):442-6

Neck pain and its associated disorders cause significant health burden in the general population and after road traffic and occupational injury. Individual level health care treatments have been well studied, but population health approaches to this problem have not. In this study they used a best evidence synthesis to examine population level approaches to the prevention and control of neck pain and its associated disorders.

The systematic review examined studies published between 1980 and 2006 that addressed the incidence, prevalence, risk factors, prevention, cost, assessment and classification, interventions, and course and prognostic factors for neck pain and its associated disorders. Citations were screened for relevance, scientifically reviewed, and synthesized. Valid studies addressing public policies or population level approaches to the prevention and control of neck pain and its associated disorders were identified and used in the evidence synthesis.

Only 8 of the 552 scientifically admissible studies were considered relevant to a public or population health approach to preventing and controlling the burden of neck pain and its associated disorders. For whiplash associated disorders, active head restraints and seat backs were protective in rear end collisions; insurance policies affected the incidence and recovery; government funding of multidisciplinary rehabilitation programs did not benefit recovery; and early intensive health care delayed recovery. In the workplace, 2 randomized trials failed to show any preventive effect for ergonomic interventions or physical training and stress management. One study documented the societal cost of neck pain.

The authors concluded there is little evidence on which to make public or population level recommendations, despite the important public health burden and costs of neck pain and its associated disorders. Population level approaches to preventing and controlling neck pain and its associated disorders should be investigated.

Delayed temporomandibular joint pain and dysfunction induced by whiplash trauma

From: J Am Dent Assoc, Vol 138, No 8, 1084-1091. 2007

The Quebec Task Force on Whiplash Associated Disorders published a systematic review of the literature on whiplash injuries in 1995 followed by an updated review in 2001. They considered 24 studies of prognosis to be scientifically admissible, one of which focused on the temporomandibular joint (TMJ) but did not include control subjects. Since the updated review, two TMJ related studies have been published. The first study was a controlled follow-up that investigated TMJ pain and dysfunction. It only included patients between the ages of 20 and 35 with signs and symptoms corresponding to whiplash associated disorders grade 11 (that is, a neck complaint of pain, stiffness or tenderness but no physical signs). The patients, therefore, were not representative of the general population that is exposed to whiplash trauma. The second study was population-based and included patients who had been exposed to either an indirect whiplash trauma or a direct trauma to the head. It evaluated the incidence and recovery of reduced or painful jaw movements that began with the car collision but did not account for whether there was TMJ affliction. Impaired and painful jaw movements can be symptoms of TMJ injury, but they also can be associated directly with the neck injury in patients who have whiplash associated disorders. It remains unclear whether a delayed onset of symptoms can occur in TMJs that appear unaffected directly after whiplash trauma.

A study was conducted to enhance knowledge about short-term and long-term TMJ pain, dysfunction or both induced by whiplash trauma. We hypothesized that delayed symptoms frequently develop in the TMJ after whiplash trauma and that the sex of the patient affects the development of posttraumatic symptoms in the TMJ.

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Whiplash (grade II) and cervical radiculopathy share a similar sensory presentation: an investigation using quantitative sensory testing

From: Clin J Pain. 2008 Sep;24(7):595-603

Recent research has identified the coexistence of generalized sensory hypersensitivity and hypoesthetic changes suggestive of a neuropathic component to chronic whiplash associated disorders. This study aimed to compare chronic whiplash with a cervical neuropathic condition cervical radiculopathy, using Quantitative Sensory Testing. Fifty participants with chronic grade II whiplash associated disorders (greater than 3 mo), 38 participants with radiculopathy, and 31 controls who were age and sex matched to participants with whiplash associated disorders participated in the study. Quantitative Sensory Testing including detection thresholds (electrical, thermal, and vibration) and pain thresholds (pressure, cold) were measured from bilateral hand sites corresponding to innervation areas of the lower cervical nerve roots and a remote site in the lower limb.

The whiplash and cervical radiculopathy groups demonstrated lower pain thresholds to both pressure and cold stimuli at all sites compared with the controls. The symptomatic limbs of the radiculopathy group showed the greatest elevation in detection thresholds for all stimuli compared with the asymptomatic limbs of this group, the whiplash and control groups. There was no difference in detection thresholds between the asymptomatic limbs of the radiculopathy group and the whiplash group but both these groups showed higher detection thresholds than the controls. Generalized sensory hypersensitivity and hypoesthesia occur in both chronic whiplash and cervical radiculopathy. This may represent disordered central pain processing but could indicate peripheral nerve dysfunction.

Validity and internal consistency of a whiplash specific disability measure

From: Spine. 2004 Feb 1;29(3):263-8

Whiplash injuries frequently occur following motor vehicle collisions. Analysis of police reported tow away crashes from Victoria, Australia (1987-1998) showed a significant percentage of occupants had whiplash injury (8% for frontal crashes and 18% for rear crashes). Data provided by the New South Wales Compulsory Third Party insurers to the Motor Accidents Association’s Claims Register showed whiplash to be the most frequently recorded crash injury in this Australian state. Further to this, approximately 60% of the injuries resulting from vehicle crashes causing disability in Sweden between 1990 and 1995 were whiplash injuries.

The Quebec Task Force on Whiplash associated disorders defined whiplash as an acceleration-deceleration mechanism of energy transfer to the neck which may result in bony or soft tissue injuries. Whiplash associated disorders can be thought of as the clinical manifestations of, or the disability caused by, whiplash injury and may include biologic, psychological, and social symptoms of the potential tissue damage.

Disability is an umbrella term for impairments, activity limitations, or participation restrictions within an environmental context. Traditionally, the focus in the whiplash associated disorders literature has been on measurement of impairments. There is increasing recognition, however, of the importance of measuring disability in the assessment of patients with whiplash associated disorders.

In the absence of a condition specific disability outcome measure for whiplash, generic disability measures are available to health professionals. Generic measures have been used to measure disability associated with whiplash associated disorders. These generic measures may quantify disability in a broad range of illnesses, but disease-specific measures address disabilities directly caused by the disease. Using generic outcome measures for disorders specific to whiplash injury means risking overlooking changes specific to whiplash. In general, disease-specific measures are thought to be more sensitive to changes in the patient’s health status, as these measure changes that are relevant to the patient, compared with generic measures. The absence of a whiplash specific questionnaire supports the development of a new disability outcome measure specific for patients with whiplash.

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Cervical helical axis characteristics and its center of rotation during active head and upper arm movements - comparisons of whiplash associated disorders, non specific neck pain and asymptomatic individuals

From: J Biomech. 2008 Aug 14; [Epub ahead of print]

The helical axis model can be used to describe translation and rotation of spine segments. The aim of this study was to investigate the cervical helical axis and its center of rotation during fast head movements (side rotation and flexion/extension) and ball catching in patients with non specific neck pain or pain due to whiplash injury as compared with matched controls. The aim was also to investigate correlations with neck pain intensity. A finite helical axis model with a time varying window was used. The intersection point of the axis during different movement conditions was calculated. A repeated-measures ANOVA model was used to investigate the cervical helical axis and its rotation center for consecutive levels of 15 degrees during head movement. Irregularities in axis movement were derived using a zero crossing approach. In addition, head, arm and upper body range of motion and velocity were observed. A general increase of axis irregularity that correlated to pain intensity was observed in the whiplash group. The rotation center was superiorly displaced in the non specific neck pain group during side rotation, with the same tendency for the whiplash group. During ball catching, an anterior displacement (and a tendency to an inferior displacement) of the center of rotation and slower and more restricted upper body movements implied a changed movement strategy in neck pain patients, possibly as an attempt to stabilize the cervical spine during head movement.

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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