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Whiplash Associated Disorders. J. Scott Bainbridge, MD Denver Back Pain Specialists www.denverbackpainspecialists.com. Definition.

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Whiplash Associated Disorders

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Whiplash Associated Disorders

J. Scott Bainbridge, MD

Denver Back Pain Specialists

www.denverbackpainspecialists.com


Definition

  • Quebec Task Force on Whiplash-Associated-Disorders redefined the term in 1995 as “an acceleration-deceleration mechanism of energy transfer to the neck which may result from rear-end or side impact, predominately in MVAs, and from other mishaps.


Definition

  • The energy transfer may result in bony or soft tissue injuries (whiplash injury), which may in turn lead to a wide variety of clinical manifestations (whiplash Associated Disorders)”.


WAD – Scope of Problem

  • Yearly Incidence 4/1,000 (.8-8)

  • $3.9 billion/yr in USA, $29 b w litigation

  • 4-42% of pts w MVA related neck injuries with sx several yrs later


Quebec Classification

  • Grade 0: No neck c/o or PE signs

  • Grade I: Neck c/o pain, stiffness or tenderness but no PE signs

  • Grade II: Neck c/o AND mskl signs

  • Grade III: Neck c/o AND neuro signs

  • Grade IV: Neck c/o AND fracture or dislocation


MVA – Spectrum Beyond WAD

  • Cervicothoracic

  • Other Musculoskeletal

  • Brain Injury, Post Concussive Syndrome

  • Other Neurological

  • Vestibular Dysfunction

  • Psychological

  • Social/Economic/Litigation


Motion Analysis of C-Spine During Whiplash Loading

  • Kaneoka, et al; Spine 24:8 pp 763-770

  • 10 males – sled glided back into damper at 4 km/hr

  • Cineradiography of C-spine

  • Each vertebra’s rotational angle and C5-6 instantaneous axes of rotation quantified

  • SEMG of SCM and C-paraspinals


Pathological Forces

  • 8 km/hr 5 mph

  • 135 N


Pathology

  • Facet: synovial fold (meniscoid) impingement, facet capsular subcatastrophic failure, capsular failure w/wo fracture or subluxation, microfracture – cart/bone

  • Disc rim lesions/herniation, anterior vs. posterior

  • Neural

  • Muscular

  • Start or speed degenerative cascade


Degenerative Cascade

  • Three Joint Complex

    • Two Zygapophyseal joints (facets joints)

    • Intervertebral disk

  • pathologic changes in one part results in changes in other segments

    Kirkaldy-Willis


Degenerative Cascade – Segmental Dysfunction

  • reactive z-joint synovitis

    • Inflammation & joint pain


Degenerative Cascade – Segmental Dysfunction

  • articular cartilage z-joint degeneration


Subchondral Sclerosis


Cartilage Degeneration


Degenerative Cascade – Instability Phase

  • Annular fibers less competent

  • Disc protrusions


Uncovertebral Joints - Joints of Luschka

  • Uncinate processes hook posterolaterally between one vertebra & the base of the next

  • With shearing stresses to anular tissue, degenerative spurs begin to develop in teenage years

  • Spurring can cause foraminal stenosis


Degenerative Cascade – Instability Phase

Normal

Foraminal narrowing


Degenerative Cascade – Stabilization Phase

  • foraminal stenosis

  • radiculopathy

  • central spinal stenosis


Degenerative Cascade – Stabilization Phase

  • ankylosis of motion segment

  • multilevel degenerative changes & spondylosis


Degenerative Cascade – Stabilization Phase

  • ankylosis of motion segment


Cervical Z Joint Pain

  • Prevalence of chronic cervical z-joint pain after whiplash injuries: 60% (Lord, Spine, 1996)

  • Z Joint pain referral patterns characterized with provocative injections (Dwyer)

  • Imaging is unremarkable

  • Confirm suspicions with dx intra-articular z-jt injections or medial branch blockade


Dwyer

Z-joint Referral Patterns

Spine

1990


Fukui

Thoracic Z-joint Referral Patterns

Regional

Anesthesia

1997


HNP

Lig.

flavum

dura

Spinal

cord


“Annular fibers restrict axial rotation more than the facet joints.” (Krismer 1996)


Posterior Tear

with epidural

leak

Normal

disc


Grubb, Kelly.

Spine 25:1382-1389, 2000

Cervical Discography

Pain Referral Patterns

173 discograms,

404 positive

discs

>50% with >3 positive discs

C2-3

C3-4

C4-5

C5-6

C6-7


C2-3

Provocative Cervical DiscographySlipman NASS 2002

C3-4

C4-5


C5-6

Provocative Cervical DiscographySlipman NASS 2002

C6-7

C7-T1


Treatment - Acute

  • Oral Steroids?

  • NSAIDs?

  • Immobilize?

  • Early Therapy?


Treatment

Facet Joints


Treatment of Facet Injury

  • Manual Therapy

  • Postural Education

  • Neuromuscular Reeducation/Stability

  • Cervical Traction

  • Spinal Injections

  • Surgical Stabilization


Manual Therapy

  • Grade 1: Small amplitude, beginning range

  • Grade 2: Large amp, resistance free

  • Grade 3: Large amp into resistance (MET)

  • Grade 4: Small amp well into resis (HVLA)

  • Grade 5: Past end-range


Spinal Injection/Nerve Ablation

  • Intraarticular Corticosteroid

  • Facet Denervation (Lord,et al; NEJM 1996; 335:1721-6)


Treatment of Disk Disorders

  • Posture/ Spine Stability Training

  • Cervical Traction

  • Treat Assoc Muscle/Facet Disorders

  • Spinal Injections

  • Surgical (ACDF, other); Treatment for axial neck pain?


Surgical Intervention

  • Neurological Compromise

  • Axial Pain?


Treatment of Muscle Disorders

  • Massage: CMT, self, theracane

  • Postural Educ

  • Neuromuscular Reeducation/Stability

  • Biofeedback

  • Trigger Point Injections/Acupuncture

  • Botulinum Toxin: Botox/Myoblock


Movement Dysfunction Dynamic Stabilityand Muscle Balanceof the Cervical Spine


Segmental Dysfunction


Movement Dysfunction


Local stability segmental control

  • The segmental stability of the spine is dependent on recruitment of the deep local stability muscles

  • The spine will fail if local activity is insufficient even if the global muscles work strongly

  • 1 –3 % MVC  muscle stiffness significantly increases stability

  • 25% MVC = optimal stiffness & stability

    (Cholewicki & McGill 1996, Crisco & Panjabi 1991,

    Hoffer & Andreasson 1981)


Inhibition

  • Inhibition: failure of normal recruitment

    • poor recruitment under low threshold stimulus

    • delayed recruitment timing

    • altered recruitment sequencing

      Inhibition ‘off’


Afferent Input & Recruitment

  • Recruitment is partially due to the influence of proprioceptive activity

  • Proprioceptive afferent (γ loop) input is essential for tonic (low threshold) recruitment

  • Sensation of effort is linked to recruitment

    • (Eccles et al. 1957, Grimby & Hannerz 1976)


Proprioception and Pathology

  • Whiplash patients have significant  in ability to reposition head after movement

    • worse with mid range movement than end range

    • worse in direction of injury mechanism (flex/ext)

  • Kinesthetic accuracy improves with specific proprioceptive exercise

    (Loudow et al 1997, Revel et al 1991 1994, Heikkla & Astrom 1996)


Evidence of Local Dysfunction

  • Uncontrolled segmental translation

  • Segmental change within cross-sectional area

  • Altered pattern of low threshold recruitment

  • Motor recruitment timing deficit

    • (review: Comerford & Mottram 2001)


Test for ability of anterior local stability muscles to control neutral (longus & RCAnt)

Control of Neutrallow load recruitment in neutral


Control

Can control greater range of 2mm Hg increments (up to 28 from baseline of 20) than WAD

Less superficial muscle activity

WAD

Can only control low increments (from baseline of 20 up to 23)

Less consistent duration of hold

More superficial muscle activity

Deep cervical flexor dysfunction

Jull 2000


Deep cervical flexor dysfunction

  • identified in different pathological situations

    • Whiplash Associated Disorder (Jull 2000)

    • Post-concussional headache (Treleaven et al 1994)

    • Cervical headache (Watson & Trott 1993,Jull et al 1999)

    • Mechanical neck pain

      (Silverman et al 1991, White & Sahrmann 1994, Jull 1998)


Dysfunction inGlobal Mobility System

  • Myofascial shortening which limits physiological and / or accessory motion

  • Overactive low load or low threshold recruitment

  • Reacts to pain and pathology with spasm


Dysfunction related to pathology

Normal

  • Able to hold head flexed and maintain position against light resistance

    Cervical pain

  •  cervical lordosis

  • Inability to hold head flexed in supine

    • Lose position into chin poke &  lordosis due to long weak longus cervicus that is compensated for by excessive scalenae and sterno-mastoid

      • (White & Sahrmann 1994)


Relative Stiffness/Relative Flexibility(Sahrmann 2002)

  • If 1 joint muscles lack ability to adequately shorten or are “weak” - they allow excessive motion

  • If 2 joint muscles lack extensibility or are overactive- they limit normal motion which must be compensated for elsewhere in the movement system


Normal

Flex / ext ROM

C5-6 (18o)

C4-5 (17o)

Translation

C5-6 (3.2mm)

C4-5 (3.2mm)

(Dvorak 1988, White et al 1975)

Abnormal

Flex / ext ROM

C5-6  (8o)

C4-5  (23o)

Translation

C5-6  (1mm)

C4-5  (6mm)

(Singer et al 1983)

Dysfunction related to pathology

Cervical discogenic pathology


Treatment Summary

Dual approach:

  • Treat the pathology

  • Identify and correct the dynamic stability dysfunction which may precipitate pathology

  • Control of neutral by integration of local stabilisers into global function

  • Retrain dynamic control of the direction of stability dysfunction (especially rotation)

  • Retrain tonic, through range control of the global stabilisers

  • Actively regain extensibility of the global mobilisers


‘Alternative’ Approaches

  • Tai Chi

  • Alexander technique

  • Yoga

  • Pilates

  • Physio ball (Swiss ball)

  • Feldenkrais


Treat Whole Person

  • Psychology

  • Work

  • Family

  • Secondary Gain Dynamics


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