ChiroACCESS Article



Whiplash Update



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September 1, 2011

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This past year a substantial number of peer reviewed publications addressing whiplash associated disorders (WAD) have appeared in the scientific literature.  These manuscripts examine a broad spectrum of topics including neurologic sequela, psychological issues, diagnosis, treatment, prevention, prognosis and compensation.  Patients respond favorably to chiropractic management of the initial whiplash symptoms, as well as the sequela of WAD, e.g. headache, postural changes and biomechanical problems.  Some of the more important findings of the recent research include the following:
  • Postural changes: Mild traumatic brain injury (MTBI) patients were compared with WAD subjects and a “similar pattern of balance impairment was present in patients with whiplash injury with and without MTBI. However, the impairment was greater for stance and complex gait tasks in WAD patients with MTBI.” Another systematic review of whiplash studies found that “the decreased postural stability in people with neck pain appears to be associated with the presence of pain and correlates with the extent of proprioceptive impairment, but appears unrelated to pain duration.” A third study evaluated postural sway in WAD patients and concluded that the “Increased magnitude of the slow sway component implies an aberration in sensory feedback or processing of sensory information in WAD.”
  • Biomechanical changes: In a comparison between WAD and asymptomatic subjects, the WAD group “revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle.”
  • Pathophysiological changes: Magnetic resonance imaging (MRI) revealed muscle fatty infiltrates in the cervical extensors.  These changes “occur soon following whiplash injury and suggest the possibility for the occurrence of a more severe injury with subsequent [post traumatic stress disorder] PTSD in patients with persistent symptoms.”
  • Symptoms/Sequela:  “Subjects with self reported whiplash injury had significantly more headache and musculoskeletal complaints than those without…”
  • Prognostic signs: One study compared those patients who recovered from WAD within three month with those that did not.  They concluded that “the recovered group had significantly better scores on all health outcome measures; SF36 Physical Component Score, SF36 Mental Component Score and the PCS (p<0.001). The significant independent predictors of poorer health and non-recovery were helplessness (p<0.001), older age (p<0.001) and pre-injury work status being affected (p<0.001) (r(2)=.624).”
  • Psychological: Anxiety and depression are characteristics often associated with WAD.  One longitudinal study concluded that “This is the first published study with a prewhiplash prospective evaluation of psychological status. Our findings are in conflict with previous research suggesting whiplash to be the cause of associated psychological symptoms rather than their consequence. Self-reported whiplash injury was clinically relevant as it independently increased subsequent disability pension award. The strength of this effect, even in the absence of neck pain, suggests the ascertainment of this diagnostic label, or factors associated with this, are important predictors of disability.”  Another study concluded that “It appears that important psychological factors (fear avoidance beliefs and pain amplification) do have some influence on self-ratings of disability in chronic WAD sufferers.”

Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash.  [Link]

Clin Rehabil. 2011 Aug 19. [Epub ahead of print]

Angst F, Verra ML, Lehmann S, Gysi F, Benz T, Aeschlimann A.
Research Department, Rehabilitation Clinic 'RehaClinic' Zurzach, Bad Zurzach, Switzerland.

Objective: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36).

Design: Prospective cohort study. Subjects: One hundred and seventy five patients after whiplash injury.

Interventions: Four-week inpatient interdisciplinary pain management programme. Main measures, analysis: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves.

Results: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up (n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 (P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up (n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar.

Conclusions: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.


Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder.  [Link]

J Appl Biomech. 2011 Aug;27(3):181-91.

Helgadottir H, Kristjansson E, Mottram S, Karduna A, Jonsson H Jr.
Faculty of Medicine, University of Iceland, Reykjavik, Iceland.

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.


Trunk sway in patients with and without, mild traumatic brain injury after whiplash injury.  [Link]

Gait Posture. 2011 Jul 29. [Epub ahead of print]

Findling O, Schuster C, Sellner J, Ettlin T, Allum JH.
Reha Rheinfelden, Rheinfelden, Switzerland; Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland.

OBJECTIVE: This study assessed the addition effect of mild traumatic brain injury (MTBI) on the balance control of patients who simultaneously suffered a whiplash associated disorder (WAD).

BACKGROUND: Dizziness is common in patients suffering from whiplash injury with or without a MTBI, but data is lacking about the additional balance problems and dizziness caused by MTBI.

METHODS: 44 patients with WAD and MTBI and 36 WAD patients without MTBI participated in the study. A dizziness handicap index (DHI) was used to quantify self-perceived handicap. Balance control was assessed using measures of trunk sway for a battery of stance and gait tests.

RESULTS: Patients with WAD and MTBI perceived significantly higher dizziness and unsteadiness (higher score in DHI Emotional category) and had greater trunk sway than WAD patients without MTBI for stance tasks and complex gait tasks (e.g. walking up and down stairs). Both groups had greater sway than controls for these tasks. Both groups of patients showed equal reductions in trunk sway with respect to controls for simple gait tasks (e.g. walking while rotating the head).

CONCLUSIONS: A similar pattern of balance impairment was present in patients with whiplash injury with and without MTBI. However, the impairment was greater for stance and complex gait tasks in WAD patients with MTBI.


Thermal Detection and Pain Thresholds but not Pressure Pain Thresholds Are Correlated With Psychological Factors in Women With Chronic Whiplash-Associated Pain.  [Link]

Clin J Pain. 2011 Jul 11. [Epub ahead of print]

Wallin M, Liedberg G, Börsbo B, Gerdle B.
Department of Social and Welfare Studies, Faculty of Health Sciences, University of Linköping, Norrköping †Department of Clinical and Experimental Medicine, Rehabilitation Medicine, Faculty of Health Sciences, University of Linköping ‡Pain and Rehabilitation Centre, University Hospital, Linköping, Sweden.

Whiplash-associated disorders (WAD) have been associated with sensory disturbances such as hypersensitivity or hypoesthesia. Different psychological factors seem to be important for prognosis and symptom presentation in WAD. Multivariate correlations between pain thresholds for pressure (PPT), cold and heat (CPT, HPT), detection thresholds for cold and warmth, pain intensity variables, and psychological aspects in women with chronic WAD (n=28) and in healthy pain-free controls (n=29) were investigated. Quantitative Sensory Testing (QST) for thermal thresholds and algometry for PPT at various sites in the body were used. Psychological aspects, including catastrophizing, anxiety, and depression were registered using a questionnaire. WAD showed generalized decreased PPT and CPT, altered HPT and cold detection thresholds in the upper part of the body, and a worse psychological situation. Multivariate correlations were found between QST and PPT variables, habitual pain, and psychological factors in WAD. Different psychological variables were generally stronger predictors of CPT and HPT than pain intensity in WAD. Pain intensity aspects were generally the strongest predictors of PPT in WAD. In contrast, no correlations existed between QST and PPT variables and psychological variables in controls. These results indicate the need to consider that a blend of factors influences the pain thresholds in chronic WAD and emphasize the need for a biopsychosocial model when interpreting QST and PPT variables.


The temporal development of fatty infiltrates in the neck muscles following whiplash injury: an association with pain and posttraumatic stress.  [Link]

PLoS One. 2011;6(6):e21194. Epub 2011 Jun 16.

Elliott J, Pedler A, Kenardy J, Galloway G, Jull G, Sterling M.
Division of Physiotherapy, School of Health and Rehabilitation Sciences, Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, The University of Queensland, Brisbane, Australia. j-elliott@northwestern.edu

BACKGROUND: Radiological findings associated with poor recovery following whiplash injury remain elusive. Muscle fatty infiltrates (MFI) in the cervical extensors on magnetic resonance imaging (MRI) in patients with chronic pain have been observed. Their association with specific aspects of pain and psychological factors have yet to be explored longitudinally.

MATERIALS AND FINDINGS: 44 subjects with whiplash injury were enrolled at 4 weeks post-injury and classified at 6 months using scores on the Neck Disability Index as recovered, mild and moderate/severe. A measure for MFI and patient self-report of pain, loss of cervical range of movement and posttraumatic stress disorder (PTSD) were collected at 4 weeks, 3 months and 6 months post-injury. The effects of time and group and the interaction of time by group on MFI were determined. We assessed the mediating effect of posttraumatic stress and cervical range of movement on the longitudinal relationship between initial pain intensity and MFI. There was no difference in MFI across all groups at enrollment. MFI values increased in the moderate/severe group and were significantly higher in comparison to the recovered and mild groups at 3 and 6 months. No differences in MFI values were found between the mild and recovered groups. Initial severity of PTSD symptoms mediated the relationship between pain intensity and MFI at 6 months. Initial ROM loss did not.

CONCLUSIONS: MFI in the cervical extensors occur soon following whiplash injury and suggest the possibility for the occurrence of a more severe injury with subsequent PTSD in patients with persistent symptoms.


Headache and musculoskeletal complaints among subjects with self reported whiplash injury: the HUNT-2 study.  [Link]

BMC Musculoskelet Disord. 2011 Jun 8;12:129. doi: 10.1186/1471-2474-12-129.

Myran R, Hagen K, Svebak S, Nygaard O, Zwart JA.
Norwegian University of Science and Technology (NTNU), Norway. rigmor.myran@ntnu.no

BACKGROUND: To evaluate the life-time prevalence of self reported whiplash injury and the relationship to chronic musculoskeletal complaints (MSCs) and headache in a large unselected adult population.

METHODS: Between 1995 and 1997, all inhabitants 20 years and older in Nord-Trondelag county in Norway were invited to a comprehensive health survey. Out of 92,936 eligible for participation, a total of 59,104 individuals (63.6%) answered the question about whiplash injury (whiplash). Among these, 46,895 (79.3%) responded to the questions of musculoskeletal complaints and headache.

RESULTS: The total life-time prevalence of self reported whiplash injury was 2.9%, for women 2.7% and for men 3.0%. There was a significant association between self reported whiplash injury and headache (OR = 2.1; 95% CI 1.8-2.4), and chronic MSCs (OR = 3.3; 95% CI 2.8-3.8), evident for all ten anatomical sites investigated. The association was most pronounced for those with a combination of headache and chronic MSC for both men (OR = 4.8; 95% CI 3.6-6.2) and women (OR = 5.2; 95% CI 3.7-7.1).

CONCLUSIONS: Subjects with self reported whiplash injury had significantly more headache and musculoskeletal complaints than those without, and may in part be due to selective reporting. The causal mechanism remains unclear and cannot be addressed in the present study design.


Altered postural sway in patients suffering from non-specific neck pain and whiplash associated disorder - A systematic review of the literature.  [Link]

Chiropr Man Therap. 2011 May 24;19(1):13.

Ruhe A, Fejer R, Walker B.
Murdoch University, Praxis fuer Chiropraktik Wolfsburg, Porschestrasse 1, 38440 Wolfsburg, Germany. alexander_ruhe@hotmail.com.

STUDY DESIGN: Systematic literature review.

OBJECTIVES: To assess differences in center of pressure (COP) measures in patients suffering from non-specific neck pain (NSNP) or whiplash-associated disorder (WAD) compared to healthy controls and any relationship between changes in postural sway and the presence of pain, its intensity, previous pain duration and the perceived level of disability.

SUMMARY OF BACKGROUND DATA: Over the past 20 years, the center of pressure (COP) has been commonly used as an index of postural stability in standing. While several studies investigated COP excursions in neck pain and WAD patients and compared these to healthy individuals, no comprehensive analysis of the reported differences in postural sway pattern exists.

SEARCH METHODS: Six online databases were systematically searched followed by a manual search of the retrieved papers.

SELECTION CRITERIA: Papers comparing COP measures derived from bipedal static task conditions on a force plate of people with NSNP and WAD to those of healthy controls.

DATA COLLECTION AND ANALYSIS: Two reviewers independently screened titles and abstracts for relevance. Screening for final inclusion, data extraction and quality assessment were carried out with a third reviewer to reconcile differences.

RESULTS: Ten papers met the inclusion criteria. Heterogeneity in study designs prevented pooling of the data and no direct comparison of data across the studies was possible. Instead, a qualitative data analysis was conducted. There was broad consensus that patients with either type of neck pain have increased COP excursions compared to healthy individuals, a difference that was more pronounced in people with WAD. An increased sway in antero-posterior direction was observed in both groups.

CONCLUSIONS: Patients with neck pain (due to either NSNP or WAD) exhibit greater postural instability than healthy controls, signified by greater COP excursions irrespective of the COP parameter chosen. Further, the decreased postural stability in people with neck pain appears to be associated with the presence of pain and correlates with the extent of proprioceptive impairment, but appears unrelated to pain duration.


Dynamic and functional balance tasks in subjects with persistent whiplash: a pilot trial.  [Link]

Man Ther. 2011 Aug;16(4):394-8. Epub 2011 Mar 1.

Stokell R, Yu A, Williams K, Treleaven J.
The Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Australia.

Disturbances in static balance have been demonstrated in subjects with persistent whiplash. Some also report loss of balance and falls. These disturbances may contribute to difficulties in dynamic tasks. The aim of this study was to determine whether subjects with whiplash had deficits in dynamic and functional balance tasks when compared to a healthy control group. Twenty subjects with persistent pain following a whiplash injury and twenty healthy controls were assessed in single leg stance with eyes open and closed, the step test, Fukuda stepping test, tandem walk on a firm and soft surface, Singleton test with eyes open and closed, a stair walking test and the timed 10 m walk with and without head movement. Subjects with whiplash demonstrated significant deficits (p < 0.01) in single leg stance with eyes closed, the step test, tandem walk on a firm and soft surface, stair walking and the timed 10 m walk with and without head movement when compared to the control subjects. Specific assessment and rehabilitation directed towards improving these deficits may need to be considered in the management of patients with persistent whiplash if these results are confirmed in a larger cohort.


Are symptoms of late whiplash specific? A comparison of SCL-90-R symptom profiles of patients with late whiplash and patients with chronic pain due to other types of trauma.  [Link]

J Rheumatol. 2011 Jun;38(6):1086-94. Epub 2011 Mar 1.

Radanov BP, Mannion AF, Ballinari P.
Pain Unit, Schulthess Klinik, Lengghalde 2, CH-8008 Zürich, Switzerland. bogdan.radanov@kws.ch

OBJECTIVE: Focusing on symptoms referred to as specific for late whiplash may contribute to misconceptions in assessment, treatment, and settlements. We compared Symptom Checklist 90-Revised (SCL-90-R) symptom profiles of patients with late whiplash and patients with chronic pain due to other types of trauma.

METHODS: We compared 156 late whiplash patients (WP group) with 54 chronic pain patients who had suffered different bodily trauma (non-WP group) with regard to the following aspects of the SCL-90-R: the Positive Symptom Total (PST); the nine SCL-90-R dimensions and additional global indices, i.e., Global Severity Index (GSI) and Positive Symptom Distress (PSD); and complaints referred to as specific for late whiplash syndrome.

RESULTS: The mean adjusted T score for PST was in the normal range for the WP group (T = 56.1, 95% CI 54.1-58.1) and in the pathological range for the non-WP group (T = 61.1, 95% CI 57.3-64.9). Both the WP and non-WP groups showed mean T scores in the pathological range for the dimensions "Somatization," "Obsessive-Compulsive," and PSD. Only the non-WP group had an average score in the pathological range for the dimensions "Depression," "Anxiety," and "Phobic Anxiety" and for the global indices GSI and PST. Multivariable regression controlling for gender and education level was used to identify complaints "specific for late whiplash" that were significantly associated with being in the WP group rather than the non-WP group: greater headache (OR 1.54; 95% CI 1.16, 2.03; p = 0.003) and lower emotional lability (OR 0.96; 95% CI 0.93, 0.98; p = 0.003) were the only significant variables.

CONCLUSION: Late whiplash is not a chronic pain condition characterized by specific symptoms, other than greater headache.


Long-term functioning following whiplash injury: the role of social support and personality traits.  [Link]

Clin Rheumatol. 2011 Jul;30(7):927-35. Epub 2011 Feb 16.

Nijs J, Inghelbrecht E, Daenen L, Hachimi-Idrissi S, Hens L, Willems B, Roussel N, Cras P, Bernheim J.
Department of Human Physiology, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Building L-Mfys, Pleinlaan 2, BE-1050, Brussels, Belgium. Jo.Nijs@vub.ac.be

Transition from acute whiplash injury to either recovery or chronicity and the development of chronic whiplash-associated disorders (WAD) remains a challenging issue for researchers and clinicians. The roles of social support and personality traits in long-term functioning following whiplash have not been studied concomitantly. The present study aimed to examine whether social support and personality traits are related to long-term functioning following whiplash. One hundred forty-three subjects, who had experienced a whiplash injury in a traffic accident 10-26 months before the study took place, participated. The initial diagnoses were a 'sprain of the neck' (ICD-9 code 847.0); only the outcome of grades I-III acute WAD was studied. Long-term functioning was considered within the biopsychosocial model: it was expressed in terms of disability, functional status, quality of life and psychological well-being. Participants filled out a set of questionnaires to measure the long-term functioning parameters (i.e. the Neck Disability Index, Medical Outcome Study Short-Form General Health Survey, Anamnestic Comparative Self-Assessment measure of overall well-being and the Symptom Checklist-90) and potential determinants of long-term functioning (the Dutch Personality Questionnaire and the Social Support List). The results suggest that social support (especially the discrepancies dimension of social support) and personality traits (i.e. inadequacy, self-satisfaction and resentment) are related to long-term functioning following whiplash injury (Spearman rho varied between 0.32 and 0.57; p?<?0.01). Within the discrepancy dimension, everyday emotional support, emotional support during problems, appreciative support and informative support were identified as important correlates of long-term functioning. Future prospective studies are required to confirm the role of social support and personality traits in relation to long-term functioning following whiplash. For such studies, a broad view of long-term functioning within the biopsychological model should be applied.


Does cervical kyphosis relate to symptoms following whiplash injury?  [Link]

Man Ther. 2011 Aug;16(4):378-83. Epub 2011 Feb 3.

Johansson MP, Baann Liane MS, Bendix T, Kasch H, Kongsted A.
Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.


Reverse Causality in the Association Between Whiplash and Symptoms of Anxiety and Depression: The HUNT Study. 

Spine (Phila Pa 1976). 2011 Aug 1;36(17):1380-6.

Mykletun A, Glozier N, Wenzel HG, Overland S, Harvey SB, Wessely S, Hotopf M.
Norwegian Institute of Public Health, Division of Mental Health, Oslo, Norway † University of Bergen, Faculty of Psychology, Department of Health Promotion and Development, Norway ‡ The University of Sydney, Disciplines of Psychiatry and Sleep Medicine, Sydney Medical School, Australia § Orkdal DPS, St. Olavs Hospital, University Hospital of Trondheim, Norway Department of Psychological Medicine, Institute of Psychiatry, Kings College London, United Kingdom.

STUDY DESIGN.: Longitudinal population-based cohort study.

OBJECTIVE.: The aim of this study was to examine the possibility of reverse causality, that is, if symptoms of anxiety and depression are associated with incident self-reported whiplash injury. The clinical relevance of self-reported whiplash injury was evaluated by its association with subsequent disability pension award.

SUMMARY OF BACKGROUND DATA.: Whiplash is associated with an increased level of anxiety and depressive symptoms. This increase in psychological distress is generally understood as the consequence of the accident and related whiplash.

METHODS.: Longitudinal data from the HUNT study was used. Baseline measures of symptoms of anxiety and depression were used in prediction of incident whiplash injury self-reported at follow-up 11 years later. Incident disability pension award was obtained from a comprehensive national registry during 2-year follow-up after self-reported whiplash injury.

RESULTS.: Case-level symptom load of anxiety and depression at baseline increased the likelihood of reporting incident whiplash at follow-up (odds ratio [OR] = 1.60, 95% confidence interval = 1.22-2.11). Self-reported whiplash increased the chances of a subsequent disability pension award (OR = 6.54), even in the absence of neck pain (OR = 3.48).

CONCLUSION.: This is the first published study with a prewhiplash prospective evaluation of psychological status. Our findings are in conflict with previous research suggesting whiplash to be the cause of associated psychological symptoms rather than their consequence. Self-reported whiplash injury was clinically relevant as it independently increased subsequent disability pension award. The strength of this effect, even in the absence of neck pain, suggests the ascertainment of this diagnostic label, or factors associated with this, are important predictors of disability.


The slow and fast components of postural sway in chronic neck pain.  [Link]

Man Ther. 2011 Jun;16(3):273-8. Epub 2010 Dec 24.

Röijezon U, Björklund M, Djupsjöbacka M.
Centre for Musculoskeletal Research, University of Gävle, Box 7629, Umeå 90712, Sweden. ulrik.roijezon@ltu.se

BACKGROUND: Several studies have reported altered postural control in people with neck pain. The aim of this study was to increase the understanding of the nature of altered postural control in neck pain by studying the slow and fast components of body sway.

METHODS: Subjects with whiplash associated disorders (WAD, n = 21) and chronic non-specific neck pain (NS, n = 24) were compared to healthy controls (CON, n = 21) in this cross-sectional study. The magnitudes of the slow and fast sway components were assessed in Rhomberg quiet stance for 30 s on a force plate with eyes closed. We also investigated associations between postural sway and symptoms, self-ratings of functioning and kinesiophobia.

RESULTS: Increased magnitude of the slow sway component was found in WAD, but not in NS. Greater magnitude of the slow component in WAD was associated with poorer physical functioning, including balance disturbances, and more severe sensory symptoms.

CONCLUSIONS: Increased magnitude of the slow sway component implies an aberration in sensory feedback or processing of sensory information in WAD. The associations between postural sway and self-rated characteristics support the clinical validity of the test. Further investigation into NS, involving a longer test time is warranted.


Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders.  [Link]

Man Ther. 2011 Jun;16(3):252-7. Epub 2010 Dec 23.

Treleaven J, Jull G, Grip H.
The Whiplash Research Unit, Division of Physiotherapy, The University of Queensland, Brisbane 4072, Australia. j.treleaven@uq.edu.au

Symptoms of dizziness, unsteadiness and visual disturbances are frequent complaints in persons with persistent whiplash associated disorders. This study investigated eye, head co-ordination and gaze stability in subjects with persistent whiplash (n = 20) and asymptomatic controls (n = 20). Wireless motion sensors and electro-oculography were used to measure: head rotation during unconstrained head movement, head rotation during gaze stability and sequential head and eye movements. Ten control subjects participated in a repeatability study (two occasions one week apart). Between-day repeatability was acceptable (ICC > 0.6) for most measures. The whiplash group had significantly less maximal eye angle to the left, range of head movement during the gaze stability task and decreased velocity of head movement in head eye co-ordination and gaze stability tasks compared to the control group (p < 0.01). There were significant correlations (r > 0.55) between both unrestrained neck movement and neck pain and head movement and velocity in the whiplash group. Deficits in gaze stability and head eye co-ordination may be related to disturbed reflex activity associated with decreased head range of motion and/or neck pain. Further research is required to explore the mechanisms behind these deficits, the nature of changes over time and the tests' ability to measure change in response to rehabilitation.


Resolution of whiplash-associated allodynia following cervicothoracic thrust and non-thrust manipulation.  [Link]

Physiother Theory Pract. 2011 Aug;27(6):451-9. Epub 2010 Oct 26.

Lowry CD, O'Hearn MA, Courtney CA.
St. John Medical Center, Tulsa, OK, USA. carina.lowry@hotmail.com

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.


Five years post whiplash injury: Symptoms and psychological factors in recovered versus non-recovered.  [Link]

BMC Res Notes. 2010 Jul 13;3:190.

Merrick D, Stålnacke BM.
Department of Community Medicine and Rehabilitation (Rehabilitation Medicine) Bldg 9A, Umeå University Hospital, Umeå University, SE-901 85 Umeå, Sweden. brittmarie.stalnacke@rehabmed.umu.se.

BACKGROUND: Few studies have focused on the differences between persons who are recovered after whiplash injury and those who suffer from persistent disability. The primary aim of this study was therefore to examine differences in symptoms, psychological factors and life satisfaction between subjects classified as recovered and those with persistent disability five years after whiplash injury based on the Neck Disability Index (NDI).

METHODS: A set of questionnaires was answered by 158 persons (75 men, 83 women) to assess disability (NDI), pain intensity (VAS), whiplash-related symptoms (Rivermead Post-Concussion Symptoms Questionnaire, RPQ), post-traumatic stress (Impact of Event Scale, IES), depression (Beck's depression inventory, BDI) and life satisfaction (LiSat-11).The participants were divided into three groups based on the results of the NDI: recovered (34.8%), mild disability (37.3%) and moderate/severe disability (27.3%).

RESULTS: The moderate/severe group reported significantly higher VAS, BDI and IES scores and lower level of physical health and psychological health compared to the mild and the recovered groups. Less significant differences were reported between the mild and the recovered groups.

CONCLUSIONS: The group with the highest disability score reported most health problems with pain, symptoms, depression, post-traumatic stress and decreased life satisfaction. These findings indicate that classifying these subjects into subgroups based on disability levels makes it possible to optimize the management and treatment after whiplash injury.


Identifying predictors of early non-recovery in a compensation setting: The Whiplash Outcome Study.  [Link]

Injury. 2010 Jul 31. [Epub ahead of print]

Casey PP, Feyer AM, Cameron ID.
Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.

CONTEXT: People with Whiplash Associated Disorder (WAD) often experience pain and disability for extended periods of time. A large proportion of these people will seek treatment through a compensation process. Rarely is data related to people's health collected within the compensation process making it difficult to identify those that are at risk of delayed recovery and appropriately direct interventions.

STUDY OBJECTIVE: To compare people with WAD who have recovered with those that have not, within 3 months of injury and identify potential predictors of poorer health and non-recovery to inform claim screening processes.

STUDY DESIGN: Cross-sectional analysis of a cohort study.

PARTICIPANTS: People who sustained a WAD and claimed compensation within an Australian Motor Accidents Compensation Scheme between November 2007 and June 2009.

MEASURE OF RECOVERY: Functional Rating Index (FRI) score (<=25).

HEALTH OUTCOME MEASURES: Short Form 36 (SF36), FRI, and the Pain Catastrophising Scale (PCS).

METHODS: 246 people who had lodged a claim for compensation were enrolled in the Whiplash Outcome Study within 3 months of sustaining a WAD injury. Participants were assigned to a recovered or non-recovered group and analysed for differences between the two groups. Multiple linear regression models were used to identify potential predictors of poorer health and non-recovery.

RESULTS: Overall 23% of the study population had recovered within 3 months of sustaining a WAD, whilst only 9% had finalised their insurance claim. The recovered group had significantly better scores on all health outcome measures; SF36 Physical Component Score, SF36 Mental Component Score and the PCS (p<0.001). The significant independent predictors of poorer health and non-recovery were helplessness (p<0.001), older age (p<0.001) and pre-injury work status being affected (p<0.001) (r(2)=.624). Regardless of the health outcome measure used, helplessness was significantly associated with poorer reported health.

CONCLUSION: Including additional information at claim notification, specifically the PCS and information on the effect the injury has on the working population could significantly improve claim screening processes, identifying those with poorer health and risk of non-recovery.


Post-traumatic headache: is it for real? Crossfire debates on headache: pro.  [Link]

Headache. 2010 Apr;50(4):710-5.

Obermann M, Keidel M, Diener HC.
Department of Neurology, University of Duisburg-Essen, Essen, Germany.

Mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Even though between 30% and 90% of patients develop post-traumatic headache, post-traumatic headache remains a very controversial disorder. Particularly when it comes to chronic post-traumatic headache following mild closed head injury and headache attributed to whiplash injury. Some experts are disputing its existence as a genuine disorder. Indistinct disease classification, unresolved pathophysiological mechanism, and the role of accident-related legal issues further fuel this controversy. The complex combination of pain and neuropsychological symptoms needs further research in understanding the underlying pathophysiological mechanisms associated with the acute headache following trauma but more so the mechanisms associated with the development of chronic pain in some patients. Investigators should refrain from oversimplifying these complex mechanisms as hysteric exaggeration of everyday complains and from implying greed as motivation for this potentially very disabling disease.


Cognitive symptoms, cervical range of motion and pain as prognostic factors after whiplash trauma.  [Link]

Acta Neurol Scand. [Epub ahead of print]

Borenstein P, Rosenfeld M, Gunnarsson R.
The Stroke Unit, Department of Internal Medicine, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.

Objectives - To evaluate pain, cervical range of motion (CROM) and cognitive symptoms as predictors for poor prognosis defined as sick leave 3 years later. Material and methods - In 97 patients CROM, pain intensity and cognitive symptoms were measured immediately following trauma, at 6 months and 3 years. Patients were also asked at 3 years if they had been on sick leave the last 6 months.

Results - Pain intensity and reduced CROM were not clinically useful as predictors of later sick leave. The best predictors were presence within 96 h after injury of the two cognitive symptoms 'being easily distracted' (odds ratio 8.7-50) and 'easily irritated' (odds ratio 5.3-31).

Conclusions - Initial pain and reduced CROM may be related to minor tissue damage which often heals while late functionality is more dependent on other factors such as cognitive dysfunction. For patients with whiplash-associated disorders two simple questions should be asked; 'Are you currently easily irritated?' and 'Are you currently easily distracted (e.g. is it difficult for you to follow a conversation if several people are talking in the room at the same time)?'. An affirmative answer to any of these questions indicates an increased risk for poor prognosis defined as sick leave 3 years later.


Psychological factors in the use of the neck disability index in chronic whiplash patients. 

Spine (Phila Pa 1976). 2010 Jan 1;35(1):E16-21.

Vernon H, Guerriero R, Kavanaugh S, Soave D, Moreton J.
Division of Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. hvernon@cmcc.ca

STUDY DESIGN: Cross-sectional clinical study.

OBJECTIVE: Determine if psychological factors "fear avoidance behavior" and "pain amplification," along with age, gender, duration, and pain severity correlate with scores of self-rated disability in chronic whiplash sufferers.

SUMMARY OF BACKGROUND DATA: The Fear Avoidance Model has gained acceptance in the understanding of whiplash-associate disorders (WAD). While the variables important in this model have been studied in acute/subacute samples and some small chronic samples, no study has explicitly investigated the role these and other psychosocial variables play in the self-ratings of neck-related disability in chronic WAD sufferers.

METHODS: Chronic WAD sufferers (>3 months) were recruited from private practice. No WAD IV subjects were included. Subjects completed a Neck Disability Index (NDI), Tampa Scale for Kinesiophobia (TSK), pain visual analogue scale, and pain diagram. Clinical and demographic data were also obtained. Univariate correlations were obtained with the Spearman rank correlation coefficient. Items achieving statistical significance on univariate analysis were loaded in a step-wise linear regression analysis.

RESULTS: One hundred seven subjects were investigated (54 females), with a mean age of 45.4 (17) years and a mean duration of 13.4 (14.6) months. Fair to moderately strong correlations were obtained between the NDI and the TSK, pain visual analogue scale and pain drawing scores, but not with "duration." The Pain Diagram correlated with NDI scores and pain severity. A multivariate model accounting for 31% of the variance of the NDI scores (P < 0.001) was obtained with the TSK, pain severity, and pain drawing.

CONCLUSION: It appears that important psychological factors (fear avoidance beliefs and pain amplification) do have some influence on self-ratings of disability in chronic WAD sufferers. This does not appear to be larger than that found in studies of acute/subacute subjects. The influence of these factors may plateau fairly early in the post-WAD period. There is some evidence that the Pain Diagram may provide insight into nonorganic pain behavior.
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