Whiplash Associated Disorders: The pathway from acute to …askdrlehman.com/ub-ortho/wad1.pdf · 2015. 8. 24. · Whiplash Neck Injury • First described by Crowe in 1928. • Most
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Whiplash Associated Disorders: The pathway from acute to
chronic pain JamesJ.Lehman,DC,MBA,FACO
UniversityofBridgeportCollegeofChiroprac@c
Learning Objec?ves
• Determinepa@ent’sprognosisandpoten@altoexperiencechronicpainsyndromefollowingawhiplashinjury,priortoprovidingchiroprac@cservices.
Whiplash Neck Injury
• FirstdescribedbyCrowein1928.• Mostcommontypeofinjuryfollowingmotorvehiclecrashes• Usually2-3weeksforrecovery• Yet,upto42%transi@onfromacutetochronicpainstatus.(1)
“Diagnosisisthekeytosuccessfultreatment!”
Quebec Task Force Defini?on
• Whiplashinjuryis“anaccelera@on-decelera@onmechanismofenergytransferredtotheneck,”usuallyresul@ngfromrear-endorside-impactmotorvehiclecollision.(2)
Whiplash Injury Costs
• Queensland,Australia=$500millionAustraliandollars(1994-2001)
• MAIC.Whiplash—ReviewofCTPQueenslandDatato31Dec2001.Brisbane,Australia:TheMotorAccidentInsuranceCommission(MAIC);2002.
• UnitedKingdom=L3billionperannum
• JoslinCC,KhanSN,BannisterGC.Long-termdisabilityagerneckinjury:acompara@vestudy.JBoneJointSurgBr.2004;86:1032–1034.
• UnitedStates=USD$29billionperannum
• BlincoeL,SeayA,ZaloshnjaE,etal.TheEconomicImpactofMotorVehicleCrashes,2000.Washington,DC;Na@onalHighwayTrafficSafetyAdministra@on:2002.
Pathomechanics of Whiplash Injury
Whiplash Injury Symptoms
• Pain,• dizziness,• visualandauditorydisturbances,• temporomandibularjointdysfunc@on,
• photophobia,• dysphonia,• dysphonia,• fa@gue,• cogni@vedifficul@essuchasconcentra@onandmemoryloss,anxiety,insomnia,anddepression(3)
•
Case One = WAD I
• Pa@entpresentswithneckcomplaintsincludings@ffnessortendernessintheneckregionsandnophysicalsignsofinjury.
• SpitzerWO,SkovronML,SalmiLR,etal.Scien@ficmonographoftheQuebecTaskForceonWhiplash-AssociatedDisorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.
• Mostlikelydiagnosisisacute,mildcervicalstrain• Prognosisisgood• Spontaneousrecoverywithin2-3weeksiscommon.
Case Two: WAD II
• Pa@entpresentswithneckcomplaintsincludings@ffnessortenderness,andsomephysicalsignsofinjury,suchaspointtendernessortroubleturningthehead.
• Acute,moderatecervicalsprain/strainismostlikelyDX• Prognosisisdifficulttopredict• Currentmanagementdoesnotappeartolessentransi@onfromacutetochronicpainstatus• Physicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredic@veofpoorrecovery
Case Three: WAD III
• Pa@entpresentswithneckcomplaintsincludings@ffnessortendernessandneurologicalsignsofinjurysuchasdeeptendonreflexormotordeficits.
• Acute,moderatesprain/strainwithresultantcervicalradiculopathy• Currentmanagementdoesnotappeartolessentransi@onfromacutetochronicpainstatus• Physicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredic@veofpoorrecovery
Case Four: WAD IV
• Pa@entpresentswithneckcomplaintsandafractureand/ordisloca@onofthecervicalspine.
Grade 3 Facet Sprains and Transverse Processes Fractures • Mul@plefacetjointrupturesandfracturesofthetransverseprocessesfromC4toC6.• Atautopsyahematomainthelonguscollimusculatureextendedalongthebrachialplexusintotheaxilla.• Theseserialfracturesweredetectedatsecondlookonthespecimenradiograms.• Thefracturesrunposteriorlythroughtheintertransversebarintothejointsthatdisplaytorncapsulesandmeniscoidsandhemarthrosis
Occipital Condyle Fracture
• Thefragmentwasavulsedbythe(intact)alarligament.• Ontheplainradiogramsthisfracturewasbarelyvisibleandwasonlydetectedatsecond–lookevalua@on.• Theavulsedfragmentisdisplacedposteriorlyandmedially,embeddingmediumfillsthewidefracturegap.• Intheatlanto–axialjointtheposteriormeniscoidandthejointcapsulearetorn,pullingtheC2nerveintothejointspace.
“Diagnosisisthekeytosuccessfultreatment!”
Quebec Task Force (QTF) Classifica?ons
• SponsoredbyapublicinsurerinCanada.• QTFsubmivedrecommenda@onsregardingclassifica@onandtreatmentofWAD,whichwasusedtodevelopaguideformanagingwhiplashin1995.• Anupdatedreportwaspublishedin2001.• Eachofthegradescorrespondstoaspecifictreatmentrecommenda@on.
Quebec Task Force (1995) Cri?cisms
1. Largelyconsensusbasedratherthanevidence-based
2. Selec@onbiasfortheliteraturereview
Swedish Study and Quebec Task Force
• NeithertheWADclassifica@onnortheQTFfollow-upregimencouldbelinkedtoabeveroutcome.
• JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classifica@onnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeagerawhiplashinjury.Aprospec@vestudyon186consecu@vepa@ents.EurSpineJ.2008Jul;17(7):930–935.
Swedish Study and Quebec Task Force
• Themul@ple-follow-upregimenisboth@meconsumingandcostlyandappearsnotbejus@fiedinarou@neclinicalsewng.
Swedish Study and Quebec Task Force
• TheWAD-classifica@oncouldnotpredictpersistentneckpainagerawhiplashinjuryinthishospitalemergencydepartmentbasedpopula@on.
Swedish Study and Quebec Task Force
• Norwasthereasta@s@callysignificantdifferenceintherateofchronicneckpainbetweentheno-follow-upregimenandthemul@ple-follow-upregimenproposedbytheQTF.
Swedish Study and Quebec Task Force
• Atthefirstvisitwerecommendacarefulhistory,physicalexamina@onandinforma@onaboutthenatureofthecondi@on.
Swedish Study Findings
• Inthisstudycaseswithneckpainbeforetheaccidentandahighdegreeofemo@onaldistressfromtheaccidenthadatenfoldincreasedriskofdevelopingchronicneckpain.(4)
Transi?on from Acute to Chronic Pain Status
• Pa@entsthatdonotresolvewithinweeksogenexhibitamyriadofsymptomssoonagertheinjuryevent.
“Diagnosisisthekeytosuccessfultreatment!”
Pathoanatomical Lesions in the Whiplash Injury
1. CervicalFacetjoints(ZygapophysealJoints)
2. DorsalRootGanglion(DRG)andNerveRoots
3. CervicalLigaments4. IntervertebralDiscInjuries5. MuscleInjuries
Facet Joint Injury Model
• Studiesemployingthecervicalfacetjointinjurymodelhaveiden@fiedtheoccurrenceofhemarthrosis,capsulardamage,jointfractures,andcapsularrupture.
• JoslinCC,KhanSN,BannisterGC.Long-termdisabilityagerneckinjury:acompara@vestudy.JBoneJointSurgBr.2004;86:1032-1034.
Cervical Facet Injury Model
• Clinicalsupportforafacetogenicmodelofpersistentpaingenera@oninwhiplashcanbefoundintheliterature.
• LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainagerwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.
Cervical Facet Injury Model
• Asaresultoffacetjointinjury,whiplashpa@entsfrequentlyencounter,headaches,backandshoulderpaininaddi@ontoneckpain.
• ElliotJM,etal.Characteriza@onofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.
Cervical Facet Joint Injury and Referred Pain
• ThemostcommonfacetstobeinjuredandhighestprevalenceofjointpainareatC2/C3andC5/C6,whichfrequentlyresultsinreferredpain.
• LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainagerwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.
Dorsal Root Ganglion and Nerve Roots
• Vulnerabletoexcessivestretchingandinjuryduringrapidaccelera@on/decelera@on(“S-shaped”curve)orlateralbendingoftheneckasdemonstratedinrear-endorside-vectorimpactwhiplash.
Dorsal Root Ganglion (DRG) Compression and SoV Tissue Changes
• Largelyundetected• Maycontributetoadapta@onintheoverallfunc@oningofthecervicalDRG• Maypredisposeanindividualtoabnormal,centrallymediatedpainprocessing.(5,6)
Cervical Ligamentous Sprain Injuries
• Possibleinjurytomechanorecep@veandnocicep@venerveendingsleadingtopain,inflamma@onandchronicpainsyndrome
• TominagaY,NduAB,CoeMP,etal.Neckligamentstrengthisdecreasedfollowingwhiplashtrauma.BMCMusculoskeletDisord.2006;7:103.
Persistent Pain: A Chronic Illness
• Acutepainusuallygoesawayageraninjuryorillnessresolves.Butwhenpainpersistsformonthsorevenyears,longagerwhateverstartedthepainhasgoneorbecausetheinjurycon@nues,itbecomesachroniccondi@onandillnessinitsownright.
• ACalltoRevolu@onizeChronicPainCareinAmerica:AnOpportunityinHealthCareReform.TheMaydayFund.November4,2009.AmendedMarch4,2010.
Na?onal Pain Strategy
• Chronicpain-Painthatoccursonatleasthalfthedaysforsixmonthsormore.
JamesJ.Lehman,DC,MBA,DABCO
Upper Cervical Ligament Sprain Injuries and the Presence of Rust’s Sign
• Historyofroll-overMVAorblowtohead• Suspectuppercervicalspineinstability• OrderimmediateCTScantocheckfornon-displacedcervicalspinefracture
“Diagnosisisthekeytosuccessfultreatment!”
Upper Cervical Ligament Sprain Injuries Leading Chronic Pain
• Severityofalarligamentinjury,headposi@onat@meofimpact,NeckDisabilityIndex(NDI)scoresandreproduc@onofpainandexcessivemobilitywithmanualexamina@on.(7,8)• SharpPurserManeuvertestforuppercervicalspineinstability.
Cervical Disc Injuries
Presentin25%ofsubjectspostwhiplashinjuryandcorrelatedwithradicularsymptoms(9,10)
Cervical Disc Injuries
• C5-6segmentallevelwasfoundtobethemostcommonlevelofdiscinjury...• greaterriskoflow-gradespinalcordinjurywithpre-exis@ngspinalcanalnarrowingatC5-6level
• ItoS,PanjabiMM,IvancicPC,PearsonAM.Spinalcanalnarrowingduringsimulatedwhiplash.Spine.2004;29:1330-1339.
Cervical Spondylo?c Myelopathy
CommonsymptomsClumsyorweakhandsLegweaknessors@ffnessNecks@ffnessPaininshouldersorarmsUnsteadygaitCommonsignsAtrophyofthehandmusculatureHyperreflexiaLhermive'ssign(electricshock-likesensa@ondownthecenterofthebackfollowingflexionoftheneck)Sensoryloss
Muscles Strained
• WhiplashhasbeendemonstratedtostrainSCM,semispinalis,spleniuscapi@sanduppertrapeziuswithrear-endimpacts.
• BraultJR,SiegmundGP,WheelerJB.Cervicalmuscleresponseduringwhiplash:evidenceofalengtheningmusclecontrac@on.ClinBiomech(Bristol,Avon).2000;15:426-435.
Physical and Psychological Features Leading to Chronic Pain Syndrome
• Pooroutcomesat2-3yearspostinjury• Highpainanddisabilitylevelswithphysicalandpsychologicalfactors• Earlypresenceofcervicalmovementloss,coldtemperaturehyperalgesia,andposvrauma@cstresssymptoms
• SterlingM,JullG,KenardyJ.Physicalandpsychologicalfactorsmaintainlong-termpredic@vecapacitypost-whiplashinjury.Pain.2006;122:102-108.
“Diagnosisisthekeytosuccessfultreatment!”
Characteris?cs of the Whiplash Presenta?on
• MotorDysfunc@on• Ac@vecervicalROMrestric@ons• Shortandlong-termdeficits• Alteredpavernsofmusclerecruitmentincervicalspineandshouldergirdle(11,12)
Characteris?cs of the Whiplash Presenta?on
• SensorimotorDysfunc@on• AcuteandchronicWAD• Greaterjointreposi@oningerrorswithchronicWADandacutewithmoreseverepainanddisability• Lossofbalanceanddisturbedneck-influencedeyemovementswithchronicWAD
• ElliovJM,etal.Characteriza@onsofAcuteandChronicWhiplash-AssociatedDisorders.JOSPT,May2009;Vol39:5:312-323.
Characteris?cs of the Whiplash Presenta?on Sensory Func?on Disturbances • Hypersensi@vity(decreasedpainthreshold)topressure,thermal,electrocutaneous• Spinalcordhypersensi@vity(centralsensi@za@on)
• SterlingM,KenardyJ.Physicalandpsychologicalaspectsofwhiplash:Importantconsidera@onsforprimarycareassessment.Manher.2008;13:93-102.
Psychological Factors and Chronic WAD or Chronic Pain Syndrome-Post-Trauma?c
• Affec@vedisorders• Anxiety• Depression• Behavioralabnormali@es(fearofmovement)• Posvrauma@cstress
Post Whiplash Injury Muscle FaZy Infiltrates
• MusclefavyinfiltratesonMRIdevelopsoonagerthewhiplashevent(between4-weeksand3-months)butonlyinthosewithhigherini@alpainlevelsandasubsequentpost-trauma@cstressresponse(PTSD).
• ElliovJ,PedlerA,KenardyJ,GallowayG,JullG,SterlingM(2011)TheTemporalDevelopmentofFavyInfiltratesintheNeckMusclesFollowingWhiplashInjury:AnAssocia@onwithPainandPosvrauma@cStress.PLoSONE6(6):e21194.doi:10.1371/journal.pone.0021194
Degenera?on of the Cervical Extensor Musculature in Chronic WAD
Contentnotquan@tyisabevermeasureofmuscledegenera@oninwhiplash.
ElliovJM,etal.ManualTherapy(2013)
Whiplash Presenta?on
• “Whiplashisamarkedlyheterogeneousandcomplexcondi@onwithvarieddisturbancesinmotor,sensorimotorandsensoryfunc@onaswellaspsychologicaldistress.”
Clinical Implica?ons and Prognosis of Chronic Pain
• Kinesthe@cdeficits(jointposi@onerror)• Cervicalmusclerecruitmentpaverns• Alteredac@vityinuppertrapeziusmuscle• Poorcontrolofbalance• Impairedeyemovement(13-17)
Tes?ng for Joint Posi?oning Error and Kinesthe?c deficits
Targetdistanceis90CMBeyondtheyellowareaisasignificanterror.(18)
TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@onshipwithcervicaljointposi@onerror.JRehabilMed.2003Jan;35(1):36---43.
Cervical muscle recruitment paZerns • Cranio-cervicalflexiontestavemptstodeterminethestrength/weaknessofthedeepflexormusclesofthecervicalspine(Longuscapi@sandcolli)• Elimina@ngtheinfluenceofthesuperficialneckflexors(Sternocleidomastoideusandanteriorscalene)
Oculomotor Control
Theassessmentofsmoothpursuitandgazestabilityisanimportantpartoftheassessmentofsensorimotorimpairmentfollowingwhiplashinjury.
Sensorimotor Ocular Tes?ng
• Smoothpursuitinvolvesthesubjectkeepingtheirheads@llandfollowingaslowmovingobjectwithjusttheireyesfromabout30°onesideofthemidlineto30°ontheoppositeside.
Sensorimotor Ocular Tes?ng
• Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.
Sensorimotor Ocular Tes?ng
• Reproduc@onofdizzinessorpain,increasedeffortordifficultyperformingthetest,allsuggestsensorimotorimpairment.
Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)
• Thistestinvolvescomparisonofsmoothpursuitperformanceinaneutralheadposi@onwithperformanceinanecktorsionedposi@on45°degreeslegand45°right.• Itistermed‘necktorsion’becausethetrunkisrotatedonthenecktoavoids@mula@onoftheves@bularsystem.
Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)
• Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.
• Reproduc@onofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.
Gaze Stability Tes?ng
• Askpa@enttolookatanobjectroughlyarm’s-lengthfromtheirfaceandtoslowlyflexandextendtheirheadandneckorgentlyrotatetheirheadandneckwhilstkeepingtheireyess@ll.• Reproduc@onofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.
Early Sensory Findings
• Brachialplexusprovoca@ontest• Pressurepainthresholds• Thermalpainthresholds• Sympathe@cvasoconstrictorreflex• Neckdisabilityindex(19)
Late Sensory Findings
• Muscularhyperalgesia• Largereferredpainareas• Possibleneurogenicpain• Findingssuggestageneralisedcentralhyperexcitabilityinpa@entssufferingfromchronicwhiplashsyndrome
• KoelbaeckJM.Generalisedmuscularhyperalgesiainchronicwhiplashsyndrome.Pain.1999Nov;83(2):229-34
Algometry with Clothes Peg
Mild Trauma?c Brain Injury and Concussion
• Theaccelera@on-decelera@onshearingforcesgeneratedbymotorvehicleaccidentsandtherota@onalshearingforcesgeneratedwithboxing,mostespeciallytheuppercut,causesdiffuseaxonalinjury.(20)
Conclusions: The evalua?on and management of whiplash injuries must aZempt to: • Discovermechanismofinjury• Revealpainseverity• Determinetheinjured@ssuesandpaingenerators• Understandbiopsychosocialfactors• Performadifferen@aldiagnosis• Provideareasonableprognosis(acuteandchronic)• Offerappropriatetreatment• Integrateahealthcareteamofproviders
First Evaluate Pa?ent and Make a Diagnosis/Prognosis Before Trea?ng Pa?ent
Evidence-based, pa?ent-centered and ethical report of findings with whiplash injuries
• Reportthediagnoses,suggestappropriatetreatment,gainpermissiontotreat(informedconsent),anddiscusstheprognosis• Avempttoreducedisabilityandchronicpainwithuseofplaceboeffect• Reportimpairmentwithmedicallegalcasesbutavoidnoceboeffect
“Diagnosisisthekeytosuccessfultreatment!”
Case
• 56y/omaleprofessorpresentswiththefollowingHPI• Acute,exacerba@onsofneckpainandunilateralupperextremityparesthesiaintheC6dermatome.• Pasthistoryofsideimpactmotorvehiclecollision(MVC)withwhiplashinjurysome20yearsearlier.Resultedinfracturedteeth,spinalandhandstrain/spraininjuries,confusionandshort-termmemoryloss.• MRIdemonstratedcervicaldiscopathyatC5-6-7twoyearsfollowingthemotorvehiclecollision• Discon@nuedracquetballduetopainandweaknessinRUE• Hehasexperienceddailyneckpainands@ffnesssincetheMVCwithepisodicneck/armpainwithparesthesias.
Engaged Learning Task (30 minutes)
• Formgroupsof6doctorseach• Completediscussionin10minutes• Selectaspokespersonwhowillprovideabriefpresenta@on
Ac?ve learning tasks Pleasestatethefollowingforthis56year-oldpa@ent:• Differen@aldiagnosis• Workingdiagnosis• Prognosis
“Diagnosisisthekeytosuccessfultreatment!”
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Disorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.
3. ElliotJM,etal.Characteriza@onofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.
4. JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classifica@onnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeagerawhiplashinjury.Aprospec@vestudyon186consecu@vepa@ents.EurSpineJ.2008Jul;17(7):930–935.
5. HasueM.Painandthenerveroot.Aninterdisciplinaryapproach.Spine.1993;18:2053-2058.
6. JansenJ,BardosiA,HildebrandtJ,LuckeA.Cervicogenic,hemicranialavacksassociatedwithvascularirrita@onorcompressionofthecervicalnerverootC2.Clinicalmanifesta@onsandmorphologicalfindings.Pain.1989;39:203-212.
7. KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Headposi@onandimpactdirec@oninwhiplashinjuries:associa@onswithMRI-verifiedlesionsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:1294-1302.
8. KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Whiplash-associateddisordersimpairmentra@ng:neckdisabilityindexscoreaccordingtoseverityofMRIfindingsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:466-475.
9. JonssonH,Jr,BringG,RauschningW,SahlstedtB.Hiddencervicalspineinjuriesintrafficaccidentvic@mswithskullfractures.JSpinalDisord.1991;4:251.
10. PeverssonK,HildingssonC,ToolanenG,FagerlundM,BjornebrinkJ.Discpathologyagerwhiplashinjury.Aprospec@vemagne@cresonanceimagingandclinicalinves@ga@on.Spine.1997;22:283-287;discussion288.263.
References 11.BorchgrevinkGE,KaasaA,McDonaghD,S@lesTC,HaraldsethO,LereimI.Acutetreatmentofwhiplashneckspraininjuries.Arandomizedtrialoftreatmentduringthefirst14daysageracaraccident.Spine.1998;23:25-31.12.KaschH,QeramaE,BachFW,JensenTS.Reducedcoldpressorpaintoleranceinnon-recoveredwhiplashpa@ents:a1-yearprospec@vestudy.EurJPain.2005;9:561-569.13.Tjell,C.andU.Rosenhall(1998).“Smoothpursuitnecktorsiontest:aspecifictestforcervicaldizziness.”Otology&Neurotology19(1):76.
14.Treleaven,J.,G.Jull,etal.(2003).“Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@onshipwithcervicaljointposi@onerror.”JournalofRehabilita@onMedicine35(1):36-43.15.Treleaven,J.,G.Jull,etal.(2005).“Smoothpursuitnecktorsiontestinwhiplash-associateddisorders:rela@onshiptoself-reportsofneckpainanddisability,dizzinessandanxiety.”JournalofRehabilita@onMedicine37(4):219-223.16.Treleaven,J.,G.Jull,etal.(2005).“Standingbalanceinpersistentwhiplash:acomparisonbetweensubjectswithandwithoutdizziness.”JournalofRehabilita@onMedicine37(4):224-229.
17.Jull,G.,D.Falla,etal.(2007).“Retrainingcervicaljointposi@onsense:Theeffectoftwoexerciseregimes.”JournalofOrthopaedicResearch25(3):404-412.
18.TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@onshipwithcervicaljointposi@onerror.JRehabilMed.2003Jan;35(1):36---43.19.SterlingM,etal.Sensoryhypersensi@vityoccurssoonagerwhiplashinjuryandisassociatedwithpoorrecoveryPain104(2003)509-517.20.AdamsJH,DoyleD,FordI,GennarelliTA,GrahamDI,McLellanDR.Diffuseaxonalinjuryinheadinjury:defini@on,diagnosisandgrading.Histopathology.1989;15:49–59.
Cranio-cervical Flexion Test
• Performedwiththepa@entinsupinecrooklyingwiththeneckinaneutralposi@on(nopillow)suchthatthelineofthefaceishorizontalandalinebisec@ngthenecklongitudinallyishorizontaltothetes@ngsurface.Layersoftowelmaybeplacedundertheheadifnecessarytoachieveaneutralposi@on.Theuninflatedpressuresensorisplacedbehindthenecksothatitabutstheocciputandisinflatedtoastablebaselinepressureof20mmHg,astandardpressuresufficienttofillthespacebetweenthetes@ngsurfaceandtheneckbutnotpushtheneckintoalordosis.Thedeviceprovidesthefeedbackanddirec@ontothepa@enttoperformtherequiredfivestagesofthetest.Thepa@entisinstructedthatthetestisnotoneofstrengthbutratheroneofprecision.Themovementisperformedgentlyandslowlyasaheadnoddingac@on(asifsaying“yes”).TheCCFTteststheac@va@onandenduranceofthedeepcervicalflexorsinprogressiveinnerrangeposi@onsasthepa@entavemptstosequen@allytargetfive,2-mmHgprogressivepressureincreasesfromthebaselineof20mmHgtoamaximumof30mmHgaswellastomaintainaisometriccontrac@onattheprogressivepressuresasanendurancetask
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