Whiplash Associated Disorders J. Scott Bainbridge, MD Denver Back Pain Specialists .

Whiplash Associated DisordersWhiplash Associated Disorders

J. Scott Bainbridge, MD

Denver Back Pain Specialists

www.denverbackpainspecialists.com

DefinitionDefinition

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.

DefinitionDefinition

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 ProblemWAD – Scope of Problem

Yearly Incidence 4/1,000 (.8-8)$3.9 billion/yr in USA, $29 b w litigation4-42% of pts w MVA related neck injuries

with sx several yrs later

Quebec ClassificationQuebec Classification

Grade 0: No neck c/o or PE signsGrade I: Neck c/o pain, stiffness or

tenderness but no PE signsGrade II: Neck c/o AND mskl signsGrade III: Neck c/o AND neuro signsGrade IV: Neck c/o AND fracture or

dislocation

MVA – Spectrum Beyond MVA – Spectrum Beyond WADWAD

Cervicothoracic Other MusculoskeletalBrain Injury, Post Concussive SyndromeOther NeurologicalVestibular DysfunctionPsychologicalSocial/Economic/Litigation

Motion Analysis of C-Spine Motion Analysis of C-Spine During Whiplash LoadingDuring Whiplash Loading

Kaneoka, et al; Spine 24:8 pp 763-77010 males – sled glided back into damper at

4 km/hrCineradiography of C-spineEach vertebra’s rotational angle and C5-6

instantaneous axes of rotation quantifiedSEMG of SCM and C-paraspinals

Pathological ForcesPathological Forces

8 km/hr 5 mph135 N

PathologyPathology

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 CascadeThree Joint Complex

– Two Zygapophyseal joints (facets joints)

– Intervertebral diskpathologic 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 – Degenerative Cascade – Segmental DysfunctionSegmental Dysfunction

articular cartilage z-joint degeneration

Subchondral Sclerosis

Cartilage Degeneration

Degenerative Cascade – Degenerative Cascade – Instability PhaseInstability Phase

Annular fibers less competent

Disc protrusions

Uncovertebral Joints - Joints of LuschkaUncovertebral 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 – Degenerative Cascade – Instability PhaseInstability Phase

Normal Foraminal narrowing

Degenerative Cascade – Degenerative Cascade – Stabilization PhaseStabilization Phase

foraminal stenosisradiculopathycentral spinal

stenosis

Degenerative Cascade – Degenerative Cascade – Stabilization PhaseStabilization Phase

ankylosis of motion segment

multilevel degenerative changes & spondylosis

Degenerative Cascade – Degenerative Cascade – Stabilization PhaseStabilization Phase

ankylosis of motion segment

Cervical Z Joint PainPrevalence 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 unremarkableConfirm suspicions with dx intra-

articular z-jt injections or medial branch blockade

DwyerZ-joint Referral Patterns Spine1990

FukuiThoracic Z-joint Referral Patterns

RegionalAnesthesia1997

Spinalcord

HNP

duraLig.flavum

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

Normal disc

Posterior Tearwith epiduralleak

Grubb, Kelly.Spine 25:1382-1389, 2000Cervical DiscographyPain Referral Patterns173 discograms, 404 positivediscs>50% with >3 positive discs

C2-3 C3-4C4-5

C5-6 C6-7

Provocative Cervical

Discography

Slipman NASS 2002

C2-3

C3-4

C4-5

C5-6

C6-7

C7-T1

Provocative Cervical

Discography

Slipman NASS 2002

Treatment - AcuteTreatment - Acute

Oral Steroids?NSAIDs?Immobilize?Early Therapy?

TreatmentTreatment

Facet Joints

Treatment of Facet InjuryTreatment of Facet Injury

Manual TherapyPostural EducationNeuromuscular Reeducation/Stability Cervical TractionSpinal InjectionsSurgical Stabilization

Manual TherapyManual Therapy

Grade 1: Small amplitude, beginning rangeGrade 2: Large amp, resistance freeGrade 3: Large amp into resistance (MET)Grade 4: Small amp well into resis (HVLA)Grade 5: Past end-range

Spinal Injection/Nerve Spinal Injection/Nerve AblationAblation

Intraarticular CorticosteroidFacet Denervation (Lord,et al; NEJM 1996;

335:1721-6)

Treatment of Disk DisordersTreatment of Disk Disorders

Posture/ Spine Stability TrainingCervical TractionTreat Assoc Muscle/Facet DisordersSpinal InjectionsSurgical (ACDF, other); Treatment for axial

neck pain?

Surgical InterventionSurgical Intervention

Neurological Compromise

Axial Pain?

Treatment of Muscle Treatment of Muscle DisordersDisorders

Massage: CMT, self, theracanePostural EducNeuromuscular Reeducation/StabilityBiofeedbackTrigger Point Injections/AcupunctureBotulinum Toxin: Botox/Myoblock

Movement Movement Dysfunction Dysfunction

Dynamic StabilityDynamic Stabilityand Muscle Balanceand Muscle Balanceof the Cervical Spineof the Cervical Spine

Segmental Dysfunction

Movement DysfunctionMovement Dysfunction

pain patholog y

dysfunctio n

abnorm al stress or strain

uncontrolled m ovem en t

loss of local or global control

Local stability segmental Local stability segmental controlcontrol

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)

InhibitionInhibition

Inhibition: failure of normal recruitment– poor recruitment under low threshold stimulus– delayed recruitment timing– altered recruitment sequencing

Inhibition ‘off’

Afferent Input & Recruitment 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 PathologyProprioception 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 DysfunctionEvidence 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)

I.I. Control of NeutralControl of Neutrallow load recruitment in low load recruitment in

neutralneutral

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

Deep cervical flexor Deep cervical flexor dysfunctiondysfunction

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

Jull 2000

Deep cervical flexor Deep cervical flexor dysfunctiondysfunction

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 inDysfunction inGlobal Mobility SystemGlobal 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 Dysfunction related to pathologypathology

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 Relative Stiffness/Relative FlexibilityFlexibility

(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

Dysfunction related to pathologyDysfunction related to pathology

NormalFlex / ext ROM

C5-6 (18o)

C4-5 (17o)Translation

C5-6 (3.2mm)

C4-5 (3.2mm)(Dvorak 1988, White et al 1975)

AbnormalFlex / ext ROM

C5-6 (8o)

C4-5 (23o)Translation

C5-6 (1mm)

C4-5 (6mm)(Singer et al 1983)

Cervical discogenic pathology

Treatment SummaryTreatment SummaryDual approach:

Treat the pathologyIdentify 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’ ApproachesAlternative’ Approaches

Tai ChiAlexander techniqueYogaPilatesPhysio ball (Swiss ball)Feldenkrais

Treat Whole PersonTreat Whole Person

PsychologyWorkFamilySecondary Gain Dynamics