Whiplash Update Clinical Whiplash

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Whiplash UpdateClinical Whiplash Neck Pain -
2 Day Courseby Chris Worsfold

• Your Name

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Whiplash Update

• Cost Controversy
• Biomechanics
• Pathology
• Clinical Features
• Subjective
• Pain, disability, dizziness,
• Psychological impairment
• Objective
• Sensorimotor, motor control, sensory changes.

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Whiplash cost

• Cost 3 billion per annum in UK alone.
• Half million people make claim for whiplash
  injury in UK every year (ABI 2008)
• Claims increasing year on year
• Huge variations in cost between countries
• Switzerland average payout is 30,000 Euros / UK
  2,500

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Whiplash controversy

• Whiplash culture blamed for rising claims cost
• Making a claim appears to increase pain and
  disability (Sterling 2010)
• For every 1 paid in compensation, 87p is paid to
  the solicitor.

This is not access to justice, this is
incitement to litigate and it must stop. Lord
Young of Graffham 2010
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Whiplash manual therapy treatment efficacy

• In chronic whiplash treatment only 10-20 have a
  completely successful outcome.
• (Stewart et al 2007, Jull et al 2007)
• Acute trials demonstrate no efficacy in
  decreasing
• incidence of those who develop persistent
  symptoms.
• (Provinciali et al 1996,
• Rosenfeld et al 2000, 2003)

?
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Whiplash biomechanics

• Major point of contact is seatback
• Lumbar extension 20ms
• Thoracic extension 60ms ramping
• Sigmoid deformation cervical spine
• Upper cervical flexion / Lower cervical extension
• Muscle contraction onset 100-125ms after onset of
  vehicle acceleration
• Full cervical extension upper lower
• Rebound phase from extension into flexion

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Whiplash pathology

• Z-joint injury
• Capsule tear / synovial fold pinched / multifidus
  attachment strain.
• Anterior Long. / Transverse / Alar Ligament
  injury
• Increased incidence alar injury with cervical
  rotation.
• Disc injury
• Nerve / dorsal root ganglion injury
• Pressure changes in the spinal canal.
• Cervical arterial injury

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Whiplash Clinical Features
Whiplash clinical features

• Subjective
• Pain NPRS / S-LANSS
• Disability Neck Disability Index.
• Dizziness Dizziness Handicap Inventory.
• Psychological distress Impact of Events Scale
  (Horowitz et al 1979)
• Objective
• Sensorimotor disturbance.
• Joint positioning error / Oculomotor control /
  Postural stability
• Muscle motor control impairment.
• Sensory changes - pressure thermal pain
  thresholds ULTT (Sterling et al 2005)

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Whiplash sensorimotor disturbance

• Why assess proprioception, eye movement
  postural stability following whiplash ?
• Muscle spindle input merged with input from
  visual and vestibular system.
• Dense network of muscle spindles in deep neck
  muscles. (Peck 1984, Richmond Bakker 1982)
• Experimental evidence of role in postural
  control. (deJong et al 1977, Pyykko et al 1989,
  Gosselin et al 2004 )

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Proprioception laser target

• Laser on head, sitting, 90cm from wall.
• A4 sheet of paper.
• Perform one practice run with eyes open
• L Rot, R rot, F, E
• Close eyes remember starting position
• Perform L rot attempt to return to starting
  position.
• Average of 3 trials L rot, R rot
• Abnormal score gt5cm

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Oculomotor Dysfunction smooth pursuit

• Oculomotor control in whiplash
• 62 impaired (Heikilla 1998)
• Impaired oculomotor control associated with poor
  prognosis (Hildingsson et al 1993).
• Cause ? disturbed afferent input vs brain stem
  involvement.

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Oculomotor dysfunction SPNT

• Smooth Pursuit Neck Torsion Test (Tjell and
  Rosenhall 1998)
• Assesses cervical afferent disturbance
• Perform smooth pursuit
• Rotate trunk 45deg left (right neck torsion)
• Repeat smooth pursuit
• Performance will deteriorate if positive ie
  increased effort, dizziness, unable to perform
  test.
• Repeat to opposite side

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Postural stability

• Standing balance
• Increased AP sway in whiplash subjects gt
  idiopathic neck pain gt normal (Field et al 2008)
• 50 non dizzy whiplash unable tandem stand eyes
  closed (Field et al 2008).
• 74 dizzy whiplash subjects unable tandem stand
  eyes closed (Treleaven et al 2008).

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Motor control

• Muscle composition changes
• Fibre type transformation Type I to Type II
• Fatty infiltration multifidus, rectus capitis
  muscles.
• Muscle strength deficits
• Motor control reorganisation

A - Whiplash, B Normal control
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Motor control in neck pain

• Deep Neck Flexors (DNF)
• Pressure biofeedback 5-stage craniocervical
  flexion
• Starting pressure 20mmHg.
• Target 22 24 26 28 - 30mmHg.
• Hold each stage for 10 seconds.

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Motor control in neck pain
(Falla et al 2004)
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Motor control in neck pain

• Exercise MUST be specific
• Low load training DNF (Jull et al 2005,2009,
  Falla et al 2007)
• Increases activation of DNF decreases neck
  pain.
• Decreases activity in SCM AS.
• These benefits NOT achieved with 6 weeks of
  higher load strength and endurance training.
• High load strength and endurance training (Falla
  et al 2003)
• Required to increase strength of cervical
  muscles.
• Decreases neck pain.

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Sensory changes in whiplash

• Hyperalgesia on manual examination
• Reduced pressure pain threshold in neck and at
  remote sites (eg Tibialis Anterior) - algometer
  (Sterling et al 2005).
• Cold pain threshold reduced thermoroller.
  (Williams et al 2007, Sterling et al 2008).
• Bilateral restriction in ULTT with VAS gt 4/10
  during test (Sterling et al 2002).

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Whiplash assessing risk of poor recovery

• Strongest predictors of poor outcome
• Pain NPRS / VAS gt 8/10
• S-LANSS gt12
• Neck Disability Index gt30
• Impact of Events Scale screen for PTSD gt26
• Cold hyperalgesia gt15deg C

(Sterling et al 2006)
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Whiplash Update

• Cost Controversy
• Biomechanics
• Pathology
• Clinical Features
• Subjective
• Pain, disability, dizziness,
• Psychological impairment
• Objective
• Sensorimotor, motor control, sensory changes.

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Clinical Whiplash Neck Pain 2 day course

• Chris Worsfold MSc PGDipManPhys
• Musculoskeletal Physiotherapist
• Specialises in neck pain, whiplash headaches.
• Further information -
• Blog / Courses
• www.ClinicalWhiplash.com
• Clinic
• www.KentNeckPainCentre.com

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Whiplash update

• THANK YOU !