Transcript - Denver Back Pain Specialists

Whiplash Associated Disorders
J. Scott Bainbridge, MD
Denver Back Pain Specialists
www.denverbackpainspecialists.com
Definition

Quebec Task Force on WhiplashAssociated-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 zjoint
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 intraarticular z-jt injections or medial
branch blockade
Dwyer
Z-joint
Referral
Patterns
Spine
1990
Fukui
Thoracic Z-joint
Referral
Patterns
Regional
Anesthesia
1997
HNP
dura
Spinal
cord
Lig.
flavum
“Annular fibers restrict
axial rotation more than
the facet joints.”
(Krismer 1996)
Posterior Tear
with epidural
leak
Normal
disc
C2-3
C3-4
C4-5
C5-6
C6-7
Grubb, Kelly.
Spine 25:13821389, 2000
Cervical
Discography
Pain Referral
Patterns
173 discograms,
404 positive
discs
>50% with >3
positive discs
C2-3
C3-4
C4-5
Provocative
Cervical
Discography
Slipman
NASS 2002
C5-6
C6-7
C7-T1
Provocative
Cervical
Discography
Slipman
NASS 2002
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 Stability
and Muscle Balance
of the Cervical Spine
Segmental Dysfunction
Movement Dysfunction
loss of local or global control
uncontrolled movement
abnormal stress or strain
dysfunction
pain
pathology
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)
I.
Control of Neutral
low load recruitment in
neutral
Test for ability of
anterior local
stability muscles
to control neutral
(longus & RCAnt)
Deep cervical flexor
dysfunction
Control
WAD

Can control greater
range of 2mm Hg
increments (up to 28
from baseline of 20)
than WAD
 Less superficial
muscle activity

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
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 in
Global 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
Dysfunction related to pathology
Cervical discogenic pathology
Normal
Flex / ext ROM
(18o)
C5-6
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)
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