Julia Treleaven

Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error.

Dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders. This study aimed to report the characteristics of these symptoms and determine whether there was any relationship to cervical joint position error. Joint position error, the accuracy to return to the natural head posture following extension and rotation, was measured in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. Whiplash subjects completed a neck pain index and answered questions about the characteristics of dizziness. The results indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects. Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following rotation (rotation (R) 4.5 degrees (0.3) vs 2.9 degrees (0.4); rotation (L) 3.9 degrees (0.3) vs 2.8 degrees (0.4) respectively) and a higher neck pain index (55.3% (1.4) vs 43.1% (1.8)). Characteristics of the dizziness were consistent for those reported for a cervical cause but no characteristics could predict the magnitude of joint position error. Cervical mechanoreceptor dysfunction is a likely cause of dizziness in whiplash-associated disorder.

Cervical range of motion discriminates between asymptomatic persons and those with whiplash.

Study Design. A comparative study of cervical range of motion in asymptomatic persons and those with whiplash. Objectives. To compare the primary and conjunct ranges of motion of the cervical spine in asymptomatic persons and those with persistent whiplash-associated disorders, and to investigate the ability of these measures of range of motion to discriminate between the groups. Summary of Background. Evidence that range of motion is an effective indicator of physical impairment in the cervical spine is not conclusive. Few studies have evaluated the ability to discriminate between asymptomatic persons and those with whiplash on the basis of range of motion or compared three-dimensional in vivo measures of range of motion in asymptomatic persons and those with whiplash-associated disorders. Methods. The study participants were 89 asymptomatic volunteers (41 men, 48 women; mean age 39.2 years) and 114 patients with persistent whiplash-associated disorders (22 men, 93 women; mean age 37.2 years) referred to a whiplash research unit for assessment of their cervical region. Range of cervical motion was measured in three dimensions with a computerized, electromagnetic, motion-tracking device. The movements assessed were flexion, extension, left and right lateral flexion, and left and right rotation. Results. Range of motion was reduced in all primary movements in patients with persistent whiplash-associated disorder. Sagittal plane movements were proportionally the most affected. On the basis of primary and conjunct range of motion, age, and gender, 90.3% of study participants could be correctly categorized as asymptomatic or as having whiplash (sensitivity 86.2%, specificity 95.3%). Conclusions. Range of motion was capable of discriminating between asymptomatic persons and those with persistent whiplash-associated disorders.

Standing balance in persistent whiplash: A comparison between subjects with and without dizziness

OBJECTIVE Dizziness and unsteadiness, associated with altered balance, are frequent complaints in subjects suffering persistent whiplash associated disorders. Research has been inconclusive with respect to possible aetiology. This study assessed balance responses in subjects with whiplash associated disorders, taking into account several possible causes. DESIGN A prospective, 3 group, observational design. SUBJECTS 100 subjects with persistent whiplash associated disorders, 50 complaining of dizziness, 50 not complaining of dizziness and 50 healthy controls. METHODS The Clinical Test for Sensory Interaction in Balance was performed in both comfortable and tandem stance. The sway trace was analysed using wavelet analysis. CONCLUSION The results indicated that the energy of the sway signal for comfortable stance tests was significantly greater in the group with dizziness compared with the group without dizziness. In the group without dizziness the energy was greater than controls for all tests, but significantly different on selected tests. In selected tandem stance tests, subjects with dizziness were significantly less able to complete the test than subjects without dizziness and controls. These deficits could not be attributed to medications, compensation, anxiety or age and are likely to be due to disturbances to the postural control system possibly originating from abnormal cervical afferent input.

Sensorimotor Function and Dizziness in Neck Pain: Implications for Assessment and Management

SYNOPSIS The term sensorimotor describes all the afferent, efferent, and central integration and processing components involved in maintaining stability in the postural control system through intrinsic motor-control properties. The scope of this paper is to highlight the sensorimotor deficits that can arise from altered cervical afferent input. From a clinical orthopaedic perspective, the peripheral mechanoreceptors are the most important in functional joint stability; but in the cervical region they are also important for postural stability, as well as head and eye movement control. Consequently, conventional musculoskeletal intervention approaches may be sufficient only for patients with neck pain and minimal sensorimotor proprioceptive disturbances. Clinical experience and research indicates that significant sensorimotor cervical proprioceptive disturbances might be an important factor in the maintenance, recurrence, or progression of various symptoms in some patients with neck pain. In these cases, more specific and novel treatment methods are needed which progressively address neck position and movement sense, as well as cervicogenic oculomotor disturbances, postural stability, and cervicogenic dizziness. In this commentary we review the most relevant theoretical and practical knowledge on this matter and implications for clinical assessment and management, and we propose future directions for research. LEVEL OF EVIDENCE Level 5.

Pressure Pain Thresholds in Chronic Whiplash Associated Disorder: Further Evidence of Altered Central Pain Processing

Objective: To investigate pressure pain thresholds [PPTs] at sites both within and remote to the region involved with whiplash trauma. Methods: One hundred and fifteen subjects with chronic whiplash associated disorder [WAD] and 95 healthy asymptomatic subjects were included in the study. Pressure pain thresholds were measured at eight sites bilaterally within the cervical spine and upper limbs and a remote site in the lower limb. Results: Subjects with chronic WAD had significantly lower PPTs than the asymptomatic subjects in both local and remote sites [all P < 0.001]. There was a greater decrease of PPTs over cervical spine sites than either the upper or lower limb sites. Conclusion: The generalized decrease in PPTs in sites both local and remote to the site of injury suggests a sensitized central nervous system contributes to persistent pain experienced by WAD patients. The greater decrease in PPTs over cervical spine sites may reflect the continuing role of sensitized nociceptors within the cervical spine in the pain syndrome.

Cervical musculoskeletal dysfunction in post-concussional headache

Persistent headache is a common symptom following a minor head injury or concussion, possibly related to simultaneous injury of structures of the cervical spine. This study measured aspects of cervical musculoskeletal function in a group of patients (12) with post-concussional headache (PCH) and in a normal control group. The PCH group was distinguished from the control group by the presence of painful upper cervical segmental joint dysfunction, less endurance in the neck flexor muscles and a higher incidence of moderately tight neck musculature. Active range of cervical motion and postural attitude were not significantly different between groups. As upper cervical joint dysfunction is a feature of cervicogenic causes of headache, the results of this study support the inclusion of a precise physical examination of the cervical region in differential diagnosis of patients suffering persistent headache following concussion.

Manual examination: is pain provocation a major cue for spinal dysfunction?

Evidence suggests that manual examination is reliable in the detection of dysfunctioned spinal segments. Clinical decisions are considered to relate to the presence of abnormal motion and tissue stiffness along with provocation of pain but there have been suggestions that pain is the major diagnostic cue. Pain provocation is important but reliance on pain could cause false positive joint dysfunction diagnoses. A single blind study was undertaken to test a manipulative physiotherapists ability to differentiate painful and non painful cervical segments without the subjects verbal pain cues. Results indicated good agreement between the examiner and subjects for their independent nomination of most painful and painless segments, suggesting pain is not the only cue.

Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma.

OBJECTIVE To determine if differences exist in reported symptoms and in outcomes of sensorimotor tests (cervical joint position error [JPE], neck-influenced eye movement control, postural stability) between subjects with persistent whiplash and subjects with unilateral vestibular pathology associated with acoustic neuroma. DESIGN Repeated measures, case controlled. SETTING Tertiary institution and metropolitan hospital. PARTICIPANTS Twenty subjects with persistent whiplash, 20 subjects with acoustic neuroma, and 20 control subjects. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Symptom descriptors, Dizziness Handicap Inventory (short form), measures of cervical JPE, the smooth pursuit neck torsion (SPNT) test, and forceplate measures of postural stability in comfortable and narrow stances. RESULTS The results showed differences in SPNT (P=.00), selected measures of postural stability (P<.04), and reported symptoms between the whiplash and vestibular groups. There was no between-group difference in cervical JPE (P>.27) or dizziness handicap (P>.69). CONCLUSIONS This study showed differences in sensorimotor disturbances between subjects with discreet whiplash and those with vestibular pathology associated with acoustic neuroma. The results support the SPNT test as a test of cervical afferent dysfunction. Further research into cervical JPE as a discreet test of cervical afferentation is warranted.

Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control—Part 2: Case studies

Recent research highlights sensorimotor control disturbances in those with neck disorders. Assessment and management of the symptoms of dizziness, altered cervical proprioception, eye and head co-ordination and disturbances to postural stability in those with neck disorders are important and are presented in a companion article. In this paper, four case studies are presented to illustrate the formulation and use of a tailored program designed to retrain balance, cervical proprioception and eye and head movement control in those with neck disorders. This program should be used in conjunction with a multi-modal approach to the management of neck disorders. Such a combined approach should address causes of abnormal cervical afferent input as well as the important links between the cervical, vestibular and ocular systems and adaptive changes in the sensorimotor control system.

Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions

INTRODUCTION Impaired proprioception has been reported as a feature in a number of musculoskeletal disorders of various body parts, from the cervical spine to the ankle. Proprioception deficits can occur as a result of traumatic damage, e.g., to ligaments and muscles, but can also occur in association with painful disorders of a gradual-onset nature. Muscle fatigue can also adversely affect proprioception and this has implications for both symptomatic and asymptomatic individuals. Due to the importance of proprioception for sensorimotor control, specific methods for assessment and training of proprioception have been developed for both the spine and the extremities. PURPOSE The aim of this first part of a two part series on proprioception in musculoskeletal rehabilitation is to present a theory based overview of the role of proprioception in sensorimotor control, assessment, causes and findings of altered proprioception in musculoskeletal disorders and general principles of interventions targeting proprioception. IMPLICATIONS An understanding of the basic science of proprioception, consequences of disturbances and theories behind assessment and interventions is vital for the clinical management of musculoskeletal disorders. Part one of this series supplies a theoretical base for part two which is more practically and clinically orientated, covering specific examples of methods for clinical assessment and interventions to improve proprioception in the spine and the extremities.