learning objec?ves whiplash associated disorders: the
TRANSCRIPT
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Whiplash Associated Disorders: The pathway from acute to
chronic pain JamesJ.Lehman,DC,MBA,FACO
UniversityofBridgeportCollegeofChiropracFc
Learning Objec?ves
• DeterminepaFent’sprognosisandpotenFaltoexperiencechronicpainsyndromefollowingawhiplashinjury,priortoprovidingchiropracFcservices.
Whiplash Neck Injury
• FirstdescribedbyCrowein1928.• Mostcommontypeofinjuryfollowingmotorvehiclecrashes• Usually2-3weeksforrecovery• Yet,upto42%transiFonfromacutetochronicpainstatus.(1)
“Diagnosisisthekeytosuccessfultreatment!”
Quebec Task Force Defini?on
• Whiplashinjuryis“anacceleraFon-deceleraFonmechanismofenergytransferredtotheneck,”usuallyresulFngfromrear-endorside-impactmotorvehiclecollision.(2)
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Whiplash Injury Costs
• Queensland,Australia=$500millionAustraliandollars(1994-2001)
• MAIC.Whiplash—ReviewofCTPQueenslandDatato31Dec2001.Brisbane,Australia:TheMotorAccidentInsuranceCommission(MAIC);2002.
• UnitedKingdom=L3billionperannum
• JoslinCC,KhanSN,BannisterGC.Long-termdisabilityaherneckinjury:acomparaFvestudy.JBoneJointSurgBr.2004;86:1032–1034.
• UnitedStates=USD$29billionperannum
• BlincoeL,SeayA,ZaloshnjaE,etal.TheEconomicImpactofMotorVehicleCrashes,2000.Washington,DC;NaFonalHighwayTrafficSafetyAdministraFon:2002.
Pathomechanics of Whiplash Injury
Whiplash Injury Symptoms
• Pain,• dizziness,• visualandauditorydisturbances,• temporomandibularjointdysfuncFon,
• photophobia,• dysphonia,• dysphonia,• faFgue,• cogniFvedifficulFessuchasconcentraFonandmemoryloss,anxiety,insomnia,anddepression(3)
•
Case One = WAD I
• PaFentpresentswithneckcomplaintsincludingsFffnessortendernessintheneckregionsandnophysicalsignsofinjury.
• SpitzerWO,SkovronML,SalmiLR,etal.ScienFficmonographoftheQuebecTaskForceonWhiplash-AssociatedDisorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.
• Mostlikelydiagnosisisacute,mildcervicalstrain• Prognosisisgood• Spontaneousrecoverywithin2-3weeksiscommon.
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Case Two: WAD II
• PaFentpresentswithneckcomplaintsincludingsFffnessortenderness,andsomephysicalsignsofinjury,suchaspointtendernessortroubleturningthehead.
• Acute,moderatecervicalsprain/strainismostlikelyDX• Prognosisisdifficulttopredict• CurrentmanagementdoesnotappeartolessentransiFonfromacutetochronicpainstatus• PhysicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredicFveofpoorrecovery
Case Three: WAD III
• PaFentpresentswithneckcomplaintsincludingsFffnessortendernessandneurologicalsignsofinjurysuchasdeeptendonreflexormotordeficits.
• Acute,moderatesprain/strainwithresultantcervicalradiculopathy• CurrentmanagementdoesnotappeartolessentransiFonfromacutetochronicpainstatus• PhysicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredicFveofpoorrecovery
Case Four: WAD IV
• PaFentpresentswithneckcomplaintsandafractureand/ordislocaFonofthecervicalspine.
Grade 3 Facet Sprains and Transverse Processes Fractures • MulFplefacetjointrupturesandfracturesofthetransverseprocessesfromC4toC6.• Atautopsyahematomainthelonguscollimusculatureextendedalongthebrachialplexusintotheaxilla.• Theseserialfracturesweredetectedatsecondlookonthespecimenradiograms.• Thefracturesrunposteriorlythroughtheintertransversebarintothejointsthatdisplaytorncapsulesandmeniscoidsandhemarthrosis
Occipital Condyle Fracture
• Thefragmentwasavulsedbythe(intact)alarligament.• Ontheplainradiogramsthisfracturewasbarelyvisibleandwasonlydetectedatsecond–lookevaluaFon.• Theavulsedfragmentisdisplacedposteriorlyandmedially,embeddingmediumfillsthewidefracturegap.• Intheatlanto–axialjointtheposteriormeniscoidandthejointcapsulearetorn,pullingtheC2nerveintothejointspace.
“Diagnosisisthekeytosuccessfultreatment!”
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Quebec Task Force (QTF) Classifica?ons
• SponsoredbyapublicinsurerinCanada.• QTFsubmivedrecommendaFonsregardingclassificaFonandtreatmentofWAD,whichwasusedtodevelopaguideformanagingwhiplashin1995.• Anupdatedreportwaspublishedin2001.• EachofthegradescorrespondstoaspecifictreatmentrecommendaFon.
Quebec Task Force (1995) Cri?cisms
1. Largelyconsensusbasedratherthanevidence-based
2. SelecFonbiasfortheliteraturereview
Swedish Study and Quebec Task Force
• NeithertheWADclassificaFonnortheQTFfollow-upregimencouldbelinkedtoabeveroutcome.
• JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classificaFonnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeaherawhiplashinjury.AprospecFvestudyon186consecuFvepaFents.EurSpineJ.2008Jul;17(7):930–935.
Swedish Study and Quebec Task Force
• ThemulFple-follow-upregimenisbothFmeconsumingandcostlyandappearsnotbejusFfiedinarouFneclinicalsewng.
Swedish Study and Quebec Task Force
• TheWAD-classificaFoncouldnotpredictpersistentneckpainaherawhiplashinjuryinthishospitalemergencydepartmentbasedpopulaFon.
Swedish Study and Quebec Task Force
• NorwasthereastaFsFcallysignificantdifferenceintherateofchronicneckpainbetweentheno-follow-upregimenandthemulFple-follow-upregimenproposedbytheQTF.
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Swedish Study and Quebec Task Force
• Atthefirstvisitwerecommendacarefulhistory,physicalexaminaFonandinformaFonaboutthenatureofthecondiFon.
Swedish Study Findings
• InthisstudycaseswithneckpainbeforetheaccidentandahighdegreeofemoFonaldistressfromtheaccidenthadatenfoldincreasedriskofdevelopingchronicneckpain.(4)
Transi?on from Acute to Chronic Pain Status
• PaFentsthatdonotresolvewithinweeksohenexhibitamyriadofsymptomssoonahertheinjuryevent.
“Diagnosisisthekeytosuccessfultreatment!”
Pathoanatomical Lesions in the Whiplash Injury
1. CervicalFacetjoints(ZygapophysealJoints)
2. DorsalRootGanglion(DRG)andNerveRoots
3. CervicalLigaments4. IntervertebralDiscInjuries5. MuscleInjuries
Facet Joint Injury Model
• StudiesemployingthecervicalfacetjointinjurymodelhaveidenFfiedtheoccurrenceofhemarthrosis,capsulardamage,jointfractures,andcapsularrupture.
• JoslinCC,KhanSN,BannisterGC.Long-termdisabilityaherneckinjury:acomparaFvestudy.JBoneJointSurgBr.2004;86:1032-1034.
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Cervical Facet Injury Model
• ClinicalsupportforafacetogenicmodelofpersistentpaingeneraFoninwhiplashcanbefoundintheliterature.
• LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainaherwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.
Cervical Facet Injury Model
• Asaresultoffacetjointinjury,whiplashpaFentsfrequentlyencounter,headaches,backandshoulderpaininaddiFontoneckpain.
• ElliotJM,etal.CharacterizaFonofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.
Cervical Facet Joint Injury and Referred Pain
• ThemostcommonfacetstobeinjuredandhighestprevalenceofjointpainareatC2/C3andC5/C6,whichfrequentlyresultsinreferredpain.
• LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainaherwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.
Dorsal Root Ganglion and Nerve Roots
• VulnerabletoexcessivestretchingandinjuryduringrapidacceleraFon/deceleraFon(“S-shaped”curve)orlateralbendingoftheneckasdemonstratedinrear-endorside-vectorimpactwhiplash.
Dorsal Root Ganglion (DRG) Compression and SoV Tissue Changes
• Largelyundetected• MaycontributetoadaptaFonintheoverallfuncFoningofthecervicalDRG• Maypredisposeanindividualtoabnormal,centrallymediatedpainprocessing.(5,6)
Cervical Ligamentous Sprain Injuries
• PossibleinjurytomechanorecepFveandnocicepFvenerveendingsleadingtopain,inflammaFonandchronicpainsyndrome
• TominagaY,NduAB,CoeMP,etal.Neckligamentstrengthisdecreasedfollowingwhiplashtrauma.BMCMusculoskeletDisord.2006;7:103.
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Persistent Pain: A Chronic Illness
• Acutepainusuallygoesawayaheraninjuryorillnessresolves.Butwhenpainpersistsformonthsorevenyears,longaherwhateverstartedthepainhasgoneorbecausetheinjuryconFnues,itbecomesachroniccondiFonandillnessinitsownright.
• ACalltoRevoluFonizeChronicPainCareinAmerica: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,headposiFonatFmeofimpact,NeckDisabilityIndex(NDI)scoresandreproducFonofpainandexcessivemobilitywithmanualexaminaFon.(7,8)• SharpPurserManeuvertestforuppercervicalspineinstability.
Cervical Disc Injuries
Presentin25%ofsubjectspostwhiplashinjuryandcorrelatedwithradicularsymptoms(9,10)
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Cervical Disc Injuries
• C5-6segmentallevelwasfoundtobethemostcommonlevelofdiscinjury...• greaterriskoflow-gradespinalcordinjurywithpre-exisFngspinalcanalnarrowingatC5-6level
• ItoS,PanjabiMM,IvancicPC,PearsonAM.Spinalcanalnarrowingduringsimulatedwhiplash.Spine.2004;29:1330-1339.
Cervical Spondylo?c Myelopathy
CommonsymptomsClumsyorweakhandsLegweaknessorsFffnessNecksFffnessPaininshouldersorarmsUnsteadygaitCommonsignsAtrophyofthehandmusculatureHyperreflexiaLhermive'ssign(electricshock-likesensaFondownthecenterofthebackfollowingflexionoftheneck)Sensoryloss
Muscles Strained
• WhiplashhasbeendemonstratedtostrainSCM,semispinalis,spleniuscapiFsanduppertrapeziuswithrear-endimpacts.
• BraultJR,SiegmundGP,WheelerJB.Cervicalmuscleresponseduringwhiplash:evidenceofalengtheningmusclecontracFon.ClinBiomech(Bristol,Avon).2000;15:426-435.
Physical and Psychological Features Leading to Chronic Pain Syndrome
• Pooroutcomesat2-3yearspostinjury• Highpainanddisabilitylevelswithphysicalandpsychologicalfactors• Earlypresenceofcervicalmovementloss,coldtemperaturehyperalgesia,andposvraumaFcstresssymptoms
• SterlingM,JullG,KenardyJ.Physicalandpsychologicalfactorsmaintainlong-termpredicFvecapacitypost-whiplashinjury.Pain.2006;122:102-108.
“Diagnosisisthekeytosuccessfultreatment!”
Characteris?cs of the Whiplash Presenta?on
• MotorDysfuncFon• AcFvecervicalROMrestricFons• Shortandlong-termdeficits• Alteredpavernsofmusclerecruitmentincervicalspineandshouldergirdle(11,12)
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Characteris?cs of the Whiplash Presenta?on
• SensorimotorDysfuncFon• AcuteandchronicWAD• GreaterjointreposiFoningerrorswithchronicWADandacutewithmoreseverepainanddisability
• Lossofbalanceanddisturbedneck-influencedeyemovementswithchronicWAD
• ElliovJM,etal.CharacterizaFonsofAcuteandChronicWhiplash-AssociatedDisorders.JOSPT,May2009;Vol39:5:312-323.
Characteris?cs of the Whiplash Presenta?on Sensory Func?on Disturbances • HypersensiFvity(decreasedpainthreshold)topressure,thermal,electrocutaneous• SpinalcordhypersensiFvity(centralsensiFzaFon)
• SterlingM,KenardyJ.Physicalandpsychologicalaspectsofwhiplash:ImportantconsideraFonsforprimarycareassessment.Manher.2008;13:93-102.
Psychological Factors and Chronic WAD or Chronic Pain Syndrome-Post-Trauma?c
• AffecFvedisorders• Anxiety• Depression• BehavioralabnormaliFes(fearofmovement)• PosvraumaFcstress
Post Whiplash Injury Muscle FaZy Infiltrates
• MusclefavyinfiltratesonMRIdevelopsoonaherthewhiplashevent(between4-weeksand3-months)butonlyinthosewithhigheriniFalpainlevelsandasubsequentpost-traumaFcstressresponse(PTSD).
• ElliovJ,PedlerA,KenardyJ,GallowayG,JullG,SterlingM(2011)TheTemporalDevelopmentofFavyInfiltratesintheNeckMusclesFollowingWhiplashInjury:AnAssociaFonwithPainandPosvraumaFcStress.PLoSONE6(6):e21194.doi:10.1371/journal.pone.0021194
Degenera?on of the Cervical Extensor Musculature in Chronic WAD
ContentnotquanFtyisabevermeasureofmuscledegeneraFoninwhiplash.
ElliovJM,etal.ManualTherapy(2013)
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Whiplash Presenta?on
• “WhiplashisamarkedlyheterogeneousandcomplexcondiFonwithvarieddisturbancesinmotor,sensorimotorandsensoryfuncFonaswellaspsychologicaldistress.”
Clinical Implica?ons and Prognosis of Chronic Pain
• KinestheFcdeficits(jointposiFonerror)• Cervicalmusclerecruitmentpaverns• AlteredacFvityinuppertrapeziusmuscle• Poorcontrolofbalance• Impairedeyemovement(13-17)
Tes?ng for Joint Posi?oning Error and Kinesthe?c deficits
Targetdistanceis90CMBeyondtheyellowareaisasignificanterror.(18)
TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characterisFcfeaturesandrelaFonshipwithcervicaljointposiFonerror.JRehabilMed.2003Jan;35(1):36---43.
Cervical muscle recruitment paZerns • Cranio-cervicalflexiontestavemptstodeterminethestrength/weaknessofthedeepflexormusclesofthecervicalspine(LonguscapiFsandcolli)• EliminaFngtheinfluenceofthesuperficialneckflexors(Sternocleidomastoideusandanteriorscalene)
Oculomotor Control
Theassessmentofsmoothpursuitandgazestabilityisanimportantpartoftheassessmentofsensorimotorimpairmentfollowingwhiplashinjury.
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Sensorimotor Ocular Tes?ng
• SmoothpursuitinvolvesthesubjectkeepingtheirheadsFllandfollowingaslowmovingobjectwithjusttheireyesfromabout30°onesideofthemidlineto30°ontheoppositeside.
Sensorimotor Ocular Tes?ng
• Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.
Sensorimotor Ocular Tes?ng
• ReproducFonofdizzinessorpain,increasedeffortordifficultyperformingthetest,allsuggestsensorimotorimpairment.
Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)
• ThistestinvolvescomparisonofsmoothpursuitperformanceinaneutralheadposiFonwithperformanceinanecktorsionedposiFon45°degreeslehand45°right.• Itistermed‘necktorsion’becausethetrunkisrotatedonthenecktoavoidsFmulaFonofthevesFbularsystem.
Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)
• Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.
• ReproducFonofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.
Gaze Stability Tes?ng
• AskpaFenttolookatanobjectroughlyarm’s-lengthfromtheirfaceandtoslowlyflexandextendtheirheadandneckorgentlyrotatetheirheadandneckwhilstkeepingtheireyessFll.• ReproducFonofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.
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Early Sensory Findings
• BrachialplexusprovocaFontest• Pressurepainthresholds• Thermalpainthresholds• SympatheFcvasoconstrictorreflex• Neckdisabilityindex(19)
Late Sensory Findings
• Muscularhyperalgesia• Largereferredpainareas• Possibleneurogenicpain• FindingssuggestageneralisedcentralhyperexcitabilityinpaFentssufferingfromchronicwhiplashsyndrome
• KoelbaeckJM.Generalisedmuscularhyperalgesiainchronicwhiplashsyndrome.Pain.1999Nov;83(2):229-34
Algometry with Clothes Peg
Mild Trauma?c Brain Injury and Concussion
• TheacceleraFon-deceleraFonshearingforcesgeneratedbymotorvehicleaccidentsandtherotaFonalshearingforcesgeneratedwithboxing,mostespeciallytheuppercut,causesdiffuseaxonalinjury.(20)
Conclusions: The evalua?on and management of whiplash injuries must aZempt to: • Discovermechanismofinjury• Revealpainseverity• DeterminetheinjuredFssuesandpaingenerators• Understandbiopsychosocialfactors• PerformadifferenFaldiagnosis• Provideareasonableprognosis(acuteandchronic)• Offerappropriatetreatment• Integrateahealthcareteamofproviders
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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,exacerbaFonsofneckpainandunilateralupperextremityparesthesiaintheC6dermatome.• Pasthistoryofsideimpactmotorvehiclecollision(MVC)withwhiplashinjurysome20yearsearlier.Resultedinfracturedteeth,spinalandhandstrain/spraininjuries,confusionandshort-termmemoryloss.• MRIdemonstratedcervicaldiscopathyatC5-6-7twoyearsfollowingthemotorvehiclecollision• DisconFnuedracquetballduetopainandweaknessinRUE• HehasexperienceddailyneckpainandsFffnesssincetheMVCwithepisodicneck/armpainwithparesthesias.
Engaged Learning Task (30 minutes)
• Formgroupsof6doctorseach• Completediscussionin10minutes• SelectaspokespersonwhowillprovideabriefpresentaFon
Ac?ve learning tasks Pleasestatethefollowingforthis56year-oldpaFent:• DifferenFaldiagnosis• Workingdiagnosis• Prognosis
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“Diagnosisisthekeytosuccessfultreatment!”
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Disorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.
3. ElliotJM,etal.CharacterizaFonofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.
4. JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classificaFonnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeaherawhiplashinjury.AprospecFvestudyon186consecuFvepaFents.EurSpineJ.2008Jul;17(7):930–935.
5. HasueM.Painandthenerveroot.Aninterdisciplinaryapproach.Spine.1993;18:2053-2058.
6. JansenJ,BardosiA,HildebrandtJ,LuckeA.Cervicogenic,hemicranialavacksassociatedwithvascularirritaFonorcompressionofthecervicalnerverootC2.ClinicalmanifestaFonsandmorphologicalfindings.Pain.1989;39:203-212.
7. KaaleBR,KrakenesJ,AlbrektsenG,WesterK.HeadposiFonandimpactdirecFoninwhiplashinjuries:associaFonswithMRI-verifiedlesionsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:1294-1302.
8. KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Whiplash-associateddisordersimpairmentraFng:neckdisabilityindexscoreaccordingtoseverityofMRIfindingsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:466-475.
9. JonssonH,Jr,BringG,RauschningW,SahlstedtB.HiddencervicalspineinjuriesintrafficaccidentvicFmswithskullfractures.JSpinalDisord.1991;4:251.
10. PeverssonK,HildingssonC,ToolanenG,FagerlundM,BjornebrinkJ.Discpathologyaherwhiplashinjury.AprospecFvemagneFcresonanceimagingandclinicalinvesFgaFon.Spine.1997;22:283-287;discussion288.263.
References 11.BorchgrevinkGE,KaasaA,McDonaghD,SFlesTC,HaraldsethO,LereimI.Acutetreatmentofwhiplashneckspraininjuries.Arandomizedtrialoftreatmentduringthefirst14daysaheracaraccident.Spine.1998;23:25-31.12.KaschH,QeramaE,BachFW,JensenTS.Reducedcoldpressorpaintoleranceinnon-recoveredwhiplashpaFents:a1-yearprospecFvestudy.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:characterisFcfeaturesandrelaFonshipwithcervicaljointposiFonerror.”JournalofRehabilitaFonMedicine35(1):36-43.15.Treleaven,J.,G.Jull,etal.(2005).“Smoothpursuitnecktorsiontestinwhiplash-associateddisorders:relaFonshiptoself-reportsofneckpainanddisability,dizzinessandanxiety.”JournalofRehabilitaFonMedicine37(4):219-223.16.Treleaven,J.,G.Jull,etal.(2005).“Standingbalanceinpersistentwhiplash:acomparisonbetweensubjectswithandwithoutdizziness.”JournalofRehabilitaFonMedicine37(4):224-229.
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18.TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characterisFcfeaturesandrelaFonshipwithcervicaljointposiFonerror.JRehabilMed.2003Jan;35(1):36---43.19.SterlingM,etal.SensoryhypersensiFvityoccurssoonaherwhiplashinjuryandisassociatedwithpoorrecoveryPain104(2003)509-517.20.AdamsJH,DoyleD,FordI,GennarelliTA,GrahamDI,McLellanDR.Diffuseaxonalinjuryinheadinjury:definiFon,diagnosisandgrading.Histopathology.1989;15:49–59.
Cranio-cervical Flexion Test
• PerformedwiththepaFentinsupinecrooklyingwiththeneckinaneutralposiFon(nopillow)suchthatthelineofthefaceishorizontalandalinebisecFngthenecklongitudinallyishorizontaltothetesFngsurface.LayersoftowelmaybeplacedundertheheadifnecessarytoachieveaneutralposiFon.Theuninflatedpressuresensorisplacedbehindthenecksothatitabutstheocciputandisinflatedtoastablebaselinepressureof20mmHg,astandardpressuresufficienttofillthespacebetweenthetesFngsurfaceandtheneckbutnotpushtheneckintoalordosis.ThedeviceprovidesthefeedbackanddirecFontothepaFenttoperformtherequiredfivestagesofthetest.ThepaFentisinstructedthatthetestisnotoneofstrengthbutratheroneofprecision.ThemovementisperformedgentlyandslowlyasaheadnoddingacFon(asifsaying“yes”).TheCCFTteststheacFvaFonandenduranceofthedeepcervicalflexorsinprogressiveinnerrangeposiFonsasthepaFentavemptstosequenFallytargetfive,2-mmHgprogressivepressureincreasesfromthebaselineof20mmHgtoamaximumof30mmHgaswellastomaintainaisometriccontracFonattheprogressivepressuresasanendurancetask