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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!”

References 1.  BarnsleyL,LordS,BogdukN.Whiplashinjury.Pain.1994;58:283–307.2.  SpitzerWO,SkovronML,SalmiLR,etal.ScienFficmonographoftheQuebecTaskForceonWhiplash-Associated

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.

17.Jull,G.,D.Falla,etal.(2007).“RetrainingcervicaljointposiFonsense:Theeffectoftwoexerciseregimes.”JournalofOrthopaedicResearch25(3):404-412.

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