1. Your Name

2.  Cost & Controversy  Biomechanics  Pathology  Clinical Features  Subjective ▪ Pain, disability, dizziness, ▪ Psychological impairment  Objective ▪ Sensorimotor, motor control, sensory changes.

3.  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

4.  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

5. 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) ?

6.  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

7.  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

8.  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)

9.  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 )

10.  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 >5cm

11.  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.

12.  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

13.  Standing balance:  Increased AP sway in whiplash subjects > idiopathic neck pain > 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).

14.  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

15.  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.

16. (Falla et al 2004)

17.  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.

18.  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 > 4/10 during test (Sterling et al 2002).

19. (Sterling et al 2006)  Strongest predictors of poor outcome:  Pain NPRS / VAS > 8/10  S-LANSS =>12  Neck Disability Index >30 %  Impact of Events Scale screen for PTSD =>26  Cold hyperalgesia >15deg C

20.  Cost & Controversy  Biomechanics  Pathology  Clinical Features  Subjective ▪ Pain, disability, dizziness, ▪ Psychological impairment  Objective ▪ Sensorimotor, motor control, sensory changes.

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

22. THANK YOU !