Proefschrift Maastricht. / Lit. opg. - Met samenvatting in het Nederlands.

The syndrome commonly referred to as whiplash injury" resulting from motor vehicle accidents is complex and remains a challenge to clinicians, as is evidenced by the recent report of the Quebec task force on the "whiplash syndrome". The main objective of this prospective randomised study was to evaluate two conservative treatment regimens (early immobilisation-experimental group-1, early active mobilisation experimental group-2) which are based on accepted physiological rationale and then to compare their effectiveness with existing treatment regimens that are commonly practiced (control group) in the management of "whiplash" type of injuries. To this stage, the current study is the only prospective randomised clinical trial of its type conducted with a sufficiently large sample size and over a long study period. The results of the current study clearly demonstrated that the subjects in the immobilised group recovered from their pain-related symptoms and returned to their normal duties sooner than those in the other two treatment groups. In addition to this, those subjects who received the immobilisation regimen did not show adverse effects on either the range of motion or the strength of the neck muscles. Thus, the immobilisation regimen was clearly shown to be the preferred option when compared to the other two treatment methodologies investigated in the current study.Although the primary interest of the current study was to compare the efficacy of three different treatment regimens, a series of statistical analyses were performed to establish the prognostic significance of several factors associated with "whiplash" injury. This showed that factors such as gender, age, speed of the vehicles involved, paraesthesia, intensity of pain at the time of the initial examination, interscapular pain, blurred vision and difficulty in focusing, all had prognostic value. ++ / Similarly, the type of collision, seating position, presence of headache within 24 hours post injury, pre-existing degenerative changes in the cervical spine, loss of lordosis and litigation factors had no prognostic significance. Another major emphasis of the current study has been to concentrate on the pain related symptoms of the neck which are of major concern to "whiplash" subjects and to those clinicians treating them. A paucity of such information is considered to be one of the most notable causes of difficulties encountered in the management of "whiplash" injuries.As an adjunct to the main study, the morphology of the deep pre- and post vertebral muscles of the neck region using embalmed cadavers and fresh post-mortem specimens was investigated, as the literature is deficient in--this regard. Similarly, a longitudinal study of 45 subjects was also performed using Magnetic Resonance Imaging (MRI) technology. The longitudinal nature of the M.R.I. study provided for the first time an account of the details associated with the progressive pathological changes that occurred in some disc lesions, at defined points in time following a MVA. The observations made from the adjunct studies help develop a better understanding of the pathoanatomy associated with the deep muscles of the neck region and the pathological changes that occur following a traumatic disc lesion as evidenced within 2 weeks, after 3 months and 12 months post- injury. On the basis of the observations made in the current study, a classification of the "whiplash" injury has been proposed for the consideration of clinicians. Similarly, the questionnaire used for data collection in the current study, can be readily modified and utilised in a clinical situation for establishing documentation, planning treatment strategies and for evaluation of the treatment outcomes of "whiplash" type of injuries.

Introduction: Little is known about the effect of beliefs on whiplash-associated disorders. Objective: To assess population beliefs regarding whiplash injury, to assess expectation as a predictor of recovery; to explore symptom attribution (Study III); and, assess the relationship between the Whiplash Disability Questionnaire (WDQ) and self-assessed recovery. Materials and Methods: Canadian residents were surveyed about whiplash injury; a whiplash cohort was assessed for association between expectations of recovery and recovery; whiplash patients were examined to correlate auditory symptoms and cerumen occlusion; and, Whiplash patients were asked a global recovery question and results compared to the whiplash Disability Questionnaire (WDQ). Results: Beliefs about whiplash injury were more negative. Expectations of recovery from injury increases the recovery rate. Cerumen explains auditory symptoms in whiplash patients. Patients responding yes to the recovery question had a low WDQ score. Conclusions: Population beliefs, expectations of recovery and symptom attribution are important in whiplash-associated disorders. / Experimental Medicine

Einleitung & Problemstellung: Beschwerden nach Beschleunigungsverletzungen der Halswirbelsäule sind oft nur unzureichend einzuordnen und diagnostizierbar. Eine eindeutige Diagnostik ist jedoch für eine entsprechende Therapie wie auch möglicherweise entstehende versicherungsrechtliche Forderungen notwendig. Die Entwicklung eines geeigneten Diagnoseverfahrens liegt damit im Interesse von Betroffenen wie auch Kostenträgern. Neben Störungen der Weichteilgewebe ist fast immer die Funktion der Halsmuskulatur in Folge eines Traumas beeinträchtigt. Dabei wird vor allem die sensorische Funktion der HWS-Muskulatur, die an der Regulation des Gleichgewichts beteiligt ist, gestört. In Folge dessen kann angenommen werden, dass es zu einer Beeinträchtigung der Gleichgewichtsregulation kommt. Die Zielstellung der Arbeit lautete deshalb, die möglicherweise gestörte Gleichgewichtsregulation nach einem Trauma im HWS-Bereich apparativ zu erfassen, um so die Verletzung eindeutig diagnostizieren zu können. Methodik: Unter Verwendung eines posturographischen Messsystems mit Kraftmomentensensorik wurden bei 478 Probanden einer Vergleichsgruppe und bei 85 Probanden eines Patientenpools Kraftmomente unter der Fußsohle als Äußerung der posturalen Balanceregulation aufgezeichnet. Die gemessenen Balancezeitreihen wurden nichtlinear analysiert, um die hohe Variabilität der Gleichgewichtsregulation optimal zu beschreiben. Über die dabei gewonnenen Parameter kann überprüft werden, ob sich spezifische Unterschiede im Schwankungsverhalten anhand der plantaren Druckverteilung zwischen HWS-Traumatisierten und den Probanden der Kontrollgruppe klassifizieren lassen. Ergebnisse: Die beste Klassifizierung konnte dabei über Parameter erzielt werden, die das Schwankungsverhalten in Phasen beschreiben, in denen die Amplitudenschwankungen relativ gering ausgeprägt waren. Die Analysen ergaben signifikante Unterschiede im Balanceverhalten zwischen der Gruppe HWS-traumatisierter Probanden und der Vergleichsgruppe. Die höchsten Trennbarkeitsraten wurden dabei durch Messungen im ruhigen beidbeinigen Stand mit geschlossenen Augen erzielt. Diskussion: Das posturale Balanceverhalten wies jedoch in allen Messpositionen eine hohe individuelle Varianz auf, so dass kein allgemeingültiges Schwankungsmuster für eine Gruppengesamtheit klassifiziert werden konnte. Eine individuelle Vorhersage der Gruppenzugehörigkeit ist damit nicht möglich. Die verwendete Messtechnik und die angewandten Auswerteverfahren tragen somit zwar zu einem Erkenntnisgewinn und zur Beschreibung des Gleichgewichtsverhaltens nach HWS-Traumatisierung bei. Sie können jedoch zum derzeitigen Stand für den Einzelfall keinen Beitrag zu einer eindeutigen Bestimmung eines Schleudertraumas leisten. / Introduction & Problem definition: Disorders after acceleration injuries of the cervical spine can often be classified and diagnosed only inadequately. But an explicit diagnosis is necessary as a basis for an adequate therapy as well as for possibly arising demands pursuant to insurance law. The development of suitable diagnosis methods is in the interest of patients as well as the cost units. Apart from disorders of the soft tissues there are almost always impairments of the function of the neck musculature. Particularly the sensory function of the cervical spine musculature, which participates in the regulation of the equilibrium, is disturbed by that. As a result in can be assumed that the postural control is also disturbed. Therefore the aim of this study was to examine the possibly disturbed postural motor balance after a whiplash injury of the cervical spine with the help of apparatus-supported methods to be able to unambigiously diagnose. Methods: postural measuring system based on the force-moment sensortechnique was used to record the postural balance regulation of 478 test persons and 85 patients which had suffered a whiplash injury. Data analysis was accomplished by linear as well as by nonlinear time series methods in order to characterise the balance regulation in an optimal way. Thus it can be determined whether there can be classified specific differences in the plantar pressure distribution covering patients with a whiplash injury and the test persons of the control group. Results: The best classification could be achieved by parameters which describe the variation of the postural balance regulation in phases in which the differences of the amplitudes of the plantar pressure distribution were relatively small. The analyses showed significant differences in the postural motor balance between the group of patients with whiplash injuries and the control group. The most significant differences (highest discriminate rates) could be observed by measurements in both-legged position with closed eyes. Discussion: Although the results achieved support the hypothesis mentioned above, is must be conceded that the postural motor balance showed a high individual variation in all positions of measurement. Therefore no universal variation model could be classified for the entirety of either group. This way an individual forecast of the group membership is impossible. As a result the measurement technology being used and the nonlinear time series analyses can contribute to the gain of knowledge and to the description of the regulation of postural control after whiplash injury. But at present they cannot contribute to an explicit determination of a whiplash injury for a particular case.

Previous studies in animals and humans show anatomic and physiological connections between the trigeminal and cervical regions. This investigation tested the hypothesis of a functional integration between the human jaw and neck motor systems in rhythmic jaw activities. By means of a wireless optoelectronic 3-D movement recording system, spatiotemporal characteristics of mandibular and head-neck movements were studied during rhythmic jaw opening-closing and chewing tasks, in healthy and in individuals with pain and dysfunction in the jaw and neck region following neck trauma, Whiplash-associated Disorders (WAD). As a basis, a methodological study evaluated the applicability of skin and teeth attached reflex markers fixed to the lower jaw and to the head in optoelectronic recording of chewing movements. The results showed concomitant and coordinated mandibular and head movements during rhythmic jaw tasks. The start of the head movement generally preceded the start of the mandibular movement. For chewing, larger size and harder texture of bolus were associated with larger head extension and larger amplitude of both mandibular and head movements. Immobilization of the head by mechanical fixation deranged jaw motor behaviour with regard to speed and amplitude of mandibular movements. Even with head fixation, muscle activity was present in neck muscles during activities. Compared to healthy subjects, WAD individuals showed smaller amplitudes and disturbed coordination of mandibular and head movements. Furthermore, a dynamic load test showed a reduced endurance during chewing in the WAD group. In conclusion, the results suggest that optimal jaw function requires free unrestricted head-neck movements and support the hypothesis of a close functional relationship between the jaw and the neck regions in rhythmic jaw activities. A new concept for human jaw function is proposed, in which "functional jaw movements" are the result of activation of jaw as well as neck muscles, leading to simultaneous movements in the temporomandibular, atlanto-occipital and cervical spine joints. The finding of an association between neck injury and disturbed jaw behaviour suggest that assessment and management of neck injured patients should include jaw function.

No description available.

Whiplash injury is a common and troublesome disorder and approximately 10-40 per cent of its victims develop chronic symptoms. The annual incidence is estimated at 1/1000 inhabitants and the prevalence at 1%. The cause of chronic symptoms after whiplash injury is still unknown and no effective treatment has been presented so far. The present study is divided into two parts; the first part includes clinical, radiographic and psychological investigations, and the second part the effect of surgical intervention as well as intervention with medication. MRI studies (n=39) showed a larger proportion of pathologic findings compared to normal subjects, but no correlation with initial neurologic deficits was found. At the 2-year follow-up all patients with disc herniations with medullary impingement had persistent symptoms. Three patients had disc herniations that deteriorated from slight and moderate initial changes on the MRI to severe changes with medullary cord impingement. This deterioration might be a first sign of disc degeneration. Thus our results indicate that disc pathology is a contributing factor in the development of chronic symptoms. Measurements from standard lateral radiographs taken in neutral position were evaluated (n=48). A graphic digitizer connected to a microcomputer was used and the sagittal diameters were determined. Multivariate analysis of variance showed that the spinal canal was significantly smaller in patients with persistent symptoms indicating that a narrow spinal canal is unfavourable in patients subjected to whiplash injury. A psychological investigation (n=70) revealed no relationship between pre-existing personality traits and persistent symptoms. In our study, whiplash patients showed no differences in personality traits compared to normal controls. Our results after discectomy and anterior cervical fusion (n=20) because of chronic symptoms after whiplash injury were not satisfactory. We noticed that about half of the cases had less headache and neck pain but no beneficial effects on radicular pain, vertigo, visual and auditory symptoms were observed. Based on the criteria of a surgical evaluation, two patients were classified as good, nine as fair and nine as poor. A prospective randomised double-blind study of high-dose methyl-prednisolone compared to placebo was conducted (n=40). A clinical follow-up with repeated neurological examinations and a standardised questionnaire including VAS-scales and a pain sketch form were used for the evaluation of initial symptoms, before drug administration and at the follow-ups at 2 weeks, 6 weeks, and 6 months after the injury. At the 6-month follow-up there was a significant difference between the actively treated patients and placebo concerning disabling symptoms defined as inability to return to previous work, number of sick-days and sick-leave profile. All the actively treated patients had returned to work and none had multiple symptoms though three of them complained of intermittent neck pain. Our conclusion is therefore that acute treatment with high-dose corticosteroids might be beneficial to the prevention of disabling symptoms after whiplash injury. / <p>Härtill 6 uppsatser</p> / digitalisering@umu

Title: Evaluation of postural stability in subjects after whiplash injury Objectives: The aim of this thesis is to assess the impact of whiplash injury on postural stability of the subjects who sustained this injury and, subsequently, to compare the results with a group of healthy subjects. Methods: In this pilot study, 16 subjects forming an experimental and a control group were involved. The experimental group consisted of 8 probands after whiplash injury, about 3-5 months after sustaining the injury. The average age of this group was 29.4 years. The control group consisted of 8 healthy probands with average age 28.8 years. All probands were free of neurological diseases, previous serious trauma and orthopedic surgeries in the region of lower extremities or torso, which might significantly affect the results of postural stability measurements. To evaluate postural stability, the device Smart EquiTest System by Neurocom was used and the data obtained were subsequently processed using the Neurocom Balance Manager Software programme. The results of both groups were statistically evaluated using the Shapiro-Wilk test of normality and then compared using the paired t-test or the Mann-Whitney test. Results: The results of this thesis point out that the persons who sustained whiplash injury show worse...

ABSTRACT Whiplash associated disorders (WAD) is one of the most debated musculoskeletal conditions. Sensory disturbances including hypersensitive responses to mechanical, thermal and electrical stimulation have been consistently shown to be a feature of both the acute and chronic stages of the whiplash condition. More importantly, such dysfunctions have also been found to be associated with higher risk of poor functional recovery. It is apparent that better understanding of the sensory disturbances in WAD is needed in order to elucidate mechanisms underlying the pain and disability of this recalcitrant condition and to facilitate the development of more effective management strategies. Comprehensive Quantitative Sensory Testing (QST) combining sensory detection and pain threshold measures is proving to be a valuable tool to advance the classification and illuminating the underlying mechanisms of an array of musculoskeletal pain disorders but such protocol has never been undertaken in a WAD cohort. In order to fill this gap in knowledge, the series of studies in the thesis aimed to utilize comprehensive QST to investigate the presence of somatosensory dysfunction in chronic WAD and to compare the somatosensory profile of WAD to cervical radiculopathy and idiopathic (non-traumatic) neck pain. Once a better understanding of the potential underlying mechanisms in chronic WAD was established, the research then focused on documenting the presence of such somatosensory disturbances soon after whiplash injury and its temporal development over a 6 months period. The results have provided a number of significant insights into some of the potential underlying mechanisms of the somatosensory dysfunction in WAD as well as other neck pain conditions of different aetiology. It is clear that generalised sensory hypoaesthesia coexisted with sensory hypersensitivity in chronic WAD and a combination of pain and detection measures best discriminated patients with WAD and controls. Similar sensory presentation was also found in patients with cervical radiculopathy but not in idiopathic neck pain patients. This finding indicates that different mechanisms underlie various musculoskeletal conditions with disordered central processes contributing to a greater degree in some conditions. Patients with whiplash and those with cervical radiculopthy may share similar underlying pain mechanisms involving the central nervous system and the discrepant findings in the idiopathic neck pain group may be due to the magnitude of nociceptive input required to induce/maintain altered central adaptive changes. Another important observation from the studies was that sensory hypoaesthesia was present in the majority of patients with whiplash injury in the acute stage. However, it persisted only in individuals who initially reported higher levels of pain and disability levels and sign of hypersensitivity. It was this group of individuals who predominantly developed persistent symptoms at six months post injury. The longitudinal findings indicate that such sensory impairments can be identified very early on and treatment interventions directed at these sensory disturbances (both sensory hypersensitivity and hypoaesthesia) should aim to reduce the nociceptive input and this may improve recovery post whiplash injury. The findings in this thesis demonstrated the clear association between sensory hypersensitivity and other sensory disturbances and their potential influence on recovery. Furthermore, the heterogeneity of the whiplash condition highlighted the importance of the early identification of “low-risk and “high-risk” patients in order to assist the clinicians to make clinical decisions on the best management approach. It cannot be overemphasised that the early assessment of whiplash injured patients should aim to identify features associated with poor recovery and a better classification system will be an important step. Implications for assessment and management of whiplash are vital in the acute stage of injury and may well go some way toward preventing the transition to chronicity, particularly in those with a more complex clinical presentation involving somatosensory disturbances. Further research directions have also been identified in order to improvement management of this complex clinical condition.

Einleitung & Problemstellung: Beschwerden nach Beschleunigungsverletzungen der Halswirbel-säule sind oft nur unzureichend einzuordnen und diagnostizierbar. Eine eindeutige Diagnostik ist jedoch für eine entsprechende Therapie wie auch möglicherweise entstehende versicherungsrechtliche Forderungen notwendig. Die Entwicklung eines geeigneten Diagnoseverfahrens liegt damit im Interesse von Betroffenen wie auch Kostenträgern. Neben Störungen der Weichteilgewebe ist fast immer die Funktion der Halsmuskulatur in Folge eines Traumas beeinträchtigt. Dabei wird vor allem die sensorische Funktion der HWS-Muskulatur, die an der Regulation des Gleichgewichts beteiligt ist, gestört. In Folge dessen kann angenommen werden, dass es zu einer Beeinträchtigung der Gleichgewichtsregulation kommt. Die Zielstellung der Arbeit lautete deshalb, die möglicherweise gestörte Gleichgewichtsregulation nach einem Trauma im HWS-Bereich apparativ zu erfassen, um so die Verletzung eindeutig diagnostizieren zu können. Methodik: Unter Verwendung eines posturographischen Messsystems mit Kraftmomentensensorik wurden bei 478 Probanden einer Vergleichsgruppe und bei 85 Probanden eines Patientenpools Kraftmomente unter der Fußsohle als Äußerung der posturalen Balanceregulation aufgezeichnet. Die gemessenen Balancezeitreihen wurden nichtlinear analysiert, um die hohe Variabilität der Gleichgewichtsregulation optimal zu beschreiben. Über die dabei gewonnenen Parameter kann überprüft werden, ob sich spezifische Unterschiede im Schwankungsverhalten anhand der plantaren Druckverteilung zwischen HWS-Traumatisierten und den Probanden der Kontrollgruppe klassifizieren lassen. Ergebnisse: Die beste Klassifizierung konnte dabei über Parameter erzielt werden, die das Schwankungsverhalten in Phasen beschreiben, in denen die Amplitudenschwankungen relativ gering ausgeprägt waren. Die Analysen ergaben signifikante Unterschiede im Balanceverhalten zwischen der Gruppe HWS-traumatisierter Probanden und der Vergleichsgruppe. Die höchsten Trennbarkeitsraten wurden dabei durch Messungen im ruhigen beidbeinigen Stand mit geschlossenen Augen erzielt. Diskussion: Das posturale Balanceverhalten wies jedoch in allen Messpositionen eine hohe individuelle Varianz auf, so dass kein allgemeingültiges Schwankungsmuster für eine Gruppen-gesamtheit klassifiziert werden konnte. Eine individuelle Vorhersage der Gruppenzugehörigkeit ist damit nicht möglich. Die verwendete Messtechnik und die angewandten Auswerteverfahren tragen somit zwar zu einem Erkenntnisgewinn und zur Beschreibung des Gleichgewichtsverhaltens nach HWS-Traumatisierung bei. Sie können jedoch zum derzeitigen Stand für den Einzelfall keinen Beitrag zu einer eindeutigen Bestimmung eines Schleudertraumas leisten. / Introduction & Problem definition: Disorders after acceleration injuries of the cervical spine can often be classified and diagnosed only inadequately. But an explicit diagnosis is necessary as a basis for an adequate therapy as well as for possibly arising demands pursuant to insurance law. The development of suitable diagnosis methods is in the interest of patients as well as the cost units. Apart from disorders of the soft tissues there are almost always impairments of the function of the neck musculature. Particularly the sensory function of the cervical spine musculature, which participates in the regulation of the equilibrium, is disturbed by that. As a result in can be assumed that the postural control is also disturbed. Therefore the aim of this study was to examine the possibly disturbed postural motor balance after a whiplash injury of the cervical spine with the help of apparatus-supported methods to be able to unambigiously diagnose. Methods: postural measuring system based on the force-moment sensortechnique was used to record the postural balance regulation of 478 test persons and 85 patients which had suffered a whiplash injury. Data analysis was accomplished by linear as well as by nonlinear time series methods in order to characterise the balance regulation in an optimal way. Thus it can be determined whether there can be classified specific differences in the plantar pressure distribution covering patients with a whiplash injury and the test persons of the control group. Results: The best classification could be achieved by parameters which describe the variation of the postural balance regulation in phases in which the differences of the amplitudes of the plantar pressure distribution were relatively small. The analyses showed significant differences in the postural motor balance between the group of patients with whiplash injuries and the control group. The most significant differences (highest discriminate rates) could be observed by measurements in both-legged position with closed eyes. Discussion: Although the results achieved support the hypothesis mentioned above, is must be conceded that the postural motor balance showed a high individual variation in all positions of measurement. Therefore no universal variation model could be classified for the entirety of either group. This way an individual forecast of the group membership is impossible. As a result the measurement technology being used and the nonlinear time series analyses can contribute to the gain of knowledge and to the description of the regulation of postural control after whiplash injury. But at present they cannot contribute to an explicit determination of a whiplash injury for a particular case.