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...

Introduction: Cognitive complaints are often reported by patients who also describe chronic pain. Reviews suggest chronic pain is likely to be associated with weaknesses, relative to control groups, in at least some cognitive functions including processing speed, attention, and possibly working memory, but differences between studies obscure the size of effects. Objective: This study provided a quantitative analysis of the magnitude of the association between chronic pain and neurocognitive test performances. Brief literature review is also done to focus on the functional brain changes associated with the chronic pain. Methods: Meta-analysis was performed using the Cochrane, PRISMA guidelines. The analysis included published experimental design and the tests were studied at least 3 times, by different researchers, and the outcomes were combined within the same cognitive test. Tests were excluded when heterogeneity of variance exceeded I2 = 0.60. Pain subgroups were combined. Results: 23 studies met criteria and involved heterogeneous pain populations, or subgroups including back pain, whiplash, and fibromyalgia. Seven tests had sufficient variance homogeneity. Effects sizes (- ve = chronic pain relative weakness) were: Tests measuring the attention such as PASAT and TEA, working memory (WAIS- digit span), executive functions such as Stroop test, TMT showed significant weaker performance on the tests performance, whereas performance on the test of visuospatial abilities such as ROCF and Corsi block test and WCST test, did not showed significant association. Conclusions: Chronic pain was associated with statistically significant performance reductions. The pattern suggests that chronic pain is associated with poorer performance in at least some tasks requiring processing speed, attention, working memory and learning. Differences between pain and control groups ranged from about 1/3 standard deviation to just under a full standard deviation. Too little research is available on non-verbal memory and executive functions in chronic pain. / Thesis / Master of Science (MSc)

CHARLES UNIVERSITY IN PRAGUE Faculty of Physical Education and Sport Dissertation thesis March 2014 Ondřej Fanta ABSTRACT Title: Detection of head biomechanical response during extreme loading Objectives: The aim of the work was to monitor the current state of knowledge on the issue of closed head injuries, in contact and contactless respectively impacts, to establish appropriate biomechanical indicators for the detection and analysis of internal mechanical response under external mechanical load and to assess the specific circumstances that may affect the resulting injury criteria especially with regard to the actual reaction of the organism before impact. Methods: To the processing research were included and cited in particular impacted world-class publications and bibliography in the number of more than 80sources. The measurements and analysis of contact impacts were taken on the constructed impactor and the analysis of the contactless collisions were taken on the impacts simulator. The monitored biomechanical values were in particularly kinematic data describing the movement of the head towards the neck, values of acceleration of the head, head injury criteria and activity of selected muscles of the neck. Results: It consists diagram of the process of head injury and analysis of two main branches -...

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Syfte Syftet med litteraturöversikten var att beskriva förekomst av whiplashtrauma hos TMD patienter. Metod En systematisk litteratursökning av PubMed, CochraneLibrary och Bandolier databaser genomfördes för artiklar publicerade från 1 januari 1966 till 11 november 2011. Den systematiska sökningen identifierade121 artiklar. Efter borttagning av brev till redaktion och författarinlägg, utfördes en initial screening av abstract på 108 artiklar. Efter den initiala screeningen lästes 32 artiklar i fulltext med tillämpning av inklusions- och exklusionskriterier. Två av författarna utvärderade den metodologiska kvaliteten på de inkluderade studierna. Resultat Sex studier mötte inklusionskriterierna och inkluderades i rapporten. Den rapporterade förekomsten av whiplashtrauma hos TMD populationerna varierade mellan 8,4 % och 70 % (median 35 %). Förekomst av whiplashtrauma hos kontrollgrupperna varierade mellan 1,7 % och 18 %. TMD patienter med historik av whiplashtrauma rapporterade gravare TMD symptom och mer smärta jämfört med TMD patienter utan nackskada.Konklusion Resultaten från denna litteraturöversikt visar en högre förekomst av whiplashtrauma hos TMD patienter vilket tyder på att whiplashtrauma kan vara en riskfaktor för TMD. Stora variationer sågs mellan de olika inkluderade studierna och i samtliga studier fanns också brister gällande diagnoskriterier. Sammantaget så gör dessa begränsningar det svårt att bedöma traumaförekomst hos TMD patienter och i vilken utsträckning whiplashskada kan bidra till utvecklingen av TMD. Fler väldesignade studier som använder tydligt definierade diagnostiska kriterier med hög reliabilitet och validitet som t.ex RDC/TMD behövs för att kunna dra en säkrare slutsats om TMD vid whiplashtrauma. / Aim The aim ofthis systemic literature review was to describe the prevalence of whiplash trauma in TMD populations. Method A systemic literature search of the PubMed, Cochrane Library and Bandolier databases was carried out for articles published from 1 January 1966 to 11 November 2011. This systemic search identified 121 articles. After exclusion of letters to editor and author replies, an initial screening of the abstracts of 108 articles was carried out. After the initial screening 32 articles were read in full text applying the inclusion and exclusion criteria. Two of the authors evaluated the methodological quality of the included studies. Result Six studies matched the inclusion criteria and were included in the review. The reported prevalence of whiplash trauma in the TMD populations varied from 8.4% to 70% (median 35%). The prevalence of whiplash trauma in the control groups varied from1.7% to 18%.TMD patients with a history of whiplash trauma reported more TMD symptom and more pain compared to TMD patient without a neck injury.Conclusion The results from this literature review show a higher prevalence of whiplash trauma in TMD patients which indicate that whiplash trauma could be risk factor for TMD. A large variation could be seen between the included studies and there were also weaknesses with regard to the diagnostic criteria. In summery we suggest that these limitations make it difficult to assess the prevalence of neck trauma in TMD patients and to which extent a whiplash injury can contribute to the development of TMD. More well designed studies using the RDC/TMD criteria and well-defined criteria with high reliability and validity for whiplash trauma are needed in order to make a more reliable conclusion.

Submitted to the Faculty of Health Sciences at the Durban University of Technology in partial compliance with the requirements for a Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Neck pain is an extremely common condition and the treatment of neck pain forms an integral part of chiropractic practice. The optimal treatment of neck pain is provided when practitioners incorporate available evidence, experience, and knowledge regarding the clinical presentation of the patient into their treatment regimes. Current evidence suggests that a combination of manual therapy, specifically manipulation and/or mobilization, and rehabilitation may offer the optimum treatment for mechanical neck pain. However, numerous factors other than available evidence, experience and clinical presentation may influence treatment choices made by practitioners. Through the assessment of practice patterns, one may asses if the optimal treatment for a neck pain is being provided by practitioners and assess if factors specific to a practitioner may influence the treatment of neck pain. Objectives: The aim of this study is to determine the chiropractic treatment and management of mechanical neck pain, to compare this to evidence based recommendations for the conservative treatment of mechanical neck pain and to assess if factors other than the available evidence may influence the treatment of mechanical neck pain. Method: A quantitative, cross-sectional descriptive survey compiled using available literature and validated by means of a focus group and pilot testing, was administered to chiropractors practicing in KwaZulu-Natal. Upon completion of the questionnaire, the data was coded into an Excel spread sheet and imported into IBM SPSS version 20 for statistical analysis. This research protocol was approved by the Durban University of Technology Institutional Research Ethics Committee (REC 82/13) and the study took place from March to July 2014. Results: Ninety-six practitioners responded to the study which is a response rate of greater than 70%. Practitioners favoured the use of spinal manipulation, auxiliary therapeutic techniques (specifically those which were manual in nature), rehabilitation, and numerous forms of education. Specific variations in treatment pattern existed when comparing various patient presentations indicating that practitioner based factors impacted on treatment choices made by practitioners. The most significant findings included the increased utilisation of auxiliary therapeutic techniques by female practitioners, the increased utilisation of traction by practitioners identifying with the straight philosophy of chiropractic. Other significant findings included the increased utilisation of cervical collars by practitioners of increased age and experience and the increased utilisation of auxiliary therapeutic techniques by practitioners who did not attend health related conferences at least once every second year or did not attend short courses or subscribe to journals or magazines since qualification. Conclusions: This study indicates that treatment for mechanical neck pain offered by chiropractors in KwaZulu-Natal is in line with current evidence based recommendations for the treatment of mechanical neck pain, with practitioners commonly using modalities which were recommended, whilst rarely using modalities which were not recommended. The use of rehabilitation was, however, slightly lower than expected. Patient presentation and practitioner based factors were found to influence the treatment of mechanical neck pain; however, as a whole these variations were small with the majority of practitioners favouring the use of modalities which were recommended within the literature. Future studies should address the gap in the literature regarding the conservative treatment of cervical radiculopathy. / M

Submitted to the Faculty of Health Sciences at the Durban University of Technology in partial compliance with the requirements for a Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Neck pain is an extremely common condition and the treatment of neck pain forms an integral part of chiropractic practice. The optimal treatment of neck pain is provided when practitioners incorporate available evidence, experience, and knowledge regarding the clinical presentation of the patient into their treatment regimes. Current evidence suggests that a combination of manual therapy, specifically manipulation and/or mobilization, and rehabilitation may offer the optimum treatment for mechanical neck pain. However, numerous factors other than available evidence, experience and clinical presentation may influence treatment choices made by practitioners. Through the assessment of practice patterns, one may asses if the optimal treatment for a neck pain is being provided by practitioners and assess if factors specific to a practitioner may influence the treatment of neck pain. Objectives: The aim of this study is to determine the chiropractic treatment and management of mechanical neck pain, to compare this to evidence based recommendations for the conservative treatment of mechanical neck pain and to assess if factors other than the available evidence may influence the treatment of mechanical neck pain. Method: A quantitative, cross-sectional descriptive survey compiled using available literature and validated by means of a focus group and pilot testing, was administered to chiropractors practicing in KwaZulu-Natal. Upon completion of the questionnaire, the data was coded into an Excel spread sheet and imported into IBM SPSS version 20 for statistical analysis. This research protocol was approved by the Durban University of Technology Institutional Research Ethics Committee (REC 82/13) and the study took place from March to July 2014. Results: Ninety-six practitioners responded to the study which is a response rate of greater than 70%. Practitioners favoured the use of spinal manipulation, auxiliary therapeutic techniques (specifically those which were manual in nature), rehabilitation, and numerous forms of education. Specific variations in treatment pattern existed when comparing various patient presentations indicating that practitioner based factors impacted on treatment choices made by practitioners. The most significant findings included the increased utilisation of auxiliary therapeutic techniques by female practitioners, the increased utilisation of traction by practitioners identifying with the straight philosophy of chiropractic. Other significant findings included the increased utilisation of cervical collars by practitioners of increased age and experience and the increased utilisation of auxiliary therapeutic techniques by practitioners who did not attend health related conferences at least once every second year or did not attend short courses or subscribe to journals or magazines since qualification. Conclusions: This study indicates that treatment for mechanical neck pain offered by chiropractors in KwaZulu-Natal is in line with current evidence based recommendations for the treatment of mechanical neck pain, with practitioners commonly using modalities which were recommended, whilst rarely using modalities which were not recommended. The use of rehabilitation was, however, slightly lower than expected. Patient presentation and practitioner based factors were found to influence the treatment of mechanical neck pain; however, as a whole these variations were small with the majority of practitioners favouring the use of modalities which were recommended within the literature. Future studies should address the gap in the literature regarding the conservative treatment of cervical radiculopathy. / M

The requirement to operate vehicles in low light and/or night environments whilst wearing night vision goggle (NVG) systems has become increasingly common during military operations. There is very limited research investigating injury risks associated with these systems during ground vehicle collisions. This study examined the injury risks associated with wearing the Australian Defence Force - Enhanced Combat Helmet (ECH) and NVG system, in frontal vehicle collisions. This project consisted of two components: (1) crash tests using a sled and (2) numerical simulations of impacts. Four dynamic sled tests were conducted using a 50th percentile, male, Hybrid III dummy positioned on a rigid seat. Frontal impact tests were performed at a 40 km/h change in velocity (*v) and 20 g deceleration. The test configurations were as follows: (a) Base; (no helmet or additional equipment); (b) ECH; and, (c) ECH and NVG. Condition (c) was carried out twice, to determine repeatability. The sled test protocols were reconstructed precisely with the numerical simulation package MADYMO and the simulations were shown to correlate well with the experimental results. Using this validated model, four parametric studies were undertaken to assess the influence of counterweights, seat cushion, seatbelt pre-tensioner, and the vehicle's *v and acceleration on injury risks. The study found that neck loads were within acceptable limits, with the exception of the neck extension moment, which was exceeded for all NVG conditions. Based on the parametric studies, no major improvements were observed in the neck extension moments with the use of counterweights or a seat cushion. In contrast the use of a seatbelt pre-tensioner was observed to decrease greatly this neck injury risk in certain scenarios. The study also identified that a *v of 15 km/h and peak acceleration of up to 14 g were required to keep the neck extension moment below the prescribed injury criteria. However, the high neck extension moment values may have been partially attributable to the stiff Hybrid III neck. This study identified a possible injury mechanism for soldiers using the ECH and NVG system during specific impact scenarios. The method applied in this project was designed to be repeatable.

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.

This thesis is on chronic neck pain after a rear impact car injury, so called whiplash associated disorder (WAD). Three empirical studies using positron emission tomography (PET) with different radioligands have been performed. The first study evaluated resting state regional cerebral blood flow (rCBF) in WAD patients and in healthy, pain-free controls, by use of oxygen-15 labeled water. Patients had heightened resting rCBF bilaterally in the posterior parahippocampal and the posterior cingulate gyri, in the right thalamus and in the right medial prefrontal gyrus. Attenuated tempero-occipital blood flow was also observed in the patient group as compared to healthy controls. Alterations in rCBF were related to patients’ neck disability ratings. Study I suggests an involvement of the posterior cingulate, the parahippocampal and the medial prefrontal gyri in WAD. This altered resting state neural activity may be linked to an increased self-relevant evaluation of pain and stress. The second study evaluated central expression of the neurokinin-1 (NK1) receptor in WAD patients and healthy controls. Using a carbon-11 labeled specific NK1 antagonist, the receptor availability was measured. Patients displayed lowered NK1 receptor availability in the insula, anterior cingulate, frontal lobe, hippocampus, amygdala and in the periaqueductal gray matter, consistent with results from animal models of chronic pain. NK1 receptor availability was most reduced in the ventromedial orbitofrontal cortex, where attenuations were linearly related to patients fear and avoidance of movement. Thirdly, carbon-11 labeled D-deprenyl was used to investigate the presence of locally inflamed soft tissue in the cervical neck in WAD patients. Although the retention mechanism of [11C]D-deprenyl is not known, the results suggest that WAD patients have chronic inflammatory processes in the neck, most commonly in the adipose tissue at the spineous process of the second vertebra. In summary, this thesis provides evidence for altered central blood flow and receptor characteristics in WAD patients. Further, WAD patients may also have signs of persistent peripheral tissue damage. Both central and peripheral pain mechanisms have been demonstrated and visualized in patients with whiplash associated disorder.