Clinical Characteristics of Whiplash-Associated Disorders (WAD), grades I-II
Investigations into the stability system of the cervical spine
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Eythor Kristjansson, PT
ABSTRACT
The studies upon which this thesis is based were intended to identify measurable physical
impairment in the stability system of the cervical spine in patients with chronic whiplashassociated disorders (WAD), grades I-II. Case-control and test-retest designs were used to
identify and define the clinical characteristics investigated. Questionnaires were used to
investigate self-reported characteristics and two radiographic studies explored the passive
integrity of the cervical spine. The same subjects, all women, participated in the three above
mentioned studies. Two studies into the muscular system investigated the deep pre- and
paravertebral cervical muscles respectively. In three successive studies relocation and
movement accuracy of the cervical spine were investigated. Different number of subjects
participated in these five last mentioned studies.
The results from the questionnaires indicated that women with chronic WAD have symptoms
which are more disabling than women with chronic insidious onset neck pain (IONP). The
first radiographic study revealed that, in the WAD group, the upper cervical lordosis was
relatively increased and the lower cervical spine lordosis was relatively decreased. The C4
vertebra was also more kyphotic in the WAD group than in the asymptomatic group. The
second radiographic study revealed increased segmental motion in the mid cervical segments
of one third of the WAD group. These results point to mechanical instability in the lower
cervical spine in a subgroup of patients with chronic WAD.
A new test, the cranio-cervical flexion test, identified altered patterns of muscle co-ordination
within the cervical flexor synergy in neck pain patients that could indicate inhibition of the
deep ventral muscles. Ultrasound imaging revealed that the cervical multifidus muscle in
WAD patients is smaller than in asymptomatic subjects. The diminished size of this muscle
further reduces the weight bearing capacity of the cervical spine and contributes to deficient
control of intersegmental motions. These findings indicate that the deep pre- and
paravertebral muscles provide inadequate support in neck pain patients. Cervical spine
proprioception was measured using a 3D measurement device (Fastrak) connected to
specially designed software programmes. The measurements revealed relocation inaccuracy
in neck pain patients, a deficit that tended to be greater in whiplash patients. A new clinical
test, developed to measure movement inaccuracy of the cervical spine was able to
discriminate between an asymptomatic group and a chronic WAD group.
When the results from all these investigations are viewed as a whole, a definite pattern of
musculoskeletal impairment emerges. Among patients with chronic WAD, there exists a
subgroup which has an identifiable pattern of clinical characteristics indicating impaired
stability of the cervical spine. This impairment pattern may be linked to the unphysilogic
movements of the cervical spine which have been documented as occurring during the early
phase of a rear-end collision. The between–group variance for the WAD groups, IONP groups
and/or the asymptomatic groups overlapped to a different degree for each clinical
characteristic investigated, suggesting that the variance in clinical characteristics in patients
with chronic WAD is greater than earlier anticipated. It is therefore recommended, that
patients with WAD be comprehensively evaluated to ensure that all clinical characteristics are
investigated. In the future, the evaluation should include a detailed physical examination, the
implementation of specially designed tests to detect subtle physical impairment and altered
pain responses, and questionnaires to screen for diverse psychosocial factors.
List of Original Papers
The thesis is based on the following papers, which will be referred to by their Roman
numerals in the chapter headings and by their Arabic numerals in the text along with
other references
I. Symptom characteristics in women with chronic WAD, grades I-II, and chronic
insidious onset neck pain. A comparative study with an 18-month follow-up.
Journal of Whiplash & Related Disorders: In Press
II. Is the sagittal configuration changed in women with chronic whiplash syndrome?
A comparative computer-assisted radiographic assessment.
Journal of Manipulative and Physiological Therapeutics 2002; 25: 550 - 555
III. Increased sagittal plane segmental motion of the lower cervical spine in women
with whiplash associated disorders, grades I-II: A case control study using a new
measurement protocol.
Spine 2003; 28: 2215 - 2221
IV. Impairment in the cervical flexors: a comparison of whiplash and insidious onset
neck pain.
Manual Therapy: 2004; 9: 89-94
V. Reliability of ultrasonography for the cervical multifidus muscle in asymptomatic
and symptomatic subjects.
Manual Therapy: 2004; 9: 83-88
VI. Cervicocephalic kinaesthesia: reliability of a new test approach.
Physiotherapy Research International 2001; 6: 224-235
VII. A study of five cervicocephalic relocation tests in three different subject groups.
Clinical Rehabilitation 2003; 17: 768 -774
VIII. A new clinical test for cervicocephalic kinesthetic sensibility: "The Fly"
Archives of Physical Medicine and Rehabilitation 2004; 85: 490-495