regis dpt class of 2009 whiplash project

Cross Sectional Area of Longus Capitis Muscle in Patients with Persistent Whiplash Associated

Disorders

Cannata E, Christensen E, DeMaris J, Kummrow J, Manning E, Nielsen E, Romero T

Elliott J, Barnes C, Noteboom J, Jull G.

WHAT DO WE KNOW?

40% will continue to have symptoms

at six-months

(Hartling et al. 2001)

10-25% will continue to have

symptoms at two-years

(Radanov et al. 1995; Sterling et al. 2003;2006)

Prognostic factors to characterize the

acute & chronic condition

(Sterling et al. 2003;2006)

Cost$

$29+ billion USD

(Blincoe et al, 2002)

Injury Mechanics

Patho-Mechanics

Injury Causing Motion

Extension Facet Spearing

Facet Spearing Mechanism“Open-Book”

Grauer et al., 1997; Kaneoka et al., 1999; Yoganandan et al., 1999; 2003; Panjabi et al., 2004

Conclusions

• Mechanisms– Differential acceleration/deceleration

between head and torso

– Abnormal non-physiological movement in spinal vertebrae

– Implications for injury to myriad of disparate tissues and development of persistent symptoms

– Females > Males?

Where is the problem (s)?

Ligamentous

Facetogenic Discogenic

Up to 90% of asymptomatic subjects would show signs of lumbar DDD

~40% of healthy subjects over 40 years of age would demonstrate similar/same findings on c-spine scans

Muscle changes have been observed clinically

Kader et al, 2000; Hyun et al., 2007

Lumbar spine

Cervical spine

Paraspinal Muscle Changes in Chronic Whiplash

Groupn = 111Females

Age (years)

(SD)

BMI (kg/m2)

(SD)

NDI(SD)

Duration (mos)(SD)

Compensation Status (% yes)

WAD (n = 77)

29.7 (7.8) 25.1 (5.73)

46.0 (16.0)

20.3 (9.55) 51/79 = 65%

Control (n = 34)

27.0 (5.6) 23.0 (4.44)

-- -- --

Demographics

Cervical Paraspinal Musculature

Multifidus

Semispinalis Cervicis

Semispinalis Capitis

Splenius Capitis

Upper Trapezius

Cross-Sectional Area (mm2) of the

Cervical Extensors on MRI

Elliott et al., Man Ther, 2008

The rCSA of extensor musculature (C3-C7) for the WAD and healthy control groups (Log values, averaged across side). * p<0.01

MultifidusrC

SA

(lo

g)

e4

e5

e6

WADNormal

Semispinalis Cervicis

Semsipinalis Capitis

C3 C4 C5 C6 C7

rCS

A (

log

)

e4

e5

e6

Splenius Capitis

C3 C4 C5 C6 C7

**

* * * *

*

* *

* *

(Elliott et al., 2008)

Multifidus

rCS

A (

log

)

e4

e5

e6

WADNormal

Semispinalis Cervicis

Semsipinalis Capitis

C3 C4 C5 C6 C7

rCS

A (

log

)

e4

e5

e6

Splenius Capitis

C3 C4 C5 C6 C7

*

*

**

*

C3 C4 C5 C7C6

Could the CSA changes be the result of increased fat content?

Elliott et al., 2006

Healthy Control WAD

Mean differences for the fat indices in the cervical extensor muscles across segmental levels (C3-C7) in the WAD group (p <0.0001)

(Elliott et al., 2006)113 Females

79 WAD & 34 Normal

C3 C4 C5 C6 C7

Fat:

Mus

cle

Inde

x

0.20

0.25

0.30

0.35

0.40

0.45Multifidus Semispinalis Cervicis Semispinalis Capitis Splenius Capitis Upper Trapezius

C3 C4 C5 C6 C7

Fat:

Mus

cle

Inde

x0.20

0.25

0.30

0.35

0.40

0.45Multifidus Semispinalis Cervicis Semispinalis Capitis Splenius Capitis Upper Trapezius

C3 C4 C5 C6 C7

Fat

:Mu

scle

Ind

ex

0.20

0.25

0.30

0.35

0.40

0.45Multifidus Semispinalis Cervicis Semispinalis Capitis Splenius Capitis Upper Trapezius

What needs to be answered?

Presence of paraspinal muscular alterations has been quantified with MRI and appears

unique to subjects with persistent whiplash Are these muscular changes UNIQUE to the posterior neck muscles?

What do we know?

OUR Investigations

Study #1- Changes in Size/Shape in Oropharynx

Atlas

Dens

Tip of Uvula

Oropharynx

Dens

Condyles of Atlas

Oropharynx

MRICro SoftwareMRICro Software

Oropharynx

Dens

Condyles of Atlas

Outlined region of interest (ROI) of the oropharynx measure for CSA in a whiplash subject at the C1-2 segmental level. b) filled in ROI of oropharynx used for calculating CSA (mm2)

a b

34 Healthy Controls & 79 WAD

OROPHARYNX MORPHOMETRY

170.5

98.7

0

50

100

150

200

250

WAD NORMAL

rCS

A (

mm

^)

P < .0001

Table 2 CSA (mm2) values and the shape ratios (mm2) for the oropharyngeal measures for whiplash and healthy controls

Whiplash Control P-values

CSA (mm2)100.8 ± 38.2(92.3 – 109.4)

170.5 ± 44.3(155.1 – 186.0)

< 0.001

Shape Ratio (mm2)

(AP/Lateral)0.43 ± 0.3(0.36 -0.50)

0.70 ± 0.2(0.63 – 0.76)

< 0.001

AP-raw values (mm) 9.0 ± 3.7

(8.2 – 9.8)21. 2 ± 6.3

(19.0 – 23. 4)< 0.001

Lateral-raw values (mm) 24. 5 ± 9.8

(22.3 – 26. 7)32. 3 ± 11.7(28. 2 – 36. 4)

< 0.001

Data are means ± SD (95% confidence intervals)

CSA (mm2) values and the shape ratios (mm2) for the oropharyngeal measures for whiplash and healthy controls

Study #2: CSA of the Longus Capitis/Colli in Chronic

Whiplash

Hang in there mate!

a

b

a

b

MRICro SoftwareMRICro Software

Longus Capitis CSA mm^

0

20

40

60

80

100

120

140

160

C1 C2

CS

A m

m^

WAD

Normal

*

* p = 0.009

CSA Group Mean(mm2)

SD SEM

 C1 WAD  99.0  29.2  3.3

NORM 111.3 62.8 11.1

 C2 WAD  118.9

 35.6

 4.0

NORM 98.1 40.5 7.2

118.9

98.1

* p = 0.009

*

Did covariates influence the size of the longus

capitis?

Could these changes reflect fatty Infiltrate?

Elliott et al., submitted

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

DALM_C0-1 DALM_C2-3 DALM_C5-6 SCM_C2-3 SCM_C5-6

Mus

cle:

Fat

Ind

ices

WAD

CONTROL

** P < 0.001

**

**

**

Summary

• Muscular degeneration is present the deep anterolateral neck muscles in persistent WAD

• These changes are consistent with those observed in the posterior muscles and are of potential detriment to the optimal recovery of patients with WAD

• Studies are underway to better investigate the mechanisms underlying these changes.

Acknowledgements

U of QueenslandJames ElliottGwen Jull

Regis Univ – Denver, USA

James Elliott, Cliff Barnes, Tim Noteboom

Funding SupportRegis University – SPARC

grant

Physiotherapy Research Foundation-grant, 2009

Motor Accident Insurance Commission - QLD

THANK YOU