Download - Regis DPT Class of 2009 Whiplash Project
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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.
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WHAT DO WE KNOW?
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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)
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Injury Mechanics
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Patho-Mechanics
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Injury Causing Motion
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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
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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?
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Where is the problem (s)?
Ligamentous
Facetogenic Discogenic
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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
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Muscle changes have been observed clinically
Kader et al, 2000; Hyun et al., 2007
Lumbar spine
Cervical spine
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Paraspinal Muscle Changes in Chronic Whiplash
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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
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Cervical Paraspinal Musculature
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Multifidus
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Semispinalis Cervicis
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Semispinalis Capitis
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Splenius Capitis
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Upper Trapezius
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Cross-Sectional Area (mm2) of the
Cervical Extensors on MRI
Elliott et al., Man Ther, 2008
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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
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Could the CSA changes be the result of increased fat content?
Elliott et al., 2006
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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
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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?
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OUR Investigations
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Study #1- Changes in Size/Shape in Oropharynx
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Atlas
Dens
Tip of Uvula
Oropharynx
Dens
Condyles of Atlas
Oropharynx
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MRICro SoftwareMRICro Software
Oropharynx
Dens
Condyles of Atlas
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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
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34 Healthy Controls & 79 WAD
OROPHARYNX MORPHOMETRY
170.5
98.7
0
50
100
150
200
250
WAD NORMAL
rCS
A (
mm
^)
P < .0001
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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
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Study #2: CSA of the Longus Capitis/Colli in Chronic
Whiplash
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Hang in there mate!
a
b
a
b
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MRICro SoftwareMRICro Software
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Longus Capitis CSA mm^
0
20
40
60
80
100
120
140
160
C1 C2
CS
A m
m^
WAD
Normal
*
* p = 0.009
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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
*
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Did covariates influence the size of the longus
capitis?
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Could these changes reflect fatty Infiltrate?
Elliott et al., submitted
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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
**
**
**
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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.
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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
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THANK YOU