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Whiplash Associated Disorders: The pathway from acute to

chronic pain JamesJ.Lehman,DC,MBA,FACO

UniversityofBridgeportCollegeofChiroprac@c

Learning Objec?ves

• Determinepa@ent’sprognosisandpoten@altoexperiencechronicpainsyndromefollowingawhiplashinjury,priortoprovidingchiroprac@cservices.

Whiplash Neck Injury

•  FirstdescribedbyCrowein1928.• Mostcommontypeofinjuryfollowingmotorvehiclecrashes• Usually2-3weeksforrecovery•  Yet,upto42%transi@onfromacutetochronicpainstatus.(1)

“Diagnosisisthekeytosuccessfultreatment!”

Quebec Task Force Defini?on

• Whiplashinjuryis“anaccelera@on-decelera@onmechanismofenergytransferredtotheneck,”usuallyresul@ngfromrear-endorside-impactmotorvehiclecollision.(2)

Whiplash Injury Costs

•  Queensland,Australia=$500millionAustraliandollars(1994-2001)

•  MAIC.Whiplash—ReviewofCTPQueenslandDatato31Dec2001.Brisbane,Australia:TheMotorAccidentInsuranceCommission(MAIC);2002.

•  UnitedKingdom=L3billionperannum

•  JoslinCC,KhanSN,BannisterGC.Long-termdisabilityagerneckinjury:[email protected];86:1032–1034.

•  UnitedStates=USD$29billionperannum

•  BlincoeL,SeayA,ZaloshnjaE,etal.TheEconomicImpactofMotorVehicleCrashes,2000.Washington,DC;Na@onalHighwayTrafficSafetyAdministra@on:2002.

Pathomechanics of Whiplash Injury

Whiplash Injury Symptoms

•  Pain,•  dizziness,•  visualandauditorydisturbances,•  temporomandibularjointdysfunc@on,

•  photophobia,•  dysphonia,•  dysphonia,•  fa@gue,•  cogni@vedifficul@essuchasconcentra@onandmemoryloss,anxiety,insomnia,anddepression(3)

• 

Case One = WAD I

• Pa@entpresentswithneckcomplaintsincludings@ffnessortendernessintheneckregionsandnophysicalsignsofinjury.

•  SpitzerWO,SkovronML,SalmiLR,etal.Scien@ficmonographoftheQuebecTaskForceonWhiplash-AssociatedDisorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.

• Mostlikelydiagnosisisacute,mildcervicalstrain• Prognosisisgood•  Spontaneousrecoverywithin2-3weeksiscommon.

Case Two: WAD II

• Pa@entpresentswithneckcomplaintsincludings@ffnessortenderness,andsomephysicalsignsofinjury,suchaspointtendernessortroubleturningthehead.

• Acute,moderatecervicalsprain/strainismostlikelyDX• Prognosisisdifficulttopredict• Currentmanagementdoesnotappeartolessentransi@onfromacutetochronicpainstatus• Physicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredic@veofpoorrecovery

Case Three: WAD III

• Pa@entpresentswithneckcomplaintsincludings@ffnessortendernessandneurologicalsignsofinjurysuchasdeeptendonreflexormotordeficits.

• Acute,moderatesprain/strainwithresultantcervicalradiculopathy• Currentmanagementdoesnotappeartolessentransi@onfromacutetochronicpainstatus• Physicalandpsychologicalimpairmentpoorlyaddressedbytreatmentspredic@veofpoorrecovery

Case Four: WAD IV

• Pa@entpresentswithneckcomplaintsandafractureand/ordisloca@onofthecervicalspine.

Grade 3 Facet Sprains and Transverse Processes Fractures •  Mul@plefacetjointrupturesandfracturesofthetransverseprocessesfromC4toC6.•  Atautopsyahematomainthelonguscollimusculatureextendedalongthebrachialplexusintotheaxilla.•  Theseserialfracturesweredetectedatsecondlookonthespecimenradiograms.•  Thefracturesrunposteriorlythroughtheintertransversebarintothejointsthatdisplaytorncapsulesandmeniscoidsandhemarthrosis

Occipital Condyle Fracture

•  Thefragmentwasavulsedbythe(intact)alarligament.•  Ontheplainradiogramsthisfracturewasbarelyvisibleandwasonlydetectedatsecond–lookevalua@on.•  Theavulsedfragmentisdisplacedposteriorlyandmedially,embeddingmediumfillsthewidefracturegap.•  Intheatlanto–axialjointtheposteriormeniscoidandthejointcapsulearetorn,pullingtheC2nerveintothejointspace.

Quebec Task Force (QTF) Classifica?ons

•  SponsoredbyapublicinsurerinCanada.• QTFsubmivedrecommenda@onsregardingclassifica@onandtreatmentofWAD,whichwasusedtodevelopaguideformanagingwhiplashin1995.• Anupdatedreportwaspublishedin2001.•  Eachofthegradescorrespondstoaspecifictreatmentrecommenda@on.

Quebec Task Force (1995) Cri?cisms

1.  Largelyconsensusbasedratherthanevidence-based

2.  Selec@onbiasfortheliteraturereview

Swedish Study and Quebec Task Force

• NeithertheWADclassifica@onnortheQTFfollow-upregimencouldbelinkedtoabeveroutcome.

•  JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classifica@onnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeagerawhiplashinjury.Aprospec@vestudyon186consecu@[email protected];17(7):930–935.


•  Themul@ple-follow-upregimenisboth@meconsumingandcostlyandappearsnotbejus@fiedinarou@neclinicalsewng.


•  TheWAD-classifica@oncouldnotpredictpersistentneckpainagerawhiplashinjuryinthishospitalemergencydepartmentbasedpopula@on.


• Norwasthereasta@s@callysignificantdifferenceintherateofchronicneckpainbetweentheno-follow-upregimenandthemul@ple-follow-upregimenproposedbytheQTF.


• Atthefirstvisitwerecommendacarefulhistory,physicalexamina@onandinforma@onaboutthenatureofthecondi@on.

Swedish Study Findings

• Inthisstudycaseswithneckpainbeforetheaccidentandahighdegreeofemo@onaldistressfromtheaccidenthadatenfoldincreasedriskofdevelopingchronicneckpain.(4)

Transi?on from Acute to Chronic Pain Status

• Pa@entsthatdonotresolvewithinweeksogenexhibitamyriadofsymptomssoonagertheinjuryevent.

Pathoanatomical Lesions in the Whiplash Injury

1.  CervicalFacetjoints(ZygapophysealJoints)

2.  DorsalRootGanglion(DRG)andNerveRoots

3.  CervicalLigaments4.  IntervertebralDiscInjuries5.  MuscleInjuries

Facet Joint Injury Model

•  Studiesemployingthecervicalfacetjointinjurymodelhaveiden@fiedtheoccurrenceofhemarthrosis,capsulardamage,jointfractures,andcapsularrupture.

•  JoslinCC,KhanSN,BannisterGC.Long-termdisabilityagerneckinjury:[email protected];86:1032-1034.

Cervical Facet Injury Model

• Clinicalsupportforafacetogenicmodelofpersistentpaingenera@oninwhiplashcanbefoundintheliterature.

•  LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainagerwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.

Cervical Facet Injury Model

• Asaresultoffacetjointinjury,whiplashpa@entsfrequentlyencounter,headaches,backandshoulderpaininaddi@ontoneckpain.

•  ElliotJM,etal.Characteriza@onofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.

Cervical Facet Joint Injury and Referred Pain

•  ThemostcommonfacetstobeinjuredandhighestprevalenceofjointpainareatC2/C3andC5/C6,whichfrequentlyresultsinreferredpain.

•  LordSM,BarnsleyL,WallisBJ,BogdukN.Chroniccervicalzygapophysialjointpainagerwhiplash.Aplacebo-controlledprevalencestudy.Spine.1996;21:1737-1744;discussion1744-1735.

Dorsal Root Ganglion and Nerve Roots

•  Vulnerabletoexcessivestretchingandinjuryduringrapidaccelera@on/decelera@on(“S-shaped”curve)orlateralbendingoftheneckasdemonstratedinrear-endorside-vectorimpactwhiplash.

Dorsal Root Ganglion (DRG) Compression and SoV Tissue Changes

•  Largelyundetected• Maycontributetoadapta@onintheoverallfunc@oningofthecervicalDRG• Maypredisposeanindividualtoabnormal,centrallymediatedpainprocessing.(5,6)

Cervical Ligamentous Sprain Injuries

• Possibleinjurytomechanorecep@veandnocicep@venerveendingsleadingtopain,inflamma@onandchronicpainsyndrome

•  TominagaY,NduAB,CoeMP,etal.Neckligamentstrengthisdecreasedfollowingwhiplashtrauma.BMCMusculoskeletDisord.2006;7:103.

Persistent Pain: A Chronic Illness

• Acutepainusuallygoesawayageraninjuryorillnessresolves.Butwhenpainpersistsformonthsorevenyears,longagerwhateverstartedthepainhasgoneorbecausetheinjurycon@nues,itbecomesachroniccondi@onandillnessinitsownright.

•  ACalltoRevolu@onizeChronicPainCareinAmerica:AnOpportunityinHealthCareReform.TheMaydayFund.November4,2009.AmendedMarch4,2010.

Na?onal Pain Strategy

• Chronicpain-Painthatoccursonatleasthalfthedaysforsixmonthsormore.

JamesJ.Lehman,DC,MBA,DABCO

Upper Cervical Ligament Sprain Injuries and the Presence of Rust’s Sign

• Historyofroll-overMVAorblowtohead•  Suspectuppercervicalspineinstability• OrderimmediateCTScantocheckfornon-displacedcervicalspinefracture

Upper Cervical Ligament Sprain Injuries Leading Chronic Pain

•  Severityofalarligamentinjury,headposi@onat@meofimpact,NeckDisabilityIndex(NDI)scoresandreproduc@onofpainandexcessivemobilitywithmanualexamina@on.(7,8)•  SharpPurserManeuvertestforuppercervicalspineinstability.

Cervical Disc Injuries

Presentin25%ofsubjectspostwhiplashinjuryandcorrelatedwithradicularsymptoms(9,10)

Cervical Disc Injuries

•  C5-6segmentallevelwasfoundtobethemostcommonlevelofdiscinjury...•  greaterriskoflow-gradespinalcordinjurywithpre-exis@ngspinalcanalnarrowingatC5-6level

•  ItoS,PanjabiMM,IvancicPC,PearsonAM.Spinalcanalnarrowingduringsimulatedwhiplash.Spine.2004;29:1330-1339.

Cervical Spondylo?c Myelopathy

CommonsymptomsClumsyorweakhandsLegweaknessors@ffnessNecks@ffnessPaininshouldersorarmsUnsteadygaitCommonsignsAtrophyofthehandmusculatureHyperreflexiaLhermive'ssign(electricshock-likesensa@ondownthecenterofthebackfollowingflexionoftheneck)Sensoryloss

Muscles Strained

• WhiplashhasbeendemonstratedtostrainSCM,semispinalis,spleniuscapi@sanduppertrapeziuswithrear-endimpacts.

•  BraultJR,SiegmundGP,WheelerJB.Cervicalmuscleresponseduringwhiplash:[email protected](Bristol,Avon).2000;15:426-435.

Physical and Psychological Features Leading to Chronic Pain Syndrome

• Pooroutcomesat2-3yearspostinjury•  Highpainanddisabilitylevelswithphysicalandpsychologicalfactors•  Earlypresenceofcervicalmovementloss,coldtemperaturehyperalgesia,andposvrauma@cstresssymptoms

•  SterlingM,JullG,KenardyJ.Physicalandpsychologicalfactorsmaintainlong-termpredic@vecapacitypost-whiplashinjury.Pain.2006;122:102-108.

Characteris?cs of the Whiplash Presenta?on

• MotorDysfunc@on•  Ac@vecervicalROMrestric@ons•  Shortandlong-termdeficits•  Alteredpavernsofmusclerecruitmentincervicalspineandshouldergirdle(11,12)

Characteris?cs of the Whiplash Presenta?on

•  SensorimotorDysfunc@on•  AcuteandchronicWAD•  Greaterjointreposi@oningerrorswithchronicWADandacutewithmoreseverepainanddisability•  Lossofbalanceanddisturbedneck-influencedeyemovementswithchronicWAD

•  ElliovJM,etal.Characteriza@onsofAcuteandChronicWhiplash-AssociatedDisorders.JOSPT,May2009;Vol39:5:312-323.

Characteris?cs of the Whiplash Presenta?on Sensory Func?on Disturbances •  Hypersensi@vity(decreasedpainthreshold)topressure,thermal,electrocutaneous•  Spinalcordhypersensi@vity(centralsensi@za@on)

•  SterlingM,KenardyJ.Physicalandpsychologicalaspectsofwhiplash:[email protected];13:93-102.

Psychological Factors and Chronic WAD or Chronic Pain Syndrome-Post-Trauma?c

• Affec@vedisorders• Anxiety• Depression• Behavioralabnormali@es(fearofmovement)• Posvrauma@cstress

Post Whiplash Injury Muscle FaZy Infiltrates

• MusclefavyinfiltratesonMRIdevelopsoonagerthewhiplashevent(between4-weeksand3-months)butonlyinthosewithhigherini@alpainlevelsandasubsequentpost-trauma@cstressresponse(PTSD).

•  ElliovJ,PedlerA,KenardyJ,GallowayG,JullG,SterlingM(2011)TheTemporalDevelopmentofFavyInfiltratesintheNeckMusclesFollowingWhiplashInjury:AnAssocia@[email protected](6):e21194.doi:10.1371/journal.pone.0021194

Degenera?on of the Cervical Extensor Musculature in Chronic WAD

Contentnotquan@tyisabevermeasureofmuscledegenera@oninwhiplash.

ElliovJM,etal.ManualTherapy(2013)

Whiplash Presenta?on

•  “Whiplashisamarkedlyheterogeneousandcomplexcondi@onwithvarieddisturbancesinmotor,sensorimotorandsensoryfunc@onaswellaspsychologicaldistress.”

Clinical Implica?ons and Prognosis of Chronic Pain

• Kinesthe@cdeficits(jointposi@onerror)• Cervicalmusclerecruitmentpaverns• Alteredac@vityinuppertrapeziusmuscle• Poorcontrolofbalance•  Impairedeyemovement(13-17)

Tes?ng for Joint Posi?oning Error and Kinesthe?c deficits

Targetdistanceis90CMBeyondtheyellowareaisasignificanterror.(18)

TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@[email protected];35(1):36---43.

Cervical muscle recruitment paZerns • Cranio-cervicalflexiontestavemptstodeterminethestrength/weaknessofthedeepflexormusclesofthecervicalspine(Longuscapi@sandcolli)•  Elimina@ngtheinfluenceofthesuperficialneckflexors(Sternocleidomastoideusandanteriorscalene)

Oculomotor Control

Theassessmentofsmoothpursuitandgazestabilityisanimportantpartoftheassessmentofsensorimotorimpairmentfollowingwhiplashinjury.

Sensorimotor Ocular Tes?ng

•  Smoothpursuitinvolvesthesubjectkeepingtheirheads@llandfollowingaslowmovingobjectwithjusttheireyesfromabout30°onesideofthemidlineto30°ontheoppositeside.


•  Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.


• Reproduc@onofdizzinessorpain,increasedeffortordifficultyperformingthetest,allsuggestsensorimotorimpairment.

Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)

•  Thistestinvolvescomparisonofsmoothpursuitperformanceinaneutralheadposi@onwithperformanceinanecktorsionedposi@on45°degreeslegand45°right.•  Itistermed‘necktorsion’becausethetrunkisrotatedonthenecktoavoids@mula@onoftheves@bularsystem.

Sensorimotor Impairment: Smooth Pursuit Neck Torsion Test (SPNT)

•  Thecliniciancloselyobservesthesubject’seyemovements,lookingforjerkyorfastmovements.

•  Reproduc@onofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.

Gaze Stability Tes?ng

• Askpa@enttolookatanobjectroughlyarm’s-lengthfromtheirfaceandtoslowlyflexandextendtheirheadandneckorgentlyrotatetheirheadandneckwhilstkeepingtheireyess@ll.• Reproduc@onofsymptomsordifficultyperformingthetestsuggestssensorimotorimpairment.

Early Sensory Findings

• Brachialplexusprovoca@ontest• Pressurepainthresholds•  Thermalpainthresholds•  Sympathe@cvasoconstrictorreflex• Neckdisabilityindex(19)

Late Sensory Findings

• Muscularhyperalgesia•  Largereferredpainareas• Possibleneurogenicpain•  Findingssuggestageneralisedcentralhyperexcitabilityinpa@entssufferingfromchronicwhiplashsyndrome

•  KoelbaeckJM.Generalisedmuscularhyperalgesiainchronicwhiplashsyndrome.Pain.1999Nov;83(2):229-34

Algometry with Clothes Peg

Mild Trauma?c Brain Injury and Concussion

•  Theaccelera@on-decelera@onshearingforcesgeneratedbymotorvehicleaccidentsandtherota@onalshearingforcesgeneratedwithboxing,mostespeciallytheuppercut,causesdiffuseaxonalinjury.(20)

Conclusions: The evalua?on and management of whiplash injuries must aZempt to: • Discovermechanismofinjury• Revealpainseverity• Determinetheinjured@ssuesandpaingenerators• Understandbiopsychosocialfactors• Performadifferen@aldiagnosis• Provideareasonableprognosis(acuteandchronic)• Offerappropriatetreatment•  Integrateahealthcareteamofproviders

First Evaluate Pa?ent and Make a Diagnosis/Prognosis Before Trea?ng Pa?ent

Evidence-based, pa?ent-centered and ethical report of findings with whiplash injuries

• Reportthediagnoses,suggestappropriatetreatment,gainpermissiontotreat(informedconsent),anddiscusstheprognosis• Avempttoreducedisabilityandchronicpainwithuseofplaceboeffect• Reportimpairmentwithmedicallegalcasesbutavoidnoceboeffect

Case

•  56y/omaleprofessorpresentswiththefollowingHPI•  Acute,exacerba@onsofneckpainandunilateralupperextremityparesthesiaintheC6dermatome.•  Pasthistoryofsideimpactmotorvehiclecollision(MVC)withwhiplashinjurysome20yearsearlier.Resultedinfracturedteeth,spinalandhandstrain/spraininjuries,confusionandshort-termmemoryloss.• MRIdemonstratedcervicaldiscopathyatC5-6-7twoyearsfollowingthemotorvehiclecollision•  Discon@nuedracquetballduetopainandweaknessinRUE•  Hehasexperienceddailyneckpainands@ffnesssincetheMVCwithepisodicneck/armpainwithparesthesias.

Engaged Learning Task (30 minutes)

•  Formgroupsof6doctorseach• Completediscussionin10minutes•  Selectaspokespersonwhowillprovideabriefpresenta@on

Ac?ve learning tasks Pleasestatethefollowingforthis56year-oldpa@ent:• Differen@aldiagnosis• Workingdiagnosis• Prognosis

References 1.  BarnsleyL,LordS,BogdukN.Whiplashinjury.Pain.1994;58:283–307.2.  SpitzerWO,SkovronML,SalmiLR,etal.Scien@ficmonographoftheQuebecTaskForceonWhiplash-Associated

Disorders:redefining“whiplash”anditsmanagement.Spine.1995;20:1S–73S.

3.  ElliotJM,etal.Characteriza@onofAcuteandChronicWhiplash-AssociatedDisorders.JournalofOrthopaedic&SportsPhysicalTherapy,2009,Volume:39Issue:5Pages:312-323.

4.  JoukoKivioja,IreneJensen,andUrbanLindgren.NeithertheWAD-classifica@onnortheQuebecTaskForcefollow-upregimenseemstobeimportantfortheoutcomeagerawhiplashinjury.Aprospec@vestudyon186consecu@[email protected];17(7):930–935.

5.  HasueM.Painandthenerveroot.Aninterdisciplinaryapproach.Spine.1993;18:2053-2058.

6.  JansenJ,BardosiA,HildebrandtJ,LuckeA.Cervicogenic,hemicranialavacksassociatedwithvascularirrita@onorcompressionofthecervicalnerverootC2.Clinicalmanifesta@onsandmorphologicalfindings.Pain.1989;39:203-212.

7.  KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Headposi@onandimpactdirec@oninwhiplashinjuries:associa@onswithMRI-verifiedlesionsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:1294-1302.

8.  KaaleBR,KrakenesJ,AlbrektsenG,WesterK.Whiplash-associateddisordersimpairmentra@ng:neckdisabilityindexscoreaccordingtoseverityofMRIfindingsofligamentsandmembranesintheuppercervicalspine.JNeurotrauma.2005;22:466-475.

9.  JonssonH,Jr,BringG,RauschningW,SahlstedtB.Hiddencervicalspineinjuriesintrafficaccidentvic@mswithskullfractures.JSpinalDisord.1991;4:251.

10.  PeverssonK,HildingssonC,ToolanenG,FagerlundM,BjornebrinkJ.Discpathologyagerwhiplashinjury.Aprospec@vemagne@cresonanceimagingandclinicalinves@[email protected];22:283-287;discussion288.263.

References 11.BorchgrevinkGE,KaasaA,McDonaghD,S@lesTC,HaraldsethO,LereimI.Acutetreatmentofwhiplashneckspraininjuries.Arandomizedtrialoftreatmentduringthefirst14daysageracaraccident.Spine.1998;23:25-31.12.KaschH,QeramaE,BachFW,JensenTS.Reducedcoldpressorpaintoleranceinnon-recoveredwhiplashpa@ents:[email protected];9:561-569.13.Tjell,C.andU.Rosenhall(1998).“Smoothpursuitnecktorsiontest:aspecifictestforcervicaldizziness.”Otology&Neurotology19(1):76.

14.Treleaven,J.,G.Jull,etal.(2003).“Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@onshipwithcervicaljointposi@onerror.”JournalofRehabilita@onMedicine35(1):36-43.15.Treleaven,J.,G.Jull,etal.(2005).“Smoothpursuitnecktorsiontestinwhiplash-associateddisorders:rela@onshiptoself-reportsofneckpainanddisability,dizzinessandanxiety.”JournalofRehabilita@onMedicine37(4):219-223.16.Treleaven,J.,G.Jull,etal.(2005).“Standingbalanceinpersistentwhiplash:acomparisonbetweensubjectswithandwithoutdizziness.”JournalofRehabilita@onMedicine37(4):224-229.

17.Jull,G.,D.Falla,etal.(2007).“Retrainingcervicaljointposi@onsense:Theeffectoftwoexerciseregimes.”JournalofOrthopaedicResearch25(3):404-412.

18.TreleavenJ,JullG,SterlingM.Dizzinessandunsteadinessfollowingwhiplashinjury:characteris@cfeaturesandrela@[email protected];35(1):36---43.19.SterlingM,etal.Sensoryhypersensi@vityoccurssoonagerwhiplashinjuryandisassociatedwithpoorrecoveryPain104(2003)509-517.20.AdamsJH,DoyleD,FordI,GennarelliTA,GrahamDI,McLellanDR.Diffuseaxonalinjuryinheadinjury:defini@on,diagnosisandgrading.Histopathology.1989;15:49–59.

Cranio-cervical Flexion Test

•  Performedwiththepa@entinsupinecrooklyingwiththeneckinaneutralposi@on(nopillow)suchthatthelineofthefaceishorizontalandalinebisec@ngthenecklongitudinallyishorizontaltothetes@ngsurface.Layersoftowelmaybeplacedundertheheadifnecessarytoachieveaneutralposi@on.Theuninflatedpressuresensorisplacedbehindthenecksothatitabutstheocciputandisinflatedtoastablebaselinepressureof20mmHg,astandardpressuresufficienttofillthespacebetweenthetes@ngsurfaceandtheneckbutnotpushtheneckintoalordosis.Thedeviceprovidesthefeedbackanddirec@[email protected]@entisinstructedthatthetestisnotoneofstrengthbutratheroneofprecision.Themovementisperformedgentlyandslowlyasaheadnoddingac@on(asifsaying“yes”).TheCCFTteststheac@va@onandenduranceofthedeepcervicalflexorsinprogressiveinnerrangeposi@onsasthepa@entavemptstosequen@allytargetfive,2-mmHgprogressivepressureincreasesfromthebaselineof20mmHgtoamaximumof30mmHgaswellastomaintainaisometriccontrac@onattheprogressivepressuresasanendurancetask

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