The impact of rehabilitation on chronic whiplash

134 J.-M. Gosnold
Joint dysfunction, such as cervical facet syndrome,
is a common manifestation <strong>of</strong> faulty movement
patterns. In 1964, Mennel 27 defined joint
dysfunction as ‘‘loss <strong>of</strong> joint-play movement that
cannot be produced by voluntary muscles’’. It has
been theorised that a loss in joint play can lead to
pain, producing reflex effects on the surrounding
muscles. 24 <strong>The</strong> result is that certain muscles
become hypertonic, whilst others become neurologically
inhibited. This imbalance leads to local dysfunction
in muscle and joint interaction, causing
faulty movement patterns. <strong>The</strong>refore, it can be
hypothesised that, to address only the joint dysfunction
through manipulation, will only create a
temporary increase in motion. If the muscle imbalance
and faulty movement patterns are not
addressed, this continued dysfunction would prevent
the joint from maintaining normal function.
This cycle <strong>of</strong> perturbing factors is commonly seen in
chronic neck pain patients both <strong>of</strong> non-traumatic
and traumatic origin. To break this cycle requires a
‘three-pronged’ approach. Firstly, to reduce joint
dysfunction via manipulation; secondly, to restore
normal muscle balance and function and, thirdly, to
re-educate the body’s movement patterns via <strong>rehabilitation</strong>.
Joint manipulation is performed to restore jointplay
and is thought to work by releasing entrapped
synovial folds or plica, relaxing hypertonic muscles
and disrupting articular or periarticular adhesions.
28 Muscle dysfunction, particularly in the case
<strong>of</strong> trigger points, can become a significant cause <strong>of</strong>
pain. This pain is <strong>of</strong>ten responsible for antalgic
posture or compensatory muscular facilitation. 29
Treatment includes s<strong>of</strong>t tissue massage, trigger
point therapy and both passive (e.g. PIR) and active
(e.g. proprioceptive neuromuscular facilitation
(PNF)) stretching techniques.
Rehabilitation via sensorimotor training and cervical
stabilisation produces several key benefits to
the chronic neck pain patient. Firstly, the efficiency
and effectiveness <strong>of</strong> common movement patterns
involving the cervical spine and shoulder girdle are
improved. This makes daily tasks less demanding,
both in terms <strong>of</strong> conscious effort on the patient’s
part and by preventing over recruitment <strong>of</strong> compensatory
muscles. In whiplash, the cervical flexion
pattern is particularly important, being tested
supine to work against gravitational resistance.
<strong>The</strong> correct and incorrect cervical flexion movement
patterns are shown in Table 2. 30 Improving the
speed and accuracy <strong>of</strong> the eye—head—neck—upper
extremity reflexes maximises neurological integration
and control, providing a protective function for
the system as a whole. Strengthening key muscle
groups acts to improve the stability <strong>of</strong> the cervical
Table 2 Correct and incorrect cervical flexion
movement patterns. 30
Correct flexion Incorrect flexion
Controlled movement Jaw juts forward
Chin tucked in Hyperextension at
Balanced activation
<strong>of</strong> both deep neck
flexors and
sternocleidomastoid
(SCM) muscles
No muscle fatigue
(‘‘shuddering’’)
cervico-cranial junction
Weak deep neck flexors
with strong SCM
Muscle fatigue leading to
unsustainable movement
spine, preventing extreme end ranges <strong>of</strong> motion
that can lead to long-term complications.
Disturbance <strong>of</strong> eye-head-neck co-ordination and
oculomotor reflexes resulting from cervical trauma
has been well documented. 31 <strong>The</strong> cervical spine
has an extremely high afferent input into the Central
Nervous System (CNS), particularly from the
muscle spindles <strong>of</strong> the intrinsic muscle groups. This
information is used to mediate various locomotor
activities, with the most important connection
being with the vestibular nucleus. This pathway
mediates both the activity <strong>of</strong> individual muscles,
and the overall posture, balance and stability
mechanisms. 24 <strong>The</strong>refore, cervical dysfunction
can disrupt these mechanisms causing functional
compromise within the CNS. <strong>The</strong> Tonic Neck Reflex
(TNR) constitutes one <strong>of</strong> the most significant
reflexes that can be affected by cervical dysfunction.
In normal circumstances, this reflex acts to
distribute muscle tone throughout the locomotor
system as a result <strong>of</strong> cervical movements. 32 <strong>The</strong>
TNR is usually quiescent, only manifesting itself
when a high degree <strong>of</strong> skill or power is required.
Fukushima and Hinoki 33 showed that the TNR might
also manifest in the presence <strong>of</strong> cervical dysfunction
and pain, the result being that certain trunk
and extremity muscles became either hypertonic
or inhibited.
Compromise to the vestibular nucleus also
affects balance, with many patients who have cervical
dysfunction also reporting vertigo or dysequilibrium.
<strong>The</strong> adaptation required in overcoming
these symptoms places further strain on the locomotor
system, lowering the margin <strong>of</strong> error in the
system and predisposing to the susceptibility <strong>of</strong>
injury and dysfunction in other areas <strong>of</strong> the body.
<strong>The</strong> Saccade and Smooth Pursuit oculomotor
reflexes are also affected. 34 Muscle imbalances in
the cervical spine, particularly in the cervical rotators
(SCM, upper trapezius, splenius capitus and