Dissertations / Theses on the topic 'Whiplash'

The research in this thesis has examined the use of texture and shape analysis to characterise Magnetic Resonance (MR) images of peripheral nerves in order to provide a potential quantitative tool for better diagnosis and treatments. Texture and shape can be considered as inherent properties of all surfaces and have the potential to provide sensitive information which cannot be quantitatively perceived by human vision. Texture analysis has been successfully used in image classification of aerial and satellite imagery and the diagnosis and prognosis of several types of cancer. However, to date, it has never been used in investigating peripheral nerve damage. In this thesis, we study the application of texture and shape analysis to the peripheral nerves in the upper extremities of patients suffering from Whiplash Associated Disorders (WAD). Specifically, quantitative texture analysis was performed on MR images of the carpal tunnel which contains the median nerve. The median nerve was studied to identify differences in textural patterns. Texture methods such as: first order features; co-occurrence matrices; run-length matrices and autocorrelation function were applied and their performance was assessed. Texture analysis was also performed to investigate nerve damage in the MR images of the brachial plexus, both in controls and patients. Further, spatial domain shape metrics were used to quantify and study the morphological differences of the median nerve in controls and patients. This highlighted that some significant differences exist between groups and thus could potentially be reliably used in combination with clinical scale metrics to identify possible nerve damage. As MR images contain noise, locating the median nerve accurately to perform image analysis is very important. Therefore, we further investigated the application of an enhanced correlation filtering method that could be trained on images of the median nerve and then applied to detect the median nerve in test images. The Optimal Trade-off Maximum Average Correlation Height (OT-MACH) filter includes the expected distortions in the target in the construction of the filter reference function. The OT-MACH filter was tuned in a bandpass to maximize the correlation peak and thereby successfully locate the position of the median nerve in the carpal tunnel. This study has successfully demonstrated that texture and shape analysis can be used to investigate possible peripheral nerve damage. Further research is required using larger datasets to establish a quantitative image analysis tool to support clinical decision making and thereby improve patient care and treatment outcome.

The main aim of this project was to encircle the subtype of temporomandibular disorders (TMD) present in patients with chronic whiplash-associated disorders (WAD) and study the debut of TMD symptoms, the provoking factors and the outcome of conservative TMD treatments. The results could add to the aetiological discussion about TMD mainly as being part of chronic WAD pain or not. The subjects were referred patients with chronic WAD at a specialized rehabilitation centre where they were diagnosed using a standardized classification of WAD diagnosing that resulted in approximately 20% WAD grade 2 and 80% WAD grade 3. In Studies I and II, a total 136 individuals with chronic WAD were found to have a significantly higher prevalence of pain associated with TMD compared to a control group of 66 general dental patients. The symptoms debuted approximately six months after the whiplash injury and were most often provoked by stress. In Study III, the effect of a therapeutic jaw exercise (TJE) program on TMD was studied over six months in patients with chronic WAD and TMD, randomized to TJE (25 subjects) or not (30 subjects). TJE had no effect on TMD. In Study IV, patients with chronic WAD and TMD were found to have a mainly myogenous origin of TMD pain. Five months of stabilisation appliance therapy (SAT) equally resulted in an almost complete perceived reduction of jaw pain and frontal headache in patients with chronic WAD and TMD (n=14) and TMD patients without WAD (n=10). In the long-term, TMD was significantly lower in patients with chronic WAD who were treated compared to patients with chronic WAD and TMD who were not treated (n=9). TMD in patients with chronic WAD grades 2 or 3 may be the same kind of musculoskeletal disorder as in TMD patients without WAD, and not primarily part of the WAD pain. A functional TMD examination as well as assessment of perceived stress can be recommended as part of the standardized screening procedure for patients with chronic WAD grades 2 and 3. Patients with symptoms and signs of TMD could be recommended SAT. Patients with symptoms of frontal headache alone should also be considered as candidates for SAT.

The aims of the present thesis were to evaluate the management of acute WAD and to develop, describe and evaluate a cognitive behavioural approach for the physiotherapy management of long-term WAD as well as to study the predictors and mediating factors for long-term disability and pain after a whiplash injury.

Two approaches for acute and chronic WAD were evaluated in experimental studies. Fifty-nine patients with acute whiplash injury (study I) and 33 patients with chronic WAD (study V), were randomised into experimental and control groups. In addition, three chronic WAD patients participated in an experimental single case study (study IV). Home exercise programmes for patients with acute WAD were used in study I. In study IV a physiotherapy management with integrated components of cognitive-behavioural origin was tried for chronic WAD patients. In study V physiotherapy treatment in primary care units and a physiotherapy management with integrated components of cognitive-behavioural origin was tried for chronic WAD patients. Study I showed that a home exercise programme including training of neck and shoulder range of motion (ROM), relaxation and general advice, appears to be a sufficient treatment for most acute WAD patients. Further, the results of study IV and V suggest that cognitive behavioural components m be useful in physiotherapy treatment for patients with chronic WAD, but its contribution is not yet fully understood.

Study III showed that the significance of coping as an explanatory factor for disability increased during the one-year period after a whiplash injury. In study V it was concluded that self-efficacy is related to patients' use of different coping styles. A model to study coping as a mediator between self-efficacy and disability was therefore introduced. In a path-analytic framework, data from subjects in study I were re-analysed to illustrate a theoretical standpoint that emphasises the process of coping. With regard to disability, the proportion of explained variance increased from 39% at three weeks after the accident, to 79% at one-year follow-up. These results also show that coping has a crucial and mediating role between self-efficacy and disability. Positive long- term outcomes in WAD-patients would therefore be improved by, shortly after an accident, boosting self- efficacy and teaching patients to use active, adaptive coping strategies to manage their problems.

Whiplash-related injuries and manifestations, typically neck pain, following car collisions are known to potentially disable individuals with a high and increasing cost to society. There is limited knowledge regarding the temporomandibular joint (TMJ) sequelae following whiplash trauma. Previous studies are typically based on retrospective data and few follow-ups are prospective and controlled in design. Furthermore, previous follow-ups have not included magnetic resonance (MR) imaging, which is a prerequisite for verification of TMJ status. The aims of this prospective long-term study were (i) to determine frequency of inaccurate recall of TMJ symptoms in patients with a history of whiplash trauma, and (ii) to evaluate incidence, prevalence and progression of TMJ pathology, verified with MR imaging, and TMJ symptoms in patients after whiplash trauma, compared with the natural course in matched volunteers. We studied 60 consecutive patients who had neck symptoms following a rear-end car collision and were seen at a hospital emergency department. Bilateral TMJ MR imaging and clinical examination were performed at inception and at follow-up on average 15 years later. A self-administered questionnaire regarding TMJ symptoms (pain, dysfunction, or both) and a subsequent interview were performed at inception, at the one-year, and 15-year follow-up. Fifty-seven patients (95%) participated in all three examinations (85% for MR imaging examinations). Concurrently, 53 volunteers matched by age and sex followed the same protocol. Fifty volunteers (94%) participated in all three examinations (89% for MR imaging examinations). Ethics approval of the study protocol and informed consent from all participants was obtained. The calculated agreement between each patient’s inceptive and retrospective reports on TMJ symptoms yielded a kappa value of 0.41 (95% CI 0.18-0.64). Sixteen patients (40%) had inaccurate recall one year after whiplash trauma. There was no statistically significant difference in TMJ symptoms reported by the patients to be present before whiplash trauma compared with matched volunteers at inception. Prevalence of TMJ symptoms increased significantly with whiplash trauma and the increase remained stable throughout the 15-year study period, which contrasted to the natural course in volunteers. After one year the difference in prevalence between patients and volunteers was 54% versus 21% (p=0.0003) and after 15 years 49% versus 18% (p=0.0017). There was no statistically significant difference between patients and volunteers in prevalence of TMJ disc displacement either at inception (63% versus 53%) or at 15-year follow-up (63% versus 55%). TMJ disc displacement was significantly more prevalent in symptomatic volunteers compared with asymptomatic volunteers (89% versus 31%, p=0.0002). Incidence or progression of MR imaging verified TMJ pathology did not differ between patients and volunteers. This prospective 15-year follow-up concludes - that future studies on TMJ sequelae following whiplash trauma should be prospective in study design with examinations conducted in close proximity to whiplash trauma. This allows for reliable baseline status and potential bias of inaccurate recall of symptoms is minimized. - that future controlled studies on TMJ pathology in patients should include control groups of not only asymptomatic but also symptomatic volunteers in order to avoid potentially biased conclusions. - that one of three patients exposed to whiplash trauma can be expected to develop TMJ symptoms beyond that which corresponds to the natural course in volunteers. This finding and previously reported impairment of jaw function in patients with symptoms after whiplash trauma points to the need for including TMJs and related muscles in routine medical examinations of patients with symptoms following whiplash trauma. - that adult individuals presenting with no or mild TMJ symptoms seldom show development or aggravation of TMJ pathology and there is no or little indication for TMJ treatment of these adult individuals. This is in contrast to the higher progression of TMJ pathology previously reported for adult patients with TMJ symptoms, which requires treatment.

Background The incidence of traumatic brain injuries (TBI) is about 500 cases per 100,000 inhabitants per year, a majority of which are mild TBI (MTBI). The incidence of whiplash injuries is about 300/100,000/year. There are several similarities between MTBI and whiplash injuries with regard to the causes of injury (traffic crashes and falls), the demographic profile of the injured (mostly young persons), and the type of symptoms exhibited by some of the injured (for example head/neck pain, fatigue, irritability, impaired cognitive functioning, and depression).  Main aim To investigate the epidemiology and long-term consequences in terms of symptoms, disability, and life satisfaction in cases of TBI and whiplash injuries in a well-defined population. Material and methods Data on frequencies and characteristics of TBI and whiplash injuries were extracted from the injury database at the emergency department (ED) of Umeå University Hospital (UUH). The results were presented as descriptive epidemiology. The 18-65 year-old persons who sustained an MTBI or whiplash injury in 2001, were provided a questionnaire three and five years after injury respectively, in which questions were asked about: Symptoms; Rivermead Post Concussion Symptoms Questionnaire (RPQ) Disability; Rivermead Head Injury Follow Up Questionnaire (RHFUQ) Life satisfaction; LiSat-11 A local reference population was used for comparison of the RPQ. A national cohort was used as reference for LiSat-11. Data on sick leave for the cases of whiplash injuries were analysed to calculate the cost to society for loss of productivity. Results In 2001, the incidence of TBI was 354/100,000/year. The mean age was 23 and 55% were men. Ninety-seven percent of the injuries were classified as mild (Glasgow coma scale 13-15). The main causes were falls (55%) and traffic related injury events (30%). In 8% of the cases (17% of the elderly persons) an intracranial bleeding was detected by using CT. The 3-year follow-up of the MTBI patients showed that women had more symptoms and disability (~50%) than men (~30%). Both women and men had more symptoms and lower life satisfaction compared with the reference population. The incidence of traffic-related whiplash injuries in adults was 235/100,000/year and the annual incidences were relatively stable during 2000-2009. Combining the incidences with national insurance data showed that the proportion of insurance claims decreased during the period. When looking at whiplash trauma following all causes of injury in 2001, traffic crashes caused 61% of the injuries and falls caused 14%. Neck fractures occurred in 3% of the cases. Five years after whiplash injury, the injured persons had more symptoms and lower life satisfaction than the references. Sick leave ≥15 days was granted in 14% of the cases of whiplash injuries. The median number of sick days was 298 and the cost of loss of productivity during the follow-up was 5.6 million USD. The frequencies of symptoms were relatively alike when comparing subjects with whiplash injuries to subjects with MTBI. Conclusion TBI and whiplash injuries are common, especially among young people, and the injuries render long-term symptoms, disability, and impaired life satisfaction in up to 50% of the cases. Symptoms exhibited are alike between the two types of injuries. The cost to society for loss of productivity is high, and there is a need for enhanced preventive measures aiming at reducing traffic-related injuries, sports injuries, alcohol-related injuries, and falls. Physical, mental, and social factors are important and should be addressed when examining and treating patients with persisting symptoms following TBI and whiplash injuries.
Bakgrund Skallskador utgör ett stort folkhälsoproblem, särskilt eftersom många som skadas är unga. Skallskador är också, parallellt med självmord, den vanligaste dödsorsaken hos ungdomar och unga vuxna. De flesta av skadorna klassas som ”lätta” i akutskedet men trots det så kommer en del av patienterna att drabbas av kvarstående besvär, t ex smärta, koncentrationssvårigheter, depression och nedsatt livstillfredsställelse. Whiplashskador är nästan lika vanligt förekommande som skallskador och uppkommer framförallt i trafikolyckor. Även fall- och sportskador orsakar emellertid ett betydande antal whiplashskador. I normalfallet avtar de akuta symptomen inom några veckor men en del av patienterna anger att de får kvarstående besvär. Ett flertal skademekanismer i nackens vävnader är kända men tyvärr svåra att verifiera eller utesluta. Huvudsyfte Att undersöka förekomsten av skallskador och whiplashskador i en väldefinierad population samt beskriva restsymptom, funktions-nedsättningar och livstillfredsställelse hos de drabbade tre till fem år efter skadan. Material och metod Förekomsten av skadorna (Studie I, III och IV) Studierna baseras på skadedatabasen vid Norrlands Universitetssjukhus i Umeå (NUS). I skadedatabasen registreras alla patienter som söker till akutmottagningen efter en skadehändelse, ca 10 000 fall per år. När patienterna anmäler sig i receptionen tilldelas de en skadejournal som de själva fyller i i väntan på att bli undersökta. När patienter inkommer med svårare skador får anhöriga i möjligaste mån fylla i journalen. Primärvårdens jour har under åren för studiens genomförande varit belägen på akutmottagningen under kvällar, nätter och helger vilket inneburit att de få skadefall som konsekvent missats har varit lättare skador som behandlats dagtid på vårdcentralerna i upptagningsområdet.   Långtidsuppföljning (Studie II, III och V) En uppföljande enkätundersökning bestående av ett antal validerade frågeformulär skickades till alla skall- och whiplashskadade patienter i arbetsför ålder tre respektive fem år efter skadehändelsen. De frågeformulär som analyserades var: För symptom: Rivermead Post Concussion Symptoms Questionnaire (RPQ) För funktionsnedsättning: Rivermead Head Injury Follow Up Questionnaire (RHFUQ) För livstillfredsställelse: Life Satisfaction-11 (LiSat-11) För smärta (hos de whiplashskadade): Visual Analogue Scale (VAS)  Resultaten från RPQ och LiSat-11 jämfördes med sedan tidigare tillgängligt material från åldersmatchade referenspopulationer. När det gäller de whiplashskadade genomfördes en femårsuppföljning avseende sjukskrivning. Data från Försäkringskassan analyserades och samhällskostnaden för produktionsbortfall beräknades baserat på den genomsnittliga kostnaden för en årsarbetare. Resultat Förekomsten av skallskador vid NUS under 2001 var 354 skadade per 100 000 invånare. Medelåldern på de skadade var 23 år och 55% var män. Andelen lätta skallskador var 97%. Fallolyckor orsakade flest skador (55%) och trafikolyckor var näst vanligast (30%). Minst 17% av patienterna (ofta medelålders personer) var alkoholpåverkade. Hos 8% av patienterna (17% av personer över 65 år) upptäcktes blödningar i hjärnan. I uppföljningen efter tre år noterades att de skallskadade patienterna i arbetsför ålder hade högre symptomfrekvens och lägre livstillfredsställelse än referenspopulationerna. Kvinnorna rapporterade högre förekomst av symptom och funktionsnedsättning än männen. Funktionsnedsättning av varierande grad samt så kallat postkommotionellt syndrom (med förekomst av minst tre specificerade symptom) fanns hos ca 50% av kvinnorna och hos ca 30% av männen. Medelförekomsten av whiplashskador till följd av trafikolyckor var under 2000-2009 235 fall per 100 000 invånare och år. Sammantaget var förekomsten relativt stabil under perioden; en ökning med 1% per år noterades. När siffrorna matchades mot data från Försäkringsförbundet noterades en minskning av andelen försäkringsärenden under perioden. 2001 års incidens av akuta whiplashskador efter alla typer av skadehändelser var 383 skadade per 100 000 invånare. Könsfördelningen var 56% män / 44% kvinnor och medelåldern var 32 år. Trafikolyckor orsakade 61% av whiplashskadorna medan fallolyckor stod för 14%. Frakturer i nacken var ovanliga och hittades hos 3% av patienterna. I femårsuppföljningen av whiplashpatienter i arbetsför ålder noterades att de hade högre frekvens (ca 50%) av symptom samt lägre livstillfredsställelse än referenspopulationerna. Funktionsnedsättning av varierande grad fanns hos ca 50% av patienterna. Kvinnorna skattade sin smärta högre än männen men i övrigt fanns ingen könsskillnad beträffande förekomsten av symptom, funktionsnedsättning och livstillfredsställelse. Vid jämförelse mellan whiplashskadade och skallskadade noterades att förekomsten av symptom med några få undantag inte skilde sig åt mellan grupperna. Fjorton procent av de whiplashskadade blev sjukskrivna i mer än 14 dagar. Sjukskrivningens medianlängd var 298 dagar och i 3% av fallen fortskred sjukskrivningen under hela 5-årsperioden. Trafikskadade sjukskrevs oftare än fallskadade och noterbart är också att nackfrakturer ej resulterade i längre sjukskrivningar än mjukdelsskador. Samhällskostnaden för produktionsbortfall var i snitt ca 600 000 kr per sjukskrivning. Konklusion Avhandlingen bidrar med nya grunddata som ytterligare förstärker bilden av att skallskador och whiplashskador är vanliga och att det framförallt är unga personer som drabbas. Grad och typ av kvarstående besvär är likartade efter båda skadetyper. Samhällskostnaden för skadorna är hög och lämpliga områden för skadepreventivt arbete tycks vara fallskadeprevention, trafikskadeprevention, skadeprevention inom hästsport, fotboll och ishockey samt prevention av alkoholrelaterade skador. Både fysiska, psykologiska och sociala faktorer inverkar på läkningsförloppet och symptombilden efter skadorna och det är viktigt att utvärdera och behandla patienterna med utgångspunkt från detta.

The goal of this Master's project was to characterize the postural control patterns of individuals with chronic whiplash-associated disorders and to compare these patterns with those of healthy individuals. The postural reactions in response to low-intensity translations of the sitting position were assessed by way of kinematic and electromyographic analyses. We found that whiplash individuals display an earlier onset of their head displacement and a pattern of trunk displacement characterized by greater flexion at the upper levels of the spine, compared to the lower levels. Moreover, whiplash individuals present a tendency for a late recruitment of their neck flexors and for a greater use of a pattern of neck extensor muscle inhibition. These results suggest that individuals with whiplash-associated disorders may compensate their altered neck functional ability by modifying their relative movements along the spine and by adopting altered motor strategies to compensate for their painful muscles.

Rear-end collisions are the most common type of automobile impact; whiplash is the predominant resulting injury which imposes a significant cost on victims, their families, and their employers. These costs include high medical expenses and major insurance claims, and result in lengthy absences from work, chronic pain, and suffering. There have been several advances leading to improved safety designs of the vehicle seat, the primary safety device for mitigating whiplash injuries. Although these advances have been beneficial, injuries continue to occur. Ideally, several safety devices, incorporating multiple seat components, should be utilized in order to compound their injury reduction effects. Currently, there is very little the seat base contributes to the safety of the occupant, therefore, there is considerable opportunity to increase safety through the redesign and use of the seat base. This research utilizes the seat base to implement energy absorbing aluminum foam as an intermediary material between the seat and the vehicle frame, which replaces their rigid connection. During a collision, the impact energy path will be interrupted and partially absorbed by the crushing foam. The relative motion between the seat and vehicle decreases the relative acceleration between the head and body, thereby reducing the peak force experienced by the occupant, and therefore the risk and severity of whiplash injuries. This research first developed a computer-based model of this concept and created a database of a variety of foam material properties through experimental testing. Using a model is a fast and inexpensive method, compared to building and physically testing various concepts, for predicting an occupant's dynamic response to an impact, and allows flexibility in the design of devices for individual vehicle manufacturers. The current research developed a physical prototype of the whiplash mitigating system, for the first time. Measurements from experimental tests were used to assess the effectiveness of the model in predicting the physical behaviour of the system, and of the concept behind the whiplash mitigating system. It was found that the concept has potential for reducing risk of injuries, however, the effectiveness of the model in predicting physical behaviour of an occupant needs improvement.
Applied Science, Faculty of
Mechanical Engineering, Department of
Graduate

Whiplash is a neck injury caused by the sudden differential movement between the head and torso. Whiplash injuries are most commonly reported as a consequence of rear impacts in car accidents. They are regarded as minor injuries, but can still lead to long-term disablement and discomfort in the neck. Whiplash injuries can be mitigated by better car seat designs. For this purpose, head restraint geometry must be improved first, and then the dynamic performance of the whole seat must be assessed at all crash seventies. A biofidelic human-body model is a key requirement in designing whiplash mitigating car seats. This thesis presents the development of a 50th percentile male multi-body human model and several energy absorbing car seat designs. The human-body model is specifically designed for rear impact and validated using the responses of seven volunteers from Japanese Automobile Research Institute (JARI) sled tests, which were performed at an impact speed of 8 kph with a rigid seat and without head restraint and seat belt. A generic multi-body car seat model is also developed to implement various seatback and recliner properties, anti-whiplash devices (A WDs) and head restraints. Using the same driving posture and the rigid seat in the JARI sled tests as the basic configuration, several anti-whiplash seats are designed to allow different types of motion for the seatback and seat-pan. The major findings of this research are: -The human-body model simulates the effects of muscle contraction and its overall response is superior in comparison to the currently used models and dummies. -A criterion called the S-shape index (SSI) is developed based on the intervertebral angles of the upper and lower cervical spine. -The car seat design concepts are able to control and use crash energy effectively with the aid of anti-whiplash devices for a wide range of crash seventies. -In order to reduce whiplash injury risk, this study advocates energy absorbing car seats which can also provide head restraint contact as early as possible.

Background: Whiplash associated disorders (WAD) account for a large proportion of the overall impairment and disability from traffic injuries and causes substantial bio psychosocial consequences for some individuals. Aims: To increase the knowledge about factors described in terms of either function /impairment, activity/disability and life satisfaction in acute and chronic WAD as well as possible implications for rehabilitation. Within this aim the incidence and recovery rate of whiplash injury and prognostic factors of interest for early rehabilitation have been studied. Subjects and Methods: Fifty-five healthy controls and 34 WAD subjects were analysed within and between groups concerning a) biomechanical out put, endurance, fatigue and muscle tension (EMG activity of trapezius, infraspinatus and deltoideus) during repetitive shoulder forward flexion b) impairments and activity/disability and life satisfaction.356 subjects seeking medical attention due to whiplash trauma, 296 were available at follow up, mean 16 months post injury. Incidence and odds ratio of accident and other background factors on disability were determined. Thirty-four out of 43 patients with whiplash injury were investigated through quantitative sensory tests at six weeks and 71 months after injury. 62 WAD participated in an interdisciplinary rehabilitation program (a pilot study) designed to evaluate such rehabilitation program for patients with chronic (in relatively early stage) WAD. Program evaluation of impairment, disability and life satisfaction (prospective and retrospective) was carried out before and after program and at 6 months. Results: No significant effects of sex or age on the ability to relax between repetitive r muscle contractions (SAR) were found in healthy subjects (study I). Significantly higher inability to relax between contractions was found for the two portions of trapezius and infraspinatus in the WAD group compared to the healthy group (study II). Significantly lower levels of activity preferences were noted for three out of five indices in females with WAD The WAD group had significantly higher prevalence of neropsychological and emotional symptoms. Both pain related symptoms and neropsychological symptoms were of significant importance for aspects of disability and life satisfaction in this group (study IV). Sensory disturbances over the trigeminal skin area persisted over the years. At follow-up a significant correlation was found between the sensory disturbances and the symptoms related to the central nervous system while no significant relationship was found with the musculoskeletal symptoms (study HI) .The annual incidence according to the grading of the Quebec Task Force on Whiplash-Associated Disorders (WAD 1-3) was 3.2/1000 and 4.2/1000 when WAD 0 was included. Sixty-eight percent of the patients recovered during the follow-up Pre-traumatic neck pain, low educational level, female gender and WAD grade E-Ill were significantly associated with a poor prognosis (study IV). . Participants in the rehabilitation program reported increased coping ability. Stress reactions seemed rather frequent (32 %). Pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found (study V). Conclusion: The higher prevalence of musculoskeletal complaints of the neck shoulder region in females cannot be explained by higher muscle tension and clinical assumption of increased muscle tension seems correct in whiplash patients Results indicate heterogeneity among WAD subjects. Females are at risk after a whiplash trauma but the severity of initial symptoms and signs also affect outcome as well as low education. High levels of neuropsychological symptoms and pain, signs of posttraumatic stress, fear and avoidance, loss of control, anxiety, bio-mechanical and psychosocial factors at work (studies) and social support are potential factors to be aware of. Extensive and costly investigations are in most cases not necessary. However most persons will recover a whiplash injury. Multidisciplinary/interdisciplinary assessment should be considered at three months if substantial negative effect on the person’s ability to function and health situation exists.

Diss. (sammanfattning) Umeå : Umeå universitet, 2001, härtill 6 uppsatser.

digitalisering@umu

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII. Effective management in the acute stage is required to prevent development of chronicity for approximately 60% patients. A novel Active Behavioural Physiotherapy Intervention (ABPI) addressing both physical and psychological components of WAD was developed and evaluated as a complex intervention for acute WADII through a sequential multiphase project. Each phase was conducted using rigorous, precise and transparent methodologies according to pre-defined protocols. A systematic review and meta-analysis found that the combination of active physiotherapy and behavioural interventions may be a useful strategy. A modified Delphi study (international research and UK clinical whiplash experts) identified the underlying principles, and physiotherapy and behavioural treatment components of the ABPI. As no underpinning psychological theory was identified, the ABPI was further developed employing self-efficacy enhancement from social-cognitive theory to enable individualised management. A cluster-randomised, double-blind, parallel two-arm (ABPI: standard physiotherapy) pilot and feasibility trial (evaluating procedures, feasibility and acceptability ABPI) employed both quantitative and qualitative methods. Findings supported that the ABPI was potentially valuable (95% ABPI participants fully recovered with low number treatment sessions) and acceptable to physiotherapists and patients, supporting a definitive trial (with minor modifications).

The diagnosis of a whiplash injury is a very subjective process. A claim of this type of injury is usually made on the basis of pain, which may or may not be accompanied by clinical signs of trauma. This study was aimed at providing a more objective, quantitative approach to identifying the potential for whiplash injury in a directfront-or-rear-end automobile collision. The Whiplash Injury Severity Estimator (WISE Index) was created using data obtained from Dr. Schneck's personal library of case files, including the collisionacceleration of the vehicle, and the height, weight, and sex of the occupant. Some extrapolated data was also used representing the low and high ranges of height, weight, and collision acceleration to increase the range of the WISE Index. Data was analyzed by the Dynaman computer program in conjunction with the Articulated Total Body Model, to calculate the response of the body to external forces and impacts. The dynamic response of the occupant, combined with preexisting medical statistics provided the information necessary to perform a regression analysis in MINITAB and thus construct the WISE Indices shown below.

Male WISE Index (R² = 0.993)

£ = 0.2643 ± 0.4071 |(accel,g)| -0.01428(PI)

1.1g<=accel<=5g;      22.4<=PI<=25.0

Female WISE Index (R² = 0.978)

£ = 0.6214 ± 0.3429 |(accel,g)| -0.02929(PI)

0.8g<=accel<=5g;      22.3<=PI<=31.0

Acceleration: Use the negative sign if it is a rear-end collision and the positive sign if it is a head-on collision.

£ : A negative value means that potential injury results from backward head rotation, as in a rear-end collision. A positive value means that potential injury results from forward head rotation, as in a head-on collision.

|£ | < 1 = " Safe "

|£ | > 1 = " Dangerous "

The WISE Index allows one to predict the potential for a whiplash injury, as well as the intensity of the injury, based solely on collision acceleration, height, weight, and sex of the occupant. It is anticipated that this work and future efforts in this area will provide the information base necessary for anyone to effectively evaluate the validity of an alleged whiplash injury.

Master of Science

Whiplash är en skada som uppstår efter ett nacktrauma och besvär som uppstår pga denna skada benämns whiplashrelaterade besvär (WAD). Alla som råkar ut för ett nacktrauma får inte bestående men, men för de 10% där besvären kvarstår påverkas livsituationen avsevärt. Skadan går inte att påvisa med den medicintekniska apparatur som finns idag. De kroniska besvären är många och omfattande, ofta diffusa och kan inte alltid logiskt kopplas till nacktraumat. Patienten känner att skadan ideligen måste ”bevisas” eftersom den inte syns. Läkarvetenskapen står dessutom oenig om vad whiplash verkligen är, och om hur tillståndet ska behandlas. Den som lider av WAD söker ofta vård och vårdpersonal tycks ha bristande kunskaper om, och förståelse för, whiplashproblematiken och detta leder till ett ökat lidande för den drabbade. För att kunna förstå och stödja dessa patienter på ett optimalt sätt är det nödvändigt att skaffa sig kunskaper om hur den som lider av whiplashrelaterade besvär upplever sin livssituation och det är syftet med detta arbete. Metoden som använts är en litteraturbaserad studie av biografier. Elva berättelser om hur det är att leva med whiplashrelaterade besvär ingick i analysen. Sex teman framkom efter att de meningsbärande enheterna satts samman utifrån innebörd, skillnader och likheter. Känsla av otrygghet och ovisshet, känsla av att inte bli trodd och inte bli förstådd, känsla av sorg och saknad, behov av stöd och uppmuntran, känsla av att inte ha kontroll, och acceptans och känsla av att kunna gå vidare, var de teman som sammanfattade de upplevelser de elva whiplashskadade berättade om i sina biografier. Diskussionen tar upp betydelsen av att sjuksköterskan har en förståelse för patientens situation. En djupare diskussion förs runt temat ”känsla av att inte bli trodd och inte bli förstådd” eftersom det temat är centralt och interagerar med de andra kategorierna.
Program: Fristående kurs

This thesis is on chronic neck pain after a rear impact car injury, so called whiplash associated disorder (WAD). Three empirical studies using positron emission tomography (PET) with different radioligands have been performed. The first study evaluated resting state regional cerebral blood flow (rCBF) in WAD patients and in healthy, pain-free controls, by use of oxygen-15 labeled water. Patients had heightened resting rCBF bilaterally in the posterior parahippocampal and the posterior cingulate gyri, in the right thalamus and in the right medial prefrontal gyrus. Attenuated tempero-occipital blood flow was also observed in the patient group as compared to healthy controls. Alterations in rCBF were related to patients’ neck disability ratings. Study I suggests an involvement of the posterior cingulate, the parahippocampal and the medial prefrontal gyri in WAD. This altered resting state neural activity may be linked to an increased self-relevant evaluation of pain and stress. The second study evaluated central expression of the neurokinin-1 (NK1) receptor in WAD patients and healthy controls. Using a carbon-11 labeled specific NK1 antagonist, the receptor availability was measured. Patients displayed lowered NK1 receptor availability in the insula, anterior cingulate, frontal lobe, hippocampus, amygdala and in the periaqueductal gray matter, consistent with results from animal models of chronic pain. NK1 receptor availability was most reduced in the ventromedial orbitofrontal cortex, where attenuations were linearly related to patients fear and avoidance of movement. Thirdly, carbon-11 labeled D-deprenyl was used to investigate the presence of locally inflamed soft tissue in the cervical neck in WAD patients. Although the retention mechanism of [11C]D-deprenyl is not known, the results suggest that WAD patients have chronic inflammatory processes in the neck, most commonly in the adipose tissue at the spineous process of the second vertebra. In summary, this thesis provides evidence for altered central blood flow and receptor characteristics in WAD patients. Further, WAD patients may also have signs of persistent peripheral tissue damage. Both central and peripheral pain mechanisms have been demonstrated and visualized in patients with whiplash associated disorder.

Background: Neck pain and disability are common after whiplash injury. One year after the accident up to 50 % still have symptoms called whiplash associated disorders (WAD). Despite decades of research the cause of persistent pain and disability are largely unknown and effective treatment and diagnostic tools are lacking. Altered neck muscle function may cause pain and disability, and real-time non-invasive methods that investigate both superficial and deep neck muscle function need to be evaluated. Aim: The general aim of the work presented in this thesis was to investigate mechanical neck muscle function and evaluate effects of three different exercise interventions related to neck muscle function in individuals with persistent pain and disability after whiplash injury. Method: The thesis comprised two studies, reported in four papers. Study A was a prospective randomized controlled trail with 216 participants. The effects of three exercise interventions; neck-specific exercises, neck-specific exercises with behavioral approach and prescription of physical activity were evaluated. Neck muscle endurance, perceived pain following testing, kinesiophobia and satisfaction with treatment were compared between the three groups (paper I). Study B was an experimental case-control study with participants consecutively recruited from the randomized controlled trial. Deformation and deformation rates in the neck muscles were investigated with real-time ultrasound imaging during ten repetitive arm elevations (paper II-IV). To investigate ventral neck muscles, 26 individuals with WAD were compared with 26 healthy controls (paper II). The dorsal neck muscles were investigated in paper III, including 40 individuals with WAD and 40 controls. In total 46 individuals, 23 with WAD and 23 healthy controls were included in paper IV to develop ventral neck muscle interaction models. Results: Paper I: Participants in the two neck-specific exercise groups (with and without behavioral approach) showed increased dorsal neck muscle endurance (p = 0.003), decreased pain intensity following testing (p = 0.04) and were more satisfied with treatment (p < 0.001) than participants in the prescribed physical activity group. Kinesiophobia did not significantly differ between groups (p > 0.12). Paper II: Deformation and deformation rate showed linear positive relationship between ventral muscle pairs in healthy controls, especially between superficial and deep neck muscles. This relationship was weaker or absent in the WAD group. Paper III: The WAD group had higher deformation rates in the deepest dorsal neck muscles during the first and tenth (only women) arm elevations compared to the control group (p < 0.04). Women in the WAD group showed a weaker linear relationship between the two deepest dorsal neck muscles compared to women in the control group. Paper IV: The results revealed two different ventral neck muscle models in individuals with WAD and healthy controls (R2Y = 0.72, Q2Y = 0.59). The models were capable to detect different neck muscle interplay in people with WAD. Conclusion: Neck-specific exercise intervention with or without a behavioral approach appears to improve neck muscle endurance in individuals with persistent WAD. Decreased pain after the neck muscle endurance test also suggests improved tolerance of load in these two groups. Altered mechanical neck muscle function was revealed in individuals with WAD indicating decreased muscular support for maintain a stable cervical spine during repetitive arm elevations. The results show great promise for improved diagnosis of neck muscle function in WAD.

The corrections in the errata list has been carried out in the electronic version.

This thesis investigates the role of cervical spine Range of Motion in the recovery from Whiplash Associated Disorders. In clinical practice, Health Care Professionals attach value to measurements of cervical spine Range of Motion for diagnostic, prognostic and treatment evaluation purposes. A systematic literature review found conflicting evidence as to whether cervical spine Range of Motion was a prognostic factor following a whiplash injury. Greater understanding of prognostic factors such as this may facilitate improvements in patient management. A second systematic literature review investigated the reliability and validity of methods for measuring cervical spine Range of Motion. The Cervical Range Of Motion (CROM) device was found to be the most rigorously tested and clinimetrically promising method and was subsequently investigated for intra- and inter-observer reliability in a group of whiplashinjured individuals and found to be substantially reliable. The CROM device was utilised in a longitudinal cohort study of 599 whiplash-injured patients to investigate the prognostic value of cervical spine Range of Motion for neck painrelated disability and patient-reported recovery at short, medium and long-term follow-up. A patient-reported version of cervical spine Range of Motion was also evaluated as a prognostic factor. Although useful for explaining disability at the time of measurement, active, passive and patient-reported forms of cervical spine Range of Motion were not significant prognostic factors for poor outcome when other physical and psychosocial factors were accounted for. The clinical implication of this research is that if patients are experiencing reduced cervical spine Range of Motion a few weeks after their whiplash injury they will not necessarily have a poor outcome in the longer term as is commonly believed at present.

Le coup du lapin reste un enjeu socio-économique fort de l’accidentologie routière. La recherche dans ce domaine a amené au développement de critère lésionnels qu'il est encore difficile de valider pour toutes les situations. Les hypothèses de ce projet sont que les stratégies de stabilisation de la tête sont influencées par les activités préalables à un évènement dynamique ainsi que par certaines disponibilités cognitives.Pour y répondre, cette thèse a expérimenté différents environnements dynamiques et exploré l'utilisation de la réalité virtuelle comme outil de simulation pour l’étude du comportement dynamique du sujet et évalué la pertinence de ces outils.Une première expérimentation a permis de montrer l’importance de l’alerte chez le sujet en utilisant un système automatique de freinage d’urgence d'un véhicule équipé. Une seconde étude consistant en la réplication de cette expérience dans un simulateur de conduite hexapode a pu montrer que le comportement du sujet était comparable malgré des performances dynamiques moindres du système. Enfin, une dernière étude menée sur des sujets accélérés sur un chariot contrôlé en laboratoire et dont l'état émotionnel a été contrôlé a pu rendre compte de l’importance de l’intégration des paramètres physiologiques dans l’étude des stratégies de stabilisation de la tête chez le sujet.Les simulations immersives se sont montrées pertinentes pour contrôler l’environnement cognitif du sujet et l’importance de ce dernier a pu être observée. L’utilisation de ces technologies permet d’entrevoir de nouvelles possibilités expérimentales pouvant amener à une meilleure compréhension des stratégies de stabilisation du sujet
Whiplash remains a strong socio-economic issue in road accidents. Research in this field has led to the development of injury criteriathat are still difficult to validate for all situations. The hypotheses of this project are that head stabilization strategies are influenced by activities prior to thedynamic event as well as by certain cognitive availabilities. To answer this, this thesis experimented different dynamic environments and explored the use of virtual reality as a simulation tool for the study of the subject's dynamic behaviorand evaluated the relevance of these tools.A first experimentation allowed to show the importance of the alert in the subject by using an automatic emergency braking system of an equipped vehicle. A second study consisting in the replication of this experiment in a hexapod driving simulator was able to show that the subject's behaviorwas comparable despite the lower dynamic performance of the system. Finally, a last study carried out on accelerated subjects on a laboratory-controlled cart, whose emotional state was controlled, was able to account for the importance of the integration of physiological parameters in the study of head stabilization strategies in the subject.Immersive simulations proved to be relevant to control the subject's cognitive environment and the importance of the latter could be observed. The use of these technologies allows us to glimpse new experimental possibilities that can lead to a better understanding of the subject's stabilization strategies

The syndrome commonly referred to as whiplash injury" resulting from motor vehicle accidents is complex and remains a challenge to clinicians, as is evidenced by the recent report of the Quebec task force on the "whiplash syndrome". The main objective of this prospective randomised study was to evaluate two conservative treatment regimens (early immobilisation-experimental group-1, early active mobilisation experimental group-2) which are based on accepted physiological rationale and then to compare their effectiveness with existing treatment regimens that are commonly practiced (control group) in the management of "whiplash" type of injuries. To this stage, the current study is the only prospective randomised clinical trial of its type conducted with a sufficiently large sample size and over a long study period. The results of the current study clearly demonstrated that the subjects in the immobilised group recovered from their pain-related symptoms and returned to their normal duties sooner than those in the other two treatment groups. In addition to this, those subjects who received the immobilisation regimen did not show adverse effects on either the range of motion or the strength of the neck muscles. Thus, the immobilisation regimen was clearly shown to be the preferred option when compared to the other two treatment methodologies investigated in the current study.Although the primary interest of the current study was to compare the efficacy of three different treatment regimens, a series of statistical analyses were performed to establish the prognostic significance of several factors associated with "whiplash" injury. This showed that factors such as gender, age, speed of the vehicles involved, paraesthesia, intensity of pain at the time of the initial examination, interscapular pain, blurred vision and difficulty in focusing, all had prognostic value. Similarly, the type of collision, seating position, presence of headache within 24 hours post injury, pre-existing degenerative changes in the cervical spine, loss of lordosis and litigation factors had no prognostic significance. Another major emphasis of the current study has been to concentrate on the pain related symptoms of the neck which are of major concern to "whiplash" subjects and to those clinicians treating them. A paucity of such information is considered to be one of the most notable causes of difficulties encountered in the management of "whiplash" injuries.As an adjunct to the main study, the morphology of the deep pre- and post vertebral muscles of the neck region using embalmed cadavers and fresh post-mortem specimens was investigated, as the literature is deficient in--this regard. Similarly, a longitudinal study of 45 subjects was also performed using Magnetic Resonance Imaging (MRI) technology. The longitudinal nature of the M.R.I. study provided for the first time an account of the details associated with the progressive pathological changes that occurred in some disc lesions, at defined points in time following a MVA. The observations made from the adjunct studies help develop a better understanding of the pathoanatomy associated with the deep muscles of the neck region and the pathological changes that occur following a traumatic disc lesion as evidenced within 2 weeks, after 3 months and 12 months post- injury. On the basis of the observations made in the current study, a classification of the "whiplash" injury has been proposed for the consideration of clinicians. Similarly, the questionnaire used for data collection in the current study, can be readily modified and utilised in a clinical situation for establishing documentation, planning treatment strategies and for evaluation of the treatment outcomes of "whiplash" type of injuries.

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Em Natal dos anos 80, uma cena musical foi sendo montada a partir da inser??o do jovem nos espa?os da cidade, como pra?as, lojas de discos, shows, parques e etc. Contudo, este cen?rio ligado ? m?sica passou por um processo de transforma??o. A cena musical, mundialmente falando, a partir das d?cadas de 50 e 60, teve como um dos atores o jovem que foi mudando seu estilo, corpo de acordo com a moda influenciada pelos artistas nos filmes, nas revistas e nos programas de televis?o. Nesse sentido, este trabalho refere-se ao cen?rio em que Natal, no Rio Grande do Norte, foi influenciado atrav?s do rock, heavy metal e punk, construindo cenas que, de alguma maneira, uniram-se para a produ??o da m?sica. A juventude natalense, de alguma forma, teve a oportunidade de experienciar, nas d?cadas de 80 e 90, a m?sica pesada e criar para si espa?os de sociabilidade. A partir de um cen?rio pol?tico e econ?mico desfavor?vel ao crescimento, a cena heavy metal teve como ponto de encontro a loja de discos Whiplash onde jovens se aglomeravam para criar v?nculos e principalmente ouvir discos que eram tocados de dentro da loja. A partir dessa uni?o, formaram-se bandas e, com isso, puderam tocar em festivais e eventos na cidade com outros grupos de rock e punk. As informa??es que inicialmente circulam dentro das cenas chegavam por meio de fanzines. O fanzine foi o meio pelo qual se criou uma rede de amizades se espalhando pelo Brasil, em que a troca de informa??o e tamb?m de material fonogr?fico ajudava a minimizar o problema da crise financeira, al?m do fato de muitos destes jovens n?o terem trabalho para comprar seus bens de consumo. Estes fanzines funcionaram tamb?m para criar uma imprensa independente onde as bandas locais e eventos eram apresentados.
In Natal of the 80s, a musical scene was being created from the insertion of the young person in the spaces of the city like squares, disc stores, concerts, parks and etc. However, this music-related scenario underwent a process of transformation. The musical scene, worldwide speaking, from the 50s and 60s had as one of the actors the young man who was changing his style, body according to the fashion influenced by the artists in the movies, magazines, and television programs. In this sense, this work refers to the scenario in which Natal in Rio Grande do Norte was influenced through rock, heavy metal and punk, constructing scenes that somehow joined for the production of music. The natal youth somehow had the opportunity to experience heavy music in the 80's and 90's and create spaces for sociability. From a political and economic scenario unfavorable to growth, the heavy metal scene had as a meeting point the Whiplash record store where young people crowded together to create bonds and especially to listen to records that were played from inside the store. From this union, bands were formed and with that they could play in festivals and events in the city with other groups of rock and punk. The information that initially circulated within the scenes came through fanzines. The fanzine was the means by which a network of friendships was created spreading through Brazil where the exchange of information and also of phonographic material helped to minimize the problem of the financial crisis and the fact that many of these young people did not have work to buy their goods of consumption. These fanzines also worked to create an independent press where the local bands and events were presented.

WAD betyder whiplash associated disorder och har sin grund i en whiplashskada, som är en svårdiagnostiserad skada på nackpartiet.Whiplashskador har i västvärlden blivit en av de vanligaste skadornatill följd av trafikolyckor. De vanligaste symptomen är smärta i huvudoch nacke samt domningar och stickningar i olika kroppsdelar. Syftet med denna studie var att undersöka huruvida det finns någon skillnad i kognitiva funktioner mellan personer med WAD och personer utan denna skada (n = 20). Detta undersöktes med hjälp av en enkät och ett kognitivt testbatteri. Resultaten tyder på en signifikant gruppeffekt för sekundärminne vid omedelbar fri återgivning, F(1, 19) =4.48, p<.05.De övriga resultaten var inte statistiskt säkerställda men visade klara tendenser till att kontrollgruppen presterade bättre på samtliga kognitiva test.