Development of motor system dysfunction following whiplash injury

Michele Sterling
a,
*
, Gwendolen Jull
a
, Bill Vicenzino
a
, Justin Kenardy
b
, Ross Darnell
c
a
The Whiplash Research Unit, Department of Physiotherapy, The University of Queensland, 4072 Brisbane, Australia
b
Department of Psychology, The University of Queensland, 4072 Brisbane, Australia
c
School of Health and Rehabilitation Sciences, The University of Queensland, 4072 Brisbane, Australia
Received 1 July 2002; accepted 7 October 2002
Abstract
Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the
early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study
measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the supercial
neck exors (EMG) during a test of cranio-cervical exion) as well as a measure of fear of re-injury (TAMPA) in 66 whiplash subjects within
1 month of injury and then 2 and 3 months post injury. Subjects were classied at 3 months post injury using scores on the neck disability
index: recovered (,8), mild pain and disability (1028) or moderate/severe pain and disability (.30). Motor system function was also
measured in 20 control subjects. All whiplash groups demonstrated decreased ROM and increased EMG (compared to controls) at 1 month
post injury. This decit persisted in the group with moderate/severe symptoms but returned to within normal limits in those who had
recovered or reported persistent mild pain at 3 months. Increased EMG persisted for 3 months in all whiplash groups. Only the moderate/
severe group showed greater JPE, within 1 month of injury, which remained unchanged at 3 months. TAMPA scores of the moderate/severe
group were higher than those of the other two groups. The differences in TAMPA did not impact on ROM, EMG or JPE. This study identies,
for the rst time, decits in the motor system, as early as 1 month post whiplash injury, that persisted not only in those reporting moderate/
severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms.
q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.
Keywords: Whiplash; Motor dysfunction; Fear of movement/re-injury
1. Introduction
The development of chronic whiplash associated disorder
(WAD) occurs in 1240% of those who sustain a whiplash
injury to the cervical spine and contributes substantially to
the economic and social costs related to this condition
(Barnsley et al., 1994; Eck et al., 2001). Previous research
has indicated that those persons with persistent symptoms of
WAD more than 3 months after injury display changes in
cervical motor system function (Heikkila and Astrom, 1996;
Nederhand et al., 2000; DallAlba et al., 2001; Dumas,
2001; Elert et al., 2001). However, little is known about
the early stages following an injury and of the progress in
the motor system in those who do or do not recover within 3
months of the injury. An understanding of these changes
early on after injury may enhance identication of those at
risk of persistent symptoms and facilitate the development
of appropriate treatment strategies.
Motor system dysfunction is present in persons with
persistent WAD. Changes observed include reduced cervi-
cal spine movements, disturbances in cervical kinaesthesia
reected by errors in head and neck repositioning and
increased electromyographic (EMG) activity in neck and
shoulder girdle muscles (Heikkila and Astrom, 1996; Oster-
bauer et al., 1996; Bono et al., 2000; Jull, 2000; Nederhand
et al., 2000; DallAlba et al., 2001; Dumas, 2001; Elert et
al., 2001). Increased EMG activity has been demonstrated
during tasks of high load demand but perhaps more relevant
to WAD, also with functional low load activities. Neder-
hand et al. (2000), using a single arm task, showed increased
EMG activity in upper trapezius muscles both during and
after the movement. Jull (2000) demonstrated increased
activity of the supercial neck exor muscles during a
task of supported cranio-cervical exion in subjects with
persistent WAD. These changes in EMG activity have
been interpreted as reecting altered muscle recruitment
patterns (Nederhand et al., 2000, Jull, 2000).
Pain 103 (2003) 6573
0304-3959/02/$30.00 q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.
PII: S0304-3959(02)00420-7
www.elsevier.com/locate/pain
* Corresponding author. Tel.: 161-7-3365-4568; fax: 161-7-3365-
2775.
E-mail address: m.sterling@shrs.uq.edu.au (M. Sterling).
Psychological factors such as beliefs about movement
induced pain and re-injury may also inuence motor
dysfunction observed in patients with persistent WAD
(Nederhand et al., 2002). Fears of movement and re-injury
have been associated with lumbar paraspinal muscle activity
in chronic low back pain (Watson et al., 1997). Similarly,
fear of pain (induced experimentally) can alter lumbar spine
muscle recruitment patterns albeit in asymptomatic subjects
(Moseley et al., 2002). Beliefs about fear of movement and
re-injury (TAMPA) are yet to be investigated in WAD.
Our study addressed the lack of information on changes in
motor system function soon after whiplash injury and the
time course of such changes in those who recover and those
who report persistent pain. The aims of this study were
threefold: to investigate the differences in motor system
function between those who recover and those who report
persistent symptoms based on their status at 3 months post
whiplash injury; to investigate the prospective longitudinal
development of changes in motor system function following
whiplash injury; to determine whether TAMPA inuences
any observed changes in motor function. Three aspects of
motor system function were chosen for investigation range
of cervical movement, kinaesthetic awareness and EMG
activity of neck exor muscles during cranio-cervical ex-
ion.
2. Methods
2.1. Study design
A prospective longitudinal design was used to study
persons who sustained a whiplash injury from within 1
month of injury to 3 months post injury. They were assessed
at three time frames within 1 month of injury, 2 and 3
months post injury. An asymptomatic control group was
assessed at three parallel time frames each 1 month apart.
2.2. Subjects
Sixty-six volunteers (21 males, 45 females, mean age
36.27 ^12.69 years) reporting neck pain as a result of a
motor vehicle crash and 20 healthy asymptomatic volun-
teers (eight males, 12 females, mean age 40.1 ^13.6
years) participated in the study. The whiplash subjects
were recruited through hospital accident and emergency
departments, primary care practices (medical and
physiotherapy) and from advertisement within radio and
print media. They were eligible if they met the Quebec
Task Force Classication of WAD II or III (Spitzer et al.,
1995). WAD IV patients were excluded. The asymptomatic
control group was recruited from the general community
from print media advertisement. The asymptomatic subjects
were included, provided they had never experienced any
prior pain or trauma to the cervical spine, head or upper
quadrant.
Ethical clearance for this study was granted from the
medical research ethics committee of the University of
Queensland, the Royal Australian College of General Prac-
titioners and from the ethics committee of the Royal Bris-
bane Hospital.
2.3. Active range of movement
Range of active cervical movement was measured in
three dimensions using an electromagnetic, motion-tracking
device (Fastrak, Polhemius, USA) (Trott et al., 1996;
DallAlba et al., 2001). Output from the device was
converted to Euler angles to describe the motion of sensor
1 (placed on the forehead) relative to sensor 2 (placed over
C7). A custom computer program was developed to allow
real-time viewing of the motion trace, placement of markers
in the data trace and storage of data. The Fastrak system has
been used previously to investigate cervical range of move-
ments (ROM) in neck pain disorders (DallAlba et al., 2001)
and has been shown to be accurate to within ^0.28 (Pearcy
and Hindle, 1989).
2.4. Cervical joint position error
Joint position error (JPE) was measured according to
Revel et al. (1994) by using the Fastrak system and set-up
described for ROM. The subjects ability, whilst blind-
folded, to relocate the head to a natural head posture was
measured following active cervical left and right rotation
and extension.
2.5. Supercial neck exor muscle activity
Surface EMG was used to measure the activity of the
supercial neck exor muscles during the cranio-cervical
exion test (CCFT) (Jull, 2000; Sterling et al., 2001). The
CCFT is a progressively staged test of cranio-cervical ex-
ion performed in the supine lying position without resis-
tance. Subjects are guided to progressively increasing
ranges of exion with use of biofeedback provided by an
air lled pressure sensor positioned behind the neck which
monitors the slight attening of the cervical lordosis which
occurs with the test action (Mayoux-Benhamou et al., 1994;
Falla et al., 2002a). To ensure high delity feedback, the
pressure sensor was calibrated at regular intervals through-
out the study using a compression tension test device. Pairs
of standard AgAgCl electrodes (Conmed, USA) were posi-
tioned along the lower one third of the muscle bellies of both
sternocleidomastoid (SCM) muscles (Falla et al., 2002b).
The EMG signals were passed through a 10 Hz high-pass
lter and amplied to 20,000 units using an AMLAB data
acquisition system (Associated Measurements Pty Ltd,
Australia).
2.6. Questionnaires
Self reported pain and disability was measured in all
whiplash subjects using the neck disability index (NDI)
(Vernon and Mior, 1991). They also completed the measure
M. Sterling et al. / Pain 103 (2003) 6573 66
of TAMPA questionnaire as an indicator of the fear of
movement/re-injury (Kori et al., 1990). As the control
subjects had never experienced neck pain it was deemed
inappropriate for them to complete the questionnaires.
2.7. Procedure
The following measures were undertaken at each of the
three time points. The whiplash subjects rst completed the
NDI and TAMPA questionnaires. Testing of both whiplash
and asymptomatic subjects was performed in the following
sequence ROM, JPE and CCFT. The same examiner (M.S.)
performed all tests. This examiner remained blind to the
subjects responses on the NDI and TAMPA questionnaires.
For all tests no verbal cues/feedback were given to the
subjects about their performance.
After completion of the questionnaires, the subjects were
seated, the Fastrak sensors applied and ROM was measured.
Subjects were instructed to assume a comfortable position
looking straight ahead, then to perform each movement
three times. They were encouraged to move at a comfortable
speed, as far as possible each time and return to the start
positioning between each repetition. The order of move-
ments assessed was exion, left lateral exion, right lateral
exion, left rotation, right rotation and extension. Means of
the three trials for each direction of ROM were calculated
and used for analysis.
Subjects were then blindfolded and kinaesthetic testing
was performed. They were asked to perform the neck move-
ments within comfortable limits and return as accurately as
possible to the starting position, which they indicated verb-
ally. This position was recorded electronically. Three trials
of each movement direction were performed in the follow-
ing order left rotation, right rotation and extension. Prior
to each new movement direction, the subjects were able to
re-align their starting position to a visible target before
being blindfolded again. JPE was calculated by using the
mean of the absolute errors for the three trials of each move-
ment for the primary movement direction.
The subjects were then positioned supine, EMG electro-
des were applied and the CCFT was performed. Each stage
of the test was held for 10 s. For purposes of normalisation
of EMG data, a standard head lift task was performed. This
involved the participant performing cranio-cervical exion
and just lifting the head off the plinth. This method of
normalisation of the supercial neck exors has been used
previously (Sterling et al., 2001). For EMG data, the 1 s of
maximum root mean square (RMS) values was calculated
for each stage of the test. The maximum RMS was standar-
dised against EMG activity in the supercial neck exor
muscles during the standard head lift task.
2.8. Data analysis
The whiplash subjects were classied into one of three
groups based on results of the NDI at 3 months post injury.
The groups were recovered (,8 NDI), mild pain and
disability (1028 NDI) and moderate/severe pain and
disability (.30 NDI) (Vernon, 1996).
Initial analysis was performed using a repeated measures
mixed model analysis of variance (ANOVA) with a between
subjects factor of group (four levels: asymptomatic, recov-
ered, mild, moderate/severe) and a within subjects factor of
time (three levels: ,1 month, 2 and 3 months post injury).
Age and gender were used as covariates in this analysis.
Differences between groups were analysed using a priori
contrasts. Where a signicant interaction occurred between
group and time, post hoc tests of simple effects were
performed at entry into the study (,1 month) and exit
from the study (3 months) to determine where these differ-
ences occurred. A repeated measures mixed model ANOVA
with a time-changing covariate of TAMPA was used to
assess the effect of TAMPA on the measures of the whiplash
groups. Signicance was set at P , 0:01.
3. Results
3.1. Subject classication on NDI at 3 months post injury
The NDI scores at 3 months post injury improved or
remained the same compared to the initial scores (Fig. 1)
and were signicantly different between the three whiplash
groups (P , 0:01). The NDI of the recovered group was
3 ^3.1 (mean ^SD), the mild group 18.5 ^5.2 and the
moderate/severe group 47.9 ^12.2. Thirty eight percent
of the whiplash subjects reported recovery by 3 months
post injury. Of the remaining whiplash subjects with persis-
tent symptoms at 3 months, 33% reported mild pain and
disability and 29% moderate/severe pain and disability
based on NDI scores at 3 months. Age and gender distribu-
tion of the four groups is illustrated in Table 1. There was an
uneven distribution of males and females and differences in
ages between the groups approached signicance
(P 0:03). As a consequence, age and gender were
included as covariates in the initial analysis.
3.2. Range of movement
There was a signicant main effect for group (P 0:007)
and an interaction between group and time (P 0:02) for
all movement directions except lateral exion (P . 0:1).
Due to interaction effects, group differences for exion,
extension, left and right rotation were examined at entry
into the study (,1 month) and exit from the study (3
months).
The groups who reported mild symptoms and moderate/
severe symptoms at 3 months had less range of exion,
extension, left and right rotation when compared to controls
at the entry point into the study (,1 month post injury),
(P , 0:01). There was no difference between these two
whiplash groups for any of these movement directions at
entry (P . 0:49). The group who recovered showed greater
range of extension than the other two whiplash groups
M. Sterling et al. / Pain 103 (2003) 6573 67
(P , 0:005) at entry but less than that of the control group
(P , 0:01). Range of movement of the groups who recov-
ered or reported mild symptoms improved with time. At 3
months post injury, their movement (in all directions) was
no longer different from controls (P . 0:3). In contrast, the
movement loss at entry persisted in the group with moder-
ate/severe symptoms and remained less than that of the
control group at 3 months the nal assessment point
(P , 0:01). The marginal means (^SEM) of the four
groups for the movements of exion, extension, left and
right rotation are presented in Figs. 2 and 3. The effect of
age on range of movement was signicant only for exten-
sion, left and right rotation (P , 0:01), with ROM decreas-
ing with increasing age. There was no effect of gender on
any measure of ROM (P . 0:2).
3.3. JPE
The results of data for JPE are presented in Fig. 4. There
was no interaction effect between group and time for all
three measures of JPE, indicating that there was no change
over time in any JPE direction. When the main effects were
considered, there was a signicant difference between the
groups for JPE (right rotation) (P 0:002) but no group
difference for JPE (left rotation, extension) (P . 0:3). The
group with persistent moderate/severe symptoms had a
signicantly greater JPE (right rotation) of 4.8 ^0.48
(marginal mean ^SEM) compared to all other groups
(P , 0:01). There were no between group differences in
those who recovered (3.6 ^0.58), those with persistent
mild symptoms (2.7 ^0.48) and the control group
(2.8 ^0.58) (P . 0:1). There was no effect of age or gender
on JPE (P . 0:06) (Table 2).
3.4. EMG activity of supercial neck exors
There was no interaction effect between group and time
for the EMG activity measured during the stages of the
CCFT. Analysis of the main effects revealed a signicant
difference in EMG activity between the groups
(P , 0:0001) and this difference persisted over time (Fig.
5). EMG activity of the supercial neck exors in the group
with moderate/severe symptoms was 40 ^4% (estimated
mean ^SEM), which was signicantly greater than the
EMG activity recorded for all other groups (P , 0:01).
EMG activity of the groups who recovered (29 ^4%) or
had mild symptoms at 3 months (27 ^3%) was also signif-
icantly greater than that of the control group (16 ^3%)
(P , 0:01). There was no effect of age or gender on EMG
(P . 0:2).
3.5. TAMPA
There was a signicant difference between the three
whiplash groups for the TAMPA score (P 0:0001). As
M. Sterling et al. / Pain 103 (2003) 6573 68
Table 1
The age, gender and classication of subject groups at 3 months according to the NDI scores (Vernon, 1996)
Group Number Age (years) (mean ^SD) Gender % female NDI classication NDI (mean ^SD)
Recovered group 25 33.5 ^10.2 60 ,8 3.0 ^3.1
Mild pain and disability group 22 34.7 ^12.6 64 1028 18.5 ^5.2
Moderate/severe pain and
disability group
19 41.3 ^13.6 84 .30 47.9 ^12.2
Control group 20 40.1 ^13.6 60
Fig. 1. Initial (1 month) and nal (3 months) classication of whiplash subjects based on NDI scores. Mild pain and disability (1028 NDI), moderate/severe
pain and disability (.30 NDI) and recovered (,8 NDI).
can be seen from the mean values in Fig. 6, the group with
persistent moderate/severe symptoms had signicantly
higher TAMPA scores than the other two groups (marginal
mean 40.55 ^2). In the groups who recovered or reported
mild symptoms at 3 months, the TAMPA scores improved
signicantly over time (P , 0:05) whereas there was no
change over time in the scores of the moderate/severe
group (P 0:783).
When TAMPA scores were included in the analysis of the
three whiplash groups, group differences remained signi-
cant for JPE (right rotation) (P 0:01) and EMG
(P , 0:01). With respect to ROM, group differences at the
time points described above also remained signicant
(P , 0:01). There was no interaction between group and
TAMPA for any measure of motor function (P . 0:13)
suggesting that the effect of TAMPA on the motor measures
is similar irrespective of group allocation. The effect size for
TAMPA on the measures of motor activity was small
(partial eta squared ranged from 0.00006 to 0.02).
4. Discussion
The results of this study provide the rst evidence of early
changes in motor system function following whiplash
injury. These changes were apparent within 1 month of
injury and occurred not only in those reporting moderate/
severe symptoms at 3 months but also in subjects who
recovered and those with persistent mild symptoms. In all
whiplash groups certain specic changes in motor system
function persisted over the 3 month study period. Sixty-two
percent of our cohort, of volunteers sustaining a whiplash
injury, reported ongoing pain at 3 months post injury, a
similar gure to data from previous longitudinal studies
(Radanov et al., 1995; Mayou and Bryant, 1996; Gargan
et al., 1997). Twenty-nine percent of the cohort reported
persistent moderate or severe symptoms. Values obtained
for control subjects for all measures of motor function were
similar to those previously reported (Revel, 1991; Jull,
2000; DallAlba et al., 2001).
Decits in cervical ROM were present within 1 month of
injury in all whiplash subjects. The loss in ROM persisted in
the group who reported moderate/severe symptoms at 3
months, while movement in the groups who reported mild
symptoms or who had recovered at 3 months improved with
time and returned to ranges that were no longer different
from healthy controls. Most cross-sectional studies investi-
gating ROM in chronic WAD have demonstrated decreased
cervical movement (Osterbauer et al., 1996; Bono et al.,
2000; DallAlba et al., 2001; Dumas, 2001). However, a
recent longitudinal study suggested that although ROM
was decreased in the rst few weeks after injury, by 3
months this loss was regained (Kasch et al., 2001) which
seems at odds with our ndings. However, Kasch et al.
(2001) did not attempt to differentiate between recovered
and non-recovered subjects as we did. The ndings of our
study reinforce the need to not only differentiate between
recovered and non-recovered subjects but also between
those who continue to report higher levels of pain and
disability from those with mild symptoms.
M. Sterling et al. / Pain 103 (2003) 6573 69
Fig. 2. Means and standard errors of the mean (SEM) for all groups (control,
recovered, mild pain and moderate/severe pain) over time (1, 2 and 3
months post injury) for active range of extension and exion.
Fig. 3. Means and standard errors of the mean (SEM) for all groups (control,
recovered, mild pain and moderate/severe pain) over time (1, 2 and 3
months post injury) for active range of left and right rotation.
Evidence of altered kinaesthetic awareness as measured
using JPE was apparent only in the group of whiplash
subjects reporting persistent moderate/severe pain at 3
months. This occurred in one movement direction reloca-
tion from right rotation, was present within 1 month of
injury and showed no change over time. These results
support our previous research where chronic WAD subjects
with a higher neck disability index (in this case the North-
wick Park questionnaire) demonstrated greater JPE (Trelea-
ven et al., 2002). Whilst only relocation from right rotation
was affected in this current study, previous researchers have
noted errors in chronic WAD subjects in other movement
directions including extension, exion and left rotation
(Heikkila and Astrom, 1996; Treleaven et al., 2002)
although Treleaven et al. (2002) showed greater JPE with
right rotation. The reasons for this discrepancy are unclear.
The majority of subjects (16 of 19) in the moderate/severe
group reported bilateral neck pain discounting the possibi-
lity that the side of pain is responsible for this nding. Hand
dominance was not considered in this study and could be
associated with this nding. Additionally, the subjects in
this study were only 3 months post injury as opposed to
the above-mentioned studies using chronic WAD subjects
with longer symptom duration. Whether JPE in other direc-
tions emerge in time remains to be seen and may require
further investigation.
Increased activity in the supercial neck exor muscles
during the CCFT is thought to be indicative of alterations in
patterns of muscle activation and recruitment and has been
identied in patients with chronic neck pain of both trau-
matic and non-traumatic origin (Jull, 2000; Jull et al., 2002).
This study demonstrates that these changes occur soon after
injury and persist not only in those reporting ongoing symp-
toms at 3 months post injury but also in those whose symp-
toms have resolved during this time. Research into low back
pain has shown that altered muscle recruitment persists
despite the patient reporting recovery and may be one factor
involved in high rate of symptom recurrence in this condi-
tion (Hides et al., 2001). Whether the whiplash patients who
recovered in this study continue to demonstrate increased
muscle activity past the 3 month period and whether this
group reports recurrence of pain at some later date is
presently under investigation.
The contribution of physical and psychosocial factors to
the development of chronic symptoms has been studied
extensively in chronic low back pain (Fritz et al., 2001),
but very little attention has been paid to their role in cervical
spine pain. Whilst the moderate/severe group in this study
showed elevated scores on the TAMPA scale similar to
those seen in chronic low back pain (Crombez et al., 1999),
differences in motor function between the whiplash groups
remained signicant when TAMPA scores were taken into
account. Furthermore the relationship between TAMPA and
the measures of motor function was weak. This would
M. Sterling et al. / Pain 103 (2003) 6573 70
Fig. 4. Means and standard errors of the mean (SEM) for all groups (control, recovered, mild pain and moderate/severe pain) over time (1, 2 and 3 months post
injury) for joint position error (JPE) from right rotation.
Table 2
Marginal means (SEM) of joint position error (JPE) right and left rotation and extension for all groups
a
Group JPE (right rotation)
(mean ^SEM)
JPE (left rotation)
(mean ^SEM)
JPE (extension)
(mean ^SEM)
Recovered 3.6 ^0.3 3.0 ^0.2 3.3 ^0.3
Mild pain and disability 2.7 ^0.3 2.7 ^0.2 3.4 ^0.3
Moderate/severe pain and disability 4.8 ^0.3 3.2 ^0.3 4.1 ^0.3
Controls 2.7 ^0.3 2.6 ^0.3 2.8 ^0.3
a
Values in bold are signicantly greater than control for P , 0:01.
suggest that ROM loss, increased supercial neck exor
muscle activity during the CCFT and JPE occurred indepen-
dently of fear of movement/re-injury. The nding that
increased muscle activity occurred in the WAD subjects
even when controlled for TAMPA beliefs occur is contrary
to ndings in chronic low back pain where abnormal para-
spinal muscle activity has shown to be inuenced by
psychological factors (Watson et al., 1997). Our ndings
indicate that motor system changes in this population are
not totally explained by the subjects TAMPA, conrming
suggestions that the relationship between fear-avoidance
beliefs and disability in cervical pain may be weaker than
that for lumbar pain (George et al., 2001).
Experimental investigations have provided evidence that
acute musculoskeletal pain is capable of inducing changes
in motor system function such as alteration of spinal motor
reexes, effects on the gamma motor system, altered motor
recruitment patterns and effects on supraspinal neurons
(Woolf and Wall, 1986; Mense and Skeppar, 1991; Made-
leine et al., 1999; Andersen et al., 2000; Ro and Capra,
2001; Thurnberg et al., 2001). Most of these studies have
used animal models or induced experimental muscle pain as
a model for acute pain making it difcult to extrapolate the
ndings to the clinical situation. Furthermore little is known
about the long-term nature of such changes. Nevertheless
evidence from clinical studies of chronic pain would suggest
that certain motor system changes do persist (Hodges and
Richardson, 1999; Madeleine et al., 1999). The ndings of
this study may reect underlying disturbances in motor
function as a consequence of the initial peripheral nocicep-
tive input (for example from injured cervical structures
following whiplash injury) in the acute stage of injury,
which appear to persist over time. Further investigation of
such potential mechanisms in WAD is required.
M. Sterling et al. / Pain 103 (2003) 6573 71
Fig. 5. Normalised EMG (mean and SEM) of the supercial neck exors for all groups (control, recovered, mild pain and moderate/severe pain) over time (1,2
and 3 months post injury) during the CCFT.
Fig. 6. Means and standard errors of the mean (SEM) for three whiplash groups (recovered, mild pain and moderate/severe pain) over time (1,2 and 3 months
post injury) for scores of TAMPA questionnaire.
The results of this study may have implications for the
clinical management of whiplash-injured patients. Rando-
mised controlled trials of specic retraining of the cranio-
cervical exion movement and rehabilitation of cervical
kinaesthesia have demonstrated efcacy in the treatment
of chronic neck pain syndromes albeit mainly neck pain
of a non-traumatic cause (Revel et al., 1994; Jull et al.,
2002). In view of the ndings of this study, where similar
motor decits were shown to occur within 1 month of
injury, the inclusion of such rehabilitation programs may
be benecial in the management of acute WAD.
Acknowledgements
This study was supported by Suncorp Metway Insurance,
Queensland and Centre of National Research on Disability
and Rehabilitation Medicine (CONROD).
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