Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury

OBJECTIVE: To investigate cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. DESIGN: A 2-year review of consecutive patients admitted to the emergency unit after whiplash injury. SETTING: An otorhinolaryngology department. PATIENTS AND SUBJECTS: Twenty-seven consecutive patients with diagnosed whiplash injury (14 men and 13 women, mean age, 33.8yrs [range, 18 to 66yrs]). The controls were healthy subjects without a history of whiplash injury. MAIN OUTCOME MEASURES: Oculomotor function was tested at 2 months and at 2 years after whiplash injury. The ability to appreciate both movement and head position was studied. Active range of cervical motion was measured. Subjective intensity of neck pain and major medical symptoms were recorded. RESULTS: Active head repositioning was significantly less precise in the whiplash subjects than in the control group. Failures in oculomotor functions were observed in 62% of subjects. Significant correlations occurred between smooth pursuit tests and active cervical range of motion. Correlations also were established between the oculomotor test and the kinesthetic sensibility test. CONCLUSION: The results suggest that restricted cervical movements and changes in the quality of proprioceptive information from the cervical spine region affect voluntary eye movements. A flexion/extension injury to the neck may result in dysfunction of the proprioceptive system. Oculomotor dysfunction after neck trauma might be related to cervical afferent input disturbances.     

High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study

STUDY DESIGN: A prospective, randomized, double-blind study comparing high-dose methylprednisolone with placebo. OBJECTIVES: To evaluate the efficacy of high-dose methylprednisolone when administered within 8 hours after whiplash injury. SUMMARY OF BACKGROUND DATA: Whiplash injury often results in chronic symptoms. The management of whiplash injuries is controversial, and pharmacologic therapy has received little evaluation. In recent reports, dysfunction of the central nervous system has been indicated in several cases. Methylprednisolone administered within 8 hours after the injury to patients with acute spinal cord injury has been demonstrated to improve the outcome. This procedure was also adopted in a randomized study of cases of whiplash injury in car accidents. METHODS: Forty patients, 22 men and 18 women with a mean age of 35 years (range, 19-65), were included in the study, 20 in each of two groups. They were treated for whiplash injury, which they had sustained in car accidents. The patients were enrolled if their diagnoses were complete and treatment had begun within 8 hours after injury. Disabling symptoms severe enough to prevent the patient from returning to work, number of sick days before and after injury, and sick-leave profile after injury were used as parameters for the evaluation of the effects of the treatment. Baseline demographic data were controlled for when statistical analysis had been performed. RESULTS: At the follow-up examination 6 months after initial treatment, there was a significant difference in disabling symptoms between the actively treated patients and the placebo group (P = 0.047), total number of sick days (P = 0.01), and sick-leave profile (P = 0.003). CONCLUSIONS: The results of this study indicate that acute treatment with high-dose methylprednisolone may be beneficial in preventing extensive sick leave after whiplash injury. However, the number of patients studied was small, and therefore further prospective, controlled studies are needed.     

Presenting symptoms and signs after whiplash injury: the influence of accident mechanisms

OBJECTIVE: To assess the relationship between accident mechanisms and initial findings after whiplash injury. DESIGN: Cohort study. SETTING: Outpatient department, Department of Neurology, University of Berne, Switzerland. PATIENTS: A population-based sample of 137 consecutive patients referred by primary care physicians. Fractures or dislocations of the cervical spine, head trauma, and preexisting neurologic disorders were exclusion criteria. MAIN OUTCOME MEASURES: Patients were interviewed and examined within 7.2 days (SD, 3.9 days) after trauma. Analyzed accident features were position in the car, use of seat belt, head restraint and its point of head contact, damage to seat, head position and state of preparedness at the moment of impact, and type of collision. Analyzed symptoms were intensity and onset delay of post-traumatic head and neck pain; pain in the shoulders, back, and anterior neck; symptoms of neurologic dysfunction according to presumed origin--cranial nerve or brainstem, radicular or myelopathic; and a score of multiple symptoms. Analyzed signs were neck muscle tenderness and restricted neck movement, and signs of cranial nerve, brainstem, or radicular dysfunction. RESULTS: Passenger position in the car, use of seat belt, and the presence of a head restraint showed no significant relationship with findings. Rotated or inclined head position at the moment of impact was associated with a higher frequency of multiple symptoms (p = 0.045 and 0.008) with more severe symptoms and signs of musculoligamental cervical strain (p = 0.048 and 0.038) and of neural, particularly radicular (p = 0.031 and 0.019), damage. Unprepared occupants had a higher frequency of multiple symptoms (p = 0.031) and more severe headache (p = 0.046). Rear-end collision was associated with a higher frequency of multiple symptoms (p = 0.006), especially of cranial nerve or brainstem dysfunction (p = 0.00003). CONCLUSION: Three features of accident mechanisms were associated with more severe symptoms: an unprepared occupant; rear-end collision, with or without subsequent frontal impact; and rotated or inclined head position at the moment of impact.     

Mild head trauma

Patients with mild traumatic brain injury constitute the overwhelming majority of head-injured patients seen in the emergency department. The indications for radiologic imaging in these patients are still undergoing study and revision. The Glasgow Coma Scale is a widely used triage score for head injury, but is less useful at identifying which patients with mild head injuries have intracranial pathology. There have been several retrospective studies and a few prospective studies examining the indications for imaging in mild to moderate head trauma. They all show that it is not easy to predict which patients will have CT abnormalities, and that some of these patients do go on to require neurosurgery. No set of clinical predictors have yet been put together that is capable of identifying all patients who are safe to be discharged without a CT scan. Pharmacologic therapy to help reduce axonal damage after head trauma and thus minimize the postconcussive sequelae of mild traumatic brain injury remains a challenge for physicians and neurobiologists into the next century.     

MRI of cerebrum and cervical columna within two days after whiplash neck sprain injury

The present study was undertaken to evaluate if MRI within 2 days of a motor vehicle accident could reveal pathology of importance for understanding long-term disability after whiplash neck-sprain injuries. As part of a prospective study cervical and cerebral MRI was performed on 40 neck sprain patients with whiplash injury after car accidents. The imaging was done within 2 days of the injury to make sure that any neck muscle bleeding, oedema or other soft tissue injuries could be detected. The MRI findings from the patients were both correlated to reported symptoms 6 months after the accident and compared to a control group of 20 volunteers. The MRI of both brain and neck revealed no significant differences between the patients and the control group. When the patients were grouped according to the main MRI findings at intake and compared according to the development of subjective symptoms reported by the patients, the only significant difference was more headaches at 6 months in the groups with disk pathology or spondylosis when compared to the group with no pathology. In conclusion, MRI within 2 days of the whiplash neck-sprain injury could not detect pathology connected to the injury nor predict symptom development and outcome.     

P300 and stress in mild head injury patients

OBJECTIVE: The P300 component of event-related potentials is affected by personal meaningfulness of the stimulus to the subject. Thus, the P300 component could provide an objective parameter in the emotional assessment of road accident mild head injury patients, when exposed to relevant stimuli. METHODS: Thirteen patients with post-traumatic symptoms and 14 healthy controls were evaluated in this study. Two word types, distinguished by color, were presented on a computer screen in active 'oddball' paradigm conditions. In the first subtest, the targets were accident-related (stressful) words; in the second subtest, the targets were non-accident-related (neutral) words. Target (20%) and non-target (80%) were defined by word color. Data recorded from Pz were analyzed for P300 parameters. RESULTS: Patients and controls differed in their reaction to word types (group x word main effect P = 0.0089), regardless of the oddball presentation. Overall, accident-related words produced a significantly larger P300 wave than neutral words in patients (P = 0.0001), but not in controls (P = 0.5741). Significant correlation was found between combined P300 amplitude difference (all stressful words vs. all neutral words) and the patient's Zung state anxiety score (r = 0.68, P = 0.01). CONCLUSION: We suggest the P300 component can provide a useful, objective tool in the assessment of mild head injury patients.     

Mild head injury in New Zealand: incidence of injury and persisting symptoms

AIMS: To define mild head injury and determine its incidence and that of persisting symptoms. METHODS: Analysis of an eight week sample of all patients with head injury passing through the Emergency Departments of the four Auckland Hospitals, and of a five year sample of patients attending a clinic for management of symptoms persisting after head injury. RESULTS: Mild head injury was defined by the acute management needed--care out of hospital or not more than 48 hours admission, corresponding reasonably with a definition using post-traumatic amnesia. Incidence in those seen at hospital was 437/10(5) whole population/year for ages 15 and over, and 252/10(5) for ages under 15. Age specific incidences were 1769/10(5)/year for 15 and over, and 2920/10(5) for ages under 15, the major causes being road accidents (RTA) and falls, respectively. For 100 cases seen at hospital approximately 60 were treated by general practitioners alone. Referrals in patients 15 years and over because of persisting symptoms occurred in 5% (95%, CI 3-7), 69% in the first four months and 6% after a year. Referrals were equally likely after RTA, sports injuries and assaults, more frequent after objects striking the head. Older people were marginally more likely to be referred and the probability was significantly greater in women injured in sport and in minor RTA not needing admission to hospital. CONCLUSIONS: Mild head injuries are economically important and deserve efficient management.     

Disturbed eye movements after whiplash due to injuries to the posture control system

Self-reports after whiplash often indicate associations with vertigo and reading problems. Neuropsychological and otoneurological tests were applied to a group of whiplash patients (n = 26) and to a carefully matched control group. The whiplash group deviated from the control group on measures of eye movements during reading, on smooth pursuit eye movements with the head in normal position, and with the body turned to the left or to the right. Clinical, caloric, and neurophysiological tests showed no injury to the vestibular system or to the CNS. Test results suggest that injuries to the neck due to whiplash can cause distortion of the posture control system as a result of disorganized neck proprioceptive activity.     

Subtle symptoms associated with self-reported mild head injury

We conducted a survey on the relationship between mild head injury incidence and a variety of psychological and educational symptoms in a sample of 1,345 high school and 2,321 university students. Once figures were adjusted to represent a 50:50 gender ratio, 30% to 37% of subjects reported having experienced a head injury incident, with 12% to 15% of the total group of subjects reporting such an incident with loss of consciousness. We found significant relationships between the incidence of such mild head injury and gender, sleep difficulties, social difficulties, handedness pattern, and diagnoses of attention deficit, depression, and speech, language, and reading disorders.     

Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system

OBJECTIVE: To determine if trauma center protocols affect the number of tests and consultations performed and the length of time spent in the emergency department or hospital. DESIGN: A retrospective review and comparison of treatment for children with isolated head injury admitted to the emergency department before trauma center designation (group 1, 1985), and 5 years after implementation of trauma center protocols (group 2, 1991). SETTING: Urban children's hospital, level I trauma center. RESULTS: One hundred sixty-five children met the enrollment criteria in 1985 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Coma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), there was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15, no loss of consciousness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of consciousness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically significant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4-67); 11 times more likely to have cervical spine radiographs (95% CI, 2.2-76.6); and 23 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mechanism of injury. CONCLUSIONS: Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic services. These practices have the potential to increase the cost of medical care without significantly improving outcome.     

Nonepileptic seizures after head injury

PURPOSE: To examine the role of head injury as a risk factor in the development of nonepileptic seizures (NES). Specifically, we will determine the relative frequency of head injury among NES patients referred to our center and will describe several pertinent clinical features and personal characteristics. METHODS: Retrospective record review of patients referred to our center for evaluation of seizures over a 4-year period. All patients with NES were evaluated as in a previously described protocol, which included intensive video EEG monitoring, provocation by suggestion, and psychiatric interview. All NES patients with a history of head injury were extracted for this report. RESULTS: Of 102 patients with NES, nearly one-third (32%) had an antecedent head injury; 52% were male, mean age was 34 years, and 12% had coexisting epilepsy. Multiple psychiatric disorders were not uncommon (79%), and a history of abuse was found in 35%. All but four patients had documented financial gain from their injury. Follow-up at 1 year found poor long-term outcome with lasting disability; despite that, the majority (91%) of head injuries were minor. CONCLUSIONS: Our preliminary findings suggest that prior head injury is associated with the development of NES and may contribute to the pathogenesis of NES in vulnerable patients. Head injury and sexual or physical abuse appear to occur in comparable proportions in patients with NES. This suggests that head injury and abuse may be equally important risk factors in the development of NES.     

Motion analysis in whiplash injuries

Motion analysis of the cervical spine is a sensitive tool in the fields of preventive and clinical biomechanics of whiplash. In the field of preventive biomechanics motion analysis contributes to validation and optimisation of dummy based crash test experiments and simulations. In the clinical field motion analysis up to now is of restricted value. Data exist about restrictions and pathologies of movement and motion of the cervical spine, coordinative disturbances, postural control, TMJ-function and oculomotor disturbances after whiplash. The standardisation of technical and clinical set-ups is necessary to establish a well proven biomechanical model of whiplash and whiplash related biomechanical dysfunction. Without this model the value of motion analysis for clinical use will be restricted due to lack of comparable data on sensitivity and specificity although motion analysis of the cervical spine is neither cost- nor time consuming and free of adverse effects. Within a prospective series of 28 patients (14 m/14 f) with a follow-up to six weeks we were lucky to describe numerically two different types of reaction to low energy (delta v < 20 km/h) rear end collision: Type I with disturbances in complex movements only, Type II with overall restriction of movement. Control of angular velocity during cyclic movements of the head was disturbed by oscillations of higher frequency in all patients. Recovery from whiplash within 6 weeks could be monitored.     

Hypnosis and attention deficits after closed head injury

In a controlled study of patients attending a concussion clinic because of ongoing postconcussion symptoms, attention deficits were recorded in the head-injured group for the aspects of alertness, assessed by the Continuous Performance Test (CPT), and processing capacity, assessed by a version of the Paced Auditory Serial Addition Test (PASAT). Selective attention was intact. Hypnotizability was assessed by the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A), with normal means and standard deviations found in both the concussed and control groups. There was a significant correlation, however, between HGSHS:A scores and PASAT scores in the concussed group only. The results of this preliminary study suggest that slower processing capacity after a closed head injury may predict higher hypnotizability and that hypnosis could be an appropriate rehabilitation technique for these patients who present with postconcussion symptoms.     

Characteristics of tinnitus induced by head injury

OBJECTIVE: To determine if the characteristics of tinnitus produced by head trauma are specific and exclusive when compared with other origins of tinnitus. DESIGN: Retrospective study using clinic test results and data from the Tinnitus Data Registry compiled from questionnaires, interviews, and testing. Tinnitus produced by head injury was compared with tinnitus of mixed origins, including no known origin. SETTING: A tinnitus referral clinic where all patients must see an otologist or an ear, nose, and throat physician prior to attending the clinic. PATIENTS: All patients had severe to moderately severe constant tinnitus and presented with tinnitus as the primary symptom. RESULTS: No exclusive characteristics were found to describe head injury-induced tinnitus. The tinnitus for the group with head injury was statistically significantly (P = .004) louder and occurred with greater incidence of continuing pain in the ears. The group with head injury also had more episodes of dizziness and a more severe form of tinnitus. However, no marked difference was noted in pitch of tinnitus, complexity (number of sounds) of tinnitus, or the minimum masking level. CONCLUSIONS: This retrospective study found that tinnitus induced by head injury was significantly (P = .004) louder than tinnitus induced from other causes but, interestingly, did not require higher levels of masking. The patients with head injury-induced tinnitus more frequently (P = .0003) displayed residual inhibition although the duration of residual inhibition was not different from that of the comparison group. Other symptoms associated with the tinnitus onset were more frequently mentioned by the group with head trauma-induced tinnitus, except for the condition of pressure sensation in the ears. Using a severity questionnaire, the group with head trauma-induced tinnitus rated their tinnitus as being more severe than did the comparison group. However, such things as pitch of the tinnitus, masking level, acceptance of wearable maskers, general hearing level, and complexity of the tinnitus did not distinguish the two groups.     

Postconcussion syndrome following sports-related head injury: Expectation as etiology.

Mild head trauma is often complicated by a persistent set of symptoms known as postconcussion syndrome (PCS). Past research has suggested that an expectancy-guided, retrospective-recall bias may account for much of the variance in PCS symptom reporting. The present study examined the influence of symptom expectations on mild head trauma symptom reports among participants in contact sports. Head-injured athletes reported symptom rates that did not differ from those of uninjured athletes but consistently underestimated the preinjury incidence of symptoms. Athletes with no head trauma history overestimated the expected degree of pre- to postinjury change in symptom status. Results suggest that individuals with mild head injury tend to overestimate postconcussion symptom change in a manner consistent with their symptom expectations. A cognitive-behavioral model that explains the persistence of PCS is proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tremor and other movement disorders after whiplash type injuries

Movement disorders are usually of central origin, but have been reported in association with peripheral trauma. Injuries to the neck of the whiplash type provide a source of both types of injuries. Six cases are reported in which the temporal relation between the injury and the movement disorder make a causal relation likely. This important cause of disability has not previously been appreciated.     

Reflex jaw motions and jaw stiffness pertaining to whiplash injury of the neck

Because a so-called mandibular whiplash injury requires the absence of short-latency jaw-closing reflexes in order to explain the postulated mechanism of injury (excessive jaw opening); the authors studied the presence and absence and more importantly, the kinematics (duration, displacement, velocity, acceleration) of monosynaptic and possibly, polysynaptic myotatic (stretch) reflexes in the jaw elevator muscles. In six healthy adults jaw jerk maneuvers were elicited through a brisk tap on the chin, and surface electromyography identified elevator reflexes while translational electrognathography identified the kinematics of the reflexes. The maneuvers were done while maintaining the rest position (3% MVC) and moderate clenching of the teeth (30% MVC). Electromyography was also used to identify phasic elevator excitations during a passive brisk neck extension maneuver. A sudden and unexpected elongation of the jaw elevators released autogenic reflex responses that, in conjunction with augmented tissue elasticity (stiffness), elevated the mandible into centric occlusion within approximately 150 milliseconds. In 86% of trials, the responses occurred regardless of the prevailing resting and clenching contractile activities. There was no evidence of a depressor force that consistently would and could anchor the mandible in a position of extreme or moderate depression, the theoretical linchpin of the mandibular whiplash injury. It was concluded that the mandibular locomotor system is very efficient in maintaining the rest and intercuspal positions of the mandible. This study found no evidence corroborating the mechanism claimed to release a so-called mandibular whiplash injury.     

Transient systolic hypotension. A serious problem in the management of head injury

OBJECTIVE: To determine the frequency and clinical impact of transient systolic hypotension (systolic blood pressure < 100 mm Hg) in patients with severe anatomic head injury. DESIGN: Retrospective case-control study. SETTING: Urban level 1 trauma center. PATIENTS: Consecutive trauma patients admitted to the intensive care unit (ICU) with severe anatomic head injury, defined as Head and Neck Abbreviated Injury Scale Score of 4 or higher. One thousand thirteen trauma patients were admitted to the ICU during the study period, 157 of whom met inclusion criteria. MAIN OUTCOME MEASURES: Acute mortality, defined as death during initial ICU admission, and functional status of ICU survivors, assessed as level of function sufficient for discharge to home. RESULTS: One hundred fifty-seven patients with severe head injury had a total of 831 episodes of systolic hypotension. Fifty-five percent of the patients suffered at least one event. Patients were grouped by total number of low systolic blood pressure events and by average number of events per ICU day. The total number of hypotensive events was associated with increased mortality rates and decreased rate of discharge to home. Average daily frequency of events was associated with increased mortality rates. After stratification by admission Glasgow Coma Scale score, the effects were most dramatic in patients with an initial Glasgow Coma Scale score higher than 8. CONCLUSIONS: Transient hypotension is common in the ICU and is associated with increased acute mortality and decreased functional status in patients with head injury. The impact of this secondary insult is greatest in patients with less severe primary injury. Strict avoidance of hypotension through enhanced monitoring and active treatment appears to be important, especially in patients with higher presenting Glasgow Coma Scale scores.     

Cognitive recovery correlates with white-matter restitution after head injury

Longitudinal measurements of local cerebral perfusion (LCBF) and local partition coefficients (L lambda) using xenon-enhanced computed tomography were examined in six patients who had suffered from head injury at a mean age of 30 +/- 9.3 years. They were selected from a larger group with head injury because all were observed longitudinally to make excellent cognitive recovery some years after acute cerebral trauma. Results were compared with similar longitudinal measurements made in six age-matched neurologically normal volunteers. In the index group, cognitive test scores were reduced at the time of the first LCBP measurement but significantly improved to normal at the time of the second. The mean interval between measurements was 2.7 +/- 0.7 years. At the time of the first measurement, all six patients exhibited abnormal volumes of white matter with reduced Hounsfield numbers and LCBF and L lambda values. Abnormalities in volume of white matter and LCBF and L lambda values improved to normal at the time of the second measurement. Perfusion values for frontal cortex, putamen, and thalamus were still slightly reduced but also improved toward normal between measurements. Cognitive recovery correlated best with restoration of white matter integrity, suggesting that following head injury, cognitive impairments may be associated with temporary disconnections of corticothalamic projection systems.     

Long-term effects of severe penetrating head injury on psychosocial adjustment.

The long-term effects of severe penetrating head injury on adjustment levels were studied. Forty-one World War II veterans who suffered penetrating injury to the brain were interviewed 40 years after their initial injury using the Washington Psycho-Social Seizure Inventory (WPSI). The results support a comparable behavioral impact of right and left hemispheric lesions. Similarly, no significant relations were found between anterior and posterior locus of damage and psychosocial difficulties, although the results pertaining to the right-anterior group could be interpreted as suggestive of much greater maladjustment in all life dimensions assessed by the WPSI. Findings are discussed in terms of theoretical positions on hemispheric specialization and long-term expectancies that hold implications for planning rehabilitation programs for such patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)