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Gait & Posture 28 (2008) 113119


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Postural control deficit in acute QTF grade II whiplash injuries


Christoph Dehner a,*, Birgit Heym a, Dirk Maier a, Silvia Sander c,
Markus Arand a, Martin Elbel a, Erich Hartwig b, Michael Kramer a
a
Department for Trauma Surgery, Hand, Plastic and Reconstructive Surgery, University of Ulm, Germany
b
Department for Trauma Surgery, Deaconesses Hospital, Karlsruhe-Rupurr, Germany
c
Institute of Biometrics, University of Ulm, Germany

Received 23 February 2007; received in revised form 21 August 2007; accepted 28 October 2007

Abstract

Study design: Experimental in vivo study.


Objective: The objective was to investigate the balance control in patients with acute QTF grade II whiplash injuries of the cervical spine.
Summary of background data: Tetra-ataxiametric posturography in chronic pain patients after whiplash injuries of the cervical spine has
revealed an impaired regulation of balance. However, so far it is unclear if this is caused by the accident or other factors that are associated
with the pain chronification process.
Methods: 40 patients with acute QTF grade II whiplash injuries and 40 healthy matched controls were examined on a posturography
platform. The stability index STS and the Fourier analysis FAS (0.101.00 Hz) were established for eight standing positions and sum scores
were calculated. The pain index was established using a visual analog scale ranging from 0 to 100. A follow-up examination was conducted
for the patients after 2 months.
Results: The patients with acute whiplash injuries of the cervical spine achieved significantly poorer results for both STS and FAS than the
healthy controls. There were no differences between the eight standing positions for both STS and FAS. After 2 months, 17 patients had no
change in the pain development, 21 patients showed an improvement in pain intensity and 2 patients had deteriorated. The subgroup of
patients with improvement in pain intensity showed a significant improvement in balance control concerning the FAS compared to patients
with unchanged pain intensity.
Conclusion: Patients with acute whiplash injuries have a reduced balance control as compared to matched controls. This study gives an
indication that post-traumatic neck pain is associated with impairments of postural control.
# 2007 Elsevier B.V. All rights reserved.

Keywords: Postural control; Acute whiplash; Neck proprioception; Neck pain

1. Introduction of the cervical spine, balance disturbances have been given


less attention.
Besides neck pain and restricted movement, patients who Regulation of balance is a complex function of the
have suffered whiplash injuries of the cervical spine sensorimotor system. Information that is received by the
frequently complain of an impaired regulation of balance sensory systems from the environment has to be centrally
[15]. While the diagnostic and therapeutic endeavours have translated into motor responses. Several sensory systems
so far focused on the neck pain and the restricted movement such as the visual, vestibular and peripheral somatosensory
systems exert an effect on the regulation of balance [68]. It
is assumed that in patients with whiplash injuries, the
function of the peripheral somatosensory system is
* Corresponding author at: Unfallchirurgie, Hand-, Plastische- und Wie-
derherstellungschirurgie, Universitat Ulm, Steinhovelstrasse 9, D-89075
impaired because of damage to the proprioceptors of the
Ulm, Germany. Tel.: +49 731 5000; fax: +49 731 500 54542. neck, and that this results in an impaired regulation of
E-mail address: christoph.dehner@uniklinik-ulm.de (C. Dehner). balance [2,7,9,10].

0966-6362/$ see front matter # 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.gaitpost.2007.10.007
114 C. Dehner et al. / Gait & Posture 28 (2008) 113119

Posturography was developed in order to determine the injuries of the cervical spine (neck pain and neurological signs) and
functional capability of the regulation of balance. Using a QTF grade IV whiplash injuries of the cervical spine (patients with
measuring platform, weight shifts are determined with force neck pain and fracture or dislocation) were excluded from this
sensors while the weight is borne on the lower extremities. analysis. Furthermore patients who had suffered previous injuries
of the cervical spine or who had muscular, neurological or mental
Information can thus be gained on the balance and stability
disorders were excluded from participation in the study. Patients
of the subject.
who had degenerative diseases or pain of the cervical spine or the
Posturographic investigations in patients with chronic lower extremities were also excluded. The control group, which
symptoms after whiplash injuries of the cervical spine consisted of healthy subjects and was made up of medical students
unanimously demonstrate a poorer regulation of balance in and hospital staff, was established by forming matched pairs with
the whiplash group as compared to healthy subjects [1116]. regard to year of birth and gender. They were not matched with
However, it has not yet been fully established what causes regard to body weight, which is inversely proportional to stability
the persistent whiplash associated disorders (WAD) and the [20,21], as this was automatically taken into account by the soft-
resulting impaired regulation of balance [12]. In patients ware of the posturographic system that was used. The work has
with chronic cervical spine pain, structural injuries such as been approved by the appropriate ethical committees and the
facet joint pathologies and intervertebral disc lesions have subjects gave informed consent to the study.
been reported with an incidence of up to 84% [17,18] and are
2.2. Study procedure
discussed as being the cause of postural control system
distortion [7,9]. However, it is not precisely known whether Using a standardised procedure, the patient group was examined
these are direct consequences of the accident or result of on a posturography platform (Tetrax IBS1, Neurodata GmbH,
secondary degenerative changes. There is only one study Vienna, Austria) within the first week (Pat 1) after the trauma
which describes that chronic pain patients with and without (median (3 days); range (16 days)) and 8 weeks after the date of
whiplash injury differ in their regulation of balance [16]. the first examination (Pat 2) [20]. On both measurement dates the
Furthermore, chronic pain and psychological effects are patients were questioned about subjective balance disturbances. At
discussed to affect the central nervous systems modulation the first examination all patients were given a prescription for a
of proprioceptive afferent information [19]. Not only physiotherapy program two times a week for a period of 5 weeks.
accident-related causes but also degenerative and psycho- The physiotherapy program consisted of soft-tissue treatment, joint
mobilization and measures for strengthening and stabilization of
logical causes are thus conceivable.
the cervical spine. The control group was only examined on one
Against this background, it would be interesting to know
occasion (Norm). The examination was conducted by an investi-
whether postural disturbances also occur shortly after a gator who was blinded with regard to history, clinical finings and
whiplash injury. At that time, degenerative and psycholo- status (patient/subject).
gical factors are unimportant in comparison to the accident- The TETRAX IBS1 system measures the subjects dynamic
related factors in the determination of the causes. There are weight distribution via four independent pressure sensors (left
no posturographic investigations in patients with acute heel = A; ball of the left foot = B; right heel = C; ball of the right
whiplash injuries in the literature to date. The present study foot = D) which are incorporated in two foot platforms (see Fig. 1).
will thus investigate the regulation of balance in a patient A detailed description of the system is available elsewhere [20].
group with acute whiplash injuries of the cervical spine For the measurement, the subject stands barefoot on the measuring
compared to a matched pair non-whiplash control group in plates, which are positioned in parallel at hip width, assuming an
upright, relaxed position with arms hanging loosely. For the
order to answer the following questions:
controlled modification of sensory input from the visual, vestib-
ular and somatosensory systems and for the assessment of the
1. Are there differences in the regulation of balance compensatory ability within the postural system eight different
between patients with acute QTF grade II whiplash position tests were performed (Table 1). Each of the posturo-
injuries of the cervical spine and healthy subjects? graphic tests took 30 s.
2. Does the elimination of the visual, somatosensory or
vestibular system lead to a decrease in balance control? 2.3. Parameters for analysis
3. Does the patients regulation of balance change over a
period of 2 months after the accident? 1. Stability index (ST), calculated as the square root of the sum of
the squared differences between adjacent pressure fluctuation
signals, sampled at a rate of 32 Hz. ST describes the state of
2. Materials and methods general stability and is an indicator of a persons stability [16].
The higher the score, the greater the sway and instability [20]. A
2.1. Subjects sum score STS of the eight different position tests was calculated
and used for group comparison.
QTF grade II whiplash injuries of the cervical spine (patients 2. Fourier analysis (FA): Fourier analyses of the postural
with neck pain and musculoskeletal signs) were the only inclusion recordings were performed. Abnormal postural performance
criterion that was defined for the study. Patients with QTF grade I due to peripheral causes is characterized by a high intensity of
whiplash injuries of the cervical spine (patients with neck pain, sway in the frequency range of 0.101.00 Hz [20,22]. Again we
stiffness or tenderness only), patients with QTF grade III whiplash used the sum score FAS for group comparison.
C. Dehner et al. / Gait & Posture 28 (2008) 113119 115

Fig. 1. Left: foot platforms with load cells labelled AD; above them are the attachable foam cushions. Right: test person standing on the foot platforms.

3. Pain (P): the patients pain score was determined according to a 3. Results
visual analog scale (0100) on both measurement dates. The
difference between the first and second measurements was 3.1. Subject participation
calculated to define the development of the pain. Pain
unchanged (PU) was defined as a minor difference of 10, Of the 76 patients with distortion injuries of the cervical
pain deteriorated (PD) as a difference of >10 and pain spine who were treated in the emergency department, 59
improved (PI) as a difference of 10. patients fulfilled the inclusion criteria, of whom 6 patients
declined to participate so that 53 patients were investigated
2.4. Statistical analysis in the first examination. 13 patients had to be excluded from
the study because they were not prepared to report for the
The differences between the controls and patients acute follow-up (investigation after 8 weeks). Of the 40 patients in
examinations were tested for statistical significance with the the patient group, 14 were female and 26 were male (median
non-parametric Wilcoxon signed-rank test for linked samples.
age: 29; range 1542).
To compare the eight standing positions for both parameters, the
The median pain score was 40 (1090) in the first
differences were analysed with the Friedman test for linked
samples. The difference between the patients acute and follow- examination and 15 (070) in the second examination. In the
up examinations was tested for statistical significance with the first examination, four patients reported a short sensation of
non-parametric Wilcoxon rank-sum test comparing the sub- dizziness and balance disturbances. At the time of the
groups (PU, PD and PI). The significance level a was set at second examination, none of the patients complained of
p = 0.05. dizziness or balance disturbances.

Table 1
Testing conditions for the eight posturographic tests
Positions Head position Eyes Ground Purpose
NO Neutral Open Solid Neutral position
NC Neutral Closed Solid Elimination of visual system
PO Neutral Open Elastic Elimination of somatosensory system
PC Neutral Closed Elastic Elimination of somatosensory and visual system
HR Rotated to the right Closed Solid Elimination of visual system and vestibular stress
HL Rotated to the left Closed Solid Elimination of visual system and vestibular stress
HB Reclined Closed Solid Elimination of visual system, vestibular and cervical stress
HF Inclined Closed Solid Elimination of visual system, vestibular and cervical stress
116 C. Dehner et al. / Gait & Posture 28 (2008) 113119

Fig. 2. Comparison of the stability index (STS) and the frequency analysis (FAS) between the acute examination of the patients (Pat 1) and the control group
(Norm). The graphs show the median, 1st quartile (lower edge of box), 3rd quartile (upper edge of box), maximum and minimum (upper and lower end of range
line) of the differences.

3.2. Comparison of patients and controls 3.4. Comparison of first and second examinations of the
patients
The patients differed significantly from the controls
with regard to the stability index (STS) ( p = 0.0001). The 17 patients had no change in the pain development, 21
median difference of the stability index (STS) between patients showed an improvement in the pain intensity and 2
patients and controls was 37.1 (range: 30.2147.4). patients had deteriorated. The subgroup PD was not
Also the Fourier analysis (FAS) shows a significant diff- analysed statistically due to the small sample size (n = 2).
erence (median: 60.2; range: 57.1406.0) ( p = 0.0001) The median difference of the FAS between the patients
(Fig. 2). acute and follow-up examinations was 10.0 (range: 33.0
121.0) in the subgroup PU and 4.0 (range: 133.065.0) in
3.3. Comparison of the eight standing positions the subgroup PI. There was a significant improvement in the
subgroup PI ( p = 0.028). In the STS, the median difference
When comparing the eight standing positions, there is no between patients acute and follow-up examinations was 0.5
significant difference between patients and controls either (range: 42.8281.0) in the subgroup PU and 13.2 (range:
for the stability index ( p = 0.533) or for the Fourier analysis 346.283.8) in the subgroup PI There was no significant
( p = 0.287) (Figs. 3 and 4). improvement in the subgroup PI ( p = 0.106) (Fig. 5).

Fig. 3. Comparison of the stability index (STS) in the eight standing positions between the acute examination of the patients (Pat 1) and the control group
(Norm). The graphs show the median, 1st quartile (lower edge of box), 3rd quartile (upper edge of box), maximum and minimum (upper and lower end of range
line) of the differences.
C. Dehner et al. / Gait & Posture 28 (2008) 113119 117

Fig. 4. Comparison of the frequency analysis (FAS) in the eight standing positions between the acute examination of the patients (Pat 1) and the control group
(Norm). The graphs show the median, 1st quartile (lower edge of box), 3rd quartile (upper edge of box), maximum and minimum (upper and lower end of range
line) of the differences.

Fig. 5. Comparison of the subgroups PU (pain unchanged) and PI (pain improved) concerning the stability index (STS) and the frequency analysis (FAS)
between the first (Pat 1) and second examinations (Pat 2) of the patients. The graphs show the median, 1st quartile (lower edge of box), 3rd quartile (upper edge
of box), maximum and minimum (upper and lower end of the range line) of the differences.

4. Discussion information but also by an additional disturbance of the


vestibular system.
This study shows that patients who have suffered a QTF This would mean that postural disturbances become
grade II whiplash injury have a posturographically measur- clinically symptomatic only when several subsystems
able impairment of their balance control, which deviates involved in balance control fail at the same time. It is
significantly from the performance of a matched-pair control conceivable that the failure of a subsystem can be
group. However, only four patients complained of balance compensated by other systems, at least when the require-
disturbances or sensations of dizziness shortly after the ment profile involves everyday tasks [7,8]. So far it has not
trauma and none of the patients complained of these been investigated whether the measurable postural deficits
symptoms after 8 weeks. Moreover, the four individuals with could still manifest themselves during the performance of
subjective balance disturbances did not have the poorest more complex balance tasks such as walking on ladders and
posturographic results. Our results thus fail to show a scaffolding or specific sports activities. As balance control is
correlation between clinical symptoms and posturographic a basic human ability, the theory of compensability of
measurements. postural subsystems is quite logical.
By contrast, Treleaven et al. found that the balance The results of our study show that no change can be
control in patients with persistent WAD and dizzy spells is provoked in the parameters STS and FAS by an increase in
significantly reduced as compared to those without dizziness the stress on the visual, vestibular and somatosensory
[14]. The authors assume that this is because the patients subsystems in acute whiplash patients. Consequently, these
with dizzy spells are affected not only by abnormal cervical subsystems do not seem to be disturbed in our population.
118 C. Dehner et al. / Gait & Posture 28 (2008) 113119

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