Cervical Lecture 3: Whiplash-Associated Disorders (WAD) and Neck Pain with Headache (CGH)

Cervical Spine Lecture 3: Neck Pain with Movement Coordination Impairments (WAD) and Headaches (CGH)

Introduction and ICF Classification

• Instructor: Dr. Daniel Maddox, PT, DPT, DSc; Board Certified Orthopaedic Clinical Specialist (OCS); Fellow, American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT).

• Neck Pain with Movement Coordination Impairments (WAD): Identified under the Olson IBC and ICF Classification (CPG) as Acute Pain with Whiplash-Associated Disorders (WAD).

• Neck Pain with Headaches (CGH): Classified as Cervicogenic Headache under Olson IBC and Cervicogenic (Headache) in the ICF system.

Neck Pain with Movement Coordination Impairments (WAD): Symptoms and Examination

• Common Symptoms (from CPG):

  • Mechanism of onset is explicitly linked to trauma or whiplash.

  • Associated (referred) pain in the shoulder girdle or upper extremity.

  • Associated varied nonspecific concussive signs and symptoms:

    • Dizziness or nausea.

    • Headache, concentration, or memory difficulties.

    • Confusion.

    • Hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli.

    • Heightened affective distress.

• Expected Exam Findings:

  • Positive cranial cervical flexion test.

  • Positive neck flexor muscle endurance test.

  • Positive pressure algometry.

  • Strength and endurance deficits of the neck muscles.

  • Neck pain occurring with mid-range motion that worsens at end-range positions.

  • Point tenderness, which may include myofascial trigger points.

  • Sensorimotor impairment, including altered muscle activation patterns, proprioceptive deficits, and issues with postural balance or control.

  • Neck and referred pain reproduced by provocation of involved cervical segments.

Understanding Whiplash and Whiplash-Associated Disorders (WAD)

• Whiplash Definition: An injury to the neck caused by sudden acceleration-deceleration forces, comparable to the cracking of a whip.

• Mechanisms of Injury: Typically the result of a Motor Vehicle Accident (MVA), but also occurs in sports, abuse, or other trauma.

• Distinction: "Whiplash" describes the mechanism of the injury, whereas "Whiplash-Associated Disorders" (WAD) describes the resulting sequelae or clinical condition.

Classification Systems for WAD

• Quebec Task Force (QTF) Classification:

  • Grade 0: No symptoms of neck pain; no physical signs.

  • Grade I: Subjective symptoms of neck pain, stiffness, or tenderness; no physical signs observed by the clinician.

  • Grade II: Neck symptoms as above, plus musculoskeletal (MSK) physical signs including decreased range of motion (ROM) and point tenderness.

  • Grade III: Neck symptoms as above, plus musculoskeletal signs, and neurologic signs such as decreased or absent Deep Tendon Reflexes (DTRs), muscle weakness, and sensory deficits.

  • Grade IV: Neck symptoms accompanied by a fracture or dislocation.

• Sterling sub-classification (Specific to WAD Grade II):

  • Developed by Michele Sterling to better guide treatment (Rx) because QTF WAD II is too broad.

  • II-A: Neck pain, motor impairment, decreased ROM, and altered muscle recruitment patterns (tested via CCFT).

  • II-B: Meets II-A criteria, plus sensory impairment (local cervical mechanical hyperalgesia) and psychological impairment (elevated psychological distress).

  • II-C: Meets II-B criteria, plus increased joint positioning errors (JPE), generalized (widespread) hypersensitivity to mechanical/thermal stimuli and neurodynamic tests, potential Sympathetic Nervous System (SNS) disturbances, and elevated post-traumatic stress levels.

Prognosis and Clinical Course of WAD

• General Recovery: Most patients recover within a few weeks.

• Chronicity: Up to $42\%$ develop persistent pain, with $10\%$ experiencing constant pain.

• Factors Predictive of Poor Recovery (Walton 2013):

  • Baseline Pain >5.5/10.

  • Headache at inception.

  • No education beyond high school (HS).

  • No seat belt during MVA.

  • Low back pain (LBP) at inception.

  • High Neck Disability Index (NDI) score (>29\%).

  • Pre-injury neck pain.

  • Neck pain at inception.

  • High levels of catastrophizing.

  • Female sex.

  • WAD classification of II or III.

• Prognostic Clinical Prediction Rule (CPR): Derived (2013) and validated (2015) by Ritchie to identify those likely to recover quickly versus those at risk for ongoing issues.

Joint Position Error (JPE) Testing

• Equipment: Laser mounted on the patient's head; targets available from skillworks.biz.

• Setup: The crown of the head is placed $90\,cm$ from the wall.

• Procedure:

  1. Start with the laser dot on the center of the target.

  2. Patient closes their eyes.

  3. Patient fully rotates their head and then attempts to return to the starting neutral position.

  4. The clinician measures the distance in $cm$ between the final point and the true neutral point.

• Calculation:

  • $\text{Degree of error} = \tan^{-1}\left(\frac{\text{error distance}}{90}\right)$

• Threshold: An error greater than $4.5^\circ$ is considered abnormal.

Treatment Considerations for WAD

• Foundational Principles: Treatment is based on assessment variables (Sterling/QTF). Central sensitization (CS) is a major factor; symptom irritability must be respected.

• Rule of Engagement: Use manual therapy and exercise, but DO NOT PROVOKE PAIN.

• Education: Early Pain Neuroscience Education (PNE) is helpful (Oliveira 2006) for protective purposes and explaining post-trauma pain.

• For Highly Irritable Patients ("Too Hot to Handle"): Consider tactile discrimination training or Graded Motor Imagery (GMI).

• Key Components:

  • Active/relative rest.

  • Cervical AROM within tolerable ranges.

  • Gentle isometrics.

  • Cervical and scapulothoracic muscle activation progressing to control/coordination and endurance exercises.

  • Proprioceptive training.

  • Moderate aerobic exercise and distant manual therapy (thoracic spine).

  • PRN components: Temporary collar use, pacing, and cognitive-affective elements (MI, graded exposure).

Appropriate Treatment Sequence for WAD

• Goal: Relieve pain, encourage movement, and enhance muscle function/proprioception.

• Focus: Identify specific motor impairments via exam. Small gains are positive; patience is required.

• Initial Intervention: Local inhibition of hyperactive superficial musculature. Training of Deep Neck Flexors (DNFs), Deep Neck Extensors (DNEs), and proprioception.

• Initial HEP: Low load, dosed frequently (e.g., DNF/DNE activation, scapular retractions). Avoid fear-instilling instructions.

• Progression: Advance targeted DNE/DNF stability, postural stability, and proprioception. Address contributory impairments with manual therapy (MT) and exercise.

Cervicogenic Headache (CGH): Definition and Anatomy

• Definition: CGH results from musculoskeletal dysfunction of the cervical spine, particularly the upper cervical spine.

• Prevalence: Accounts for $14\% - 18\%$ of all headaches.

• Demographics: Women are affected $4\times$ as much as men.

• Mechanism: Referred pain due to the convergence of afferent input from the nociceptive source region (upper neck) and the referred symptom region (head). Direct irritation of the C2 or C3 nerve roots is also a potential mechanism.

• Involved Nerves:

  • Great auricular ($C2, C3$)

  • Greater occipital ($C2$)

  • Lesser occipital ($C2, C3$)

  • Third occipital ($C3$)

  • Trigeminal nerve ($CN\,V$) convergence.

• Referred Pain Patterns: Stimulation of basal occipital periosteum ($O-C1$) and interspinous muscles from $C1-2$ down to $C5-6$ demonstrates referred patterns to the frontal and orbital regions.

Diagnostic Criteria for CGH

1. Symptoms and signs of neck involvement (at least one must be present):

   • Precipitation of head pain by neck movement, sustained awkward head positioning, or external pressure over the upper cervical/occipital region on the symptomatic side.

   • Restriction of neck ROM.

   • Ipsilateral neck, shoulder, or arm pain.

2. Confirmatory evidence by diagnostic anesthetic blocks: Reduction of headache (required for research, not clinical practice).

3. Unilateral head pain without side shift: Pain remains on one side of the head most of the time.

4. Head pain characteristics: Moderate-severe, non-throbbing, non-lancinating pain usually starting in the neck; episodes of varying duration or fluctuating continuous pain.

Differential Diagnosis of Headache

• Cervicogenic Headache: Female:Male parity is $50:50$ (per table, though earlier text says females $4\times$ more). Location is occipital to frontoparietal/orbital. Frequency is chronic/episodic. Pain is non-throbbing. Triggered by neck movement/posture.

• Migraine: Female:Male ratio $75:25$. $60\%$ unilateral with side shift. Location is frontal/periorbital/temporal. Pain is throbbing/pulsating. Associated with nausea, vomiting, visual changes, phonophobia, and photophobia.

• Tension-type Headache: Female:Male ratio $60:40$. Diffuse bilateral location. Severity is mild/moderate. Pain character is dull. Duration can last days to weeks.

CGH Common Exam Findings

• Decreased cervical ROM.

• OA ($O-C1$), AA ($C1-C2$), or $C2-C3$ dysfunction involving hypomobility or tenderness.

• Muscle inflexibility or Myofascial Trigger Points (MTrPs) in muscles like Splenius capitis, Obliquus capitis superior/inferior, Rectus capitis posterior major/minor, Sternocleidomastoid, and Trapezius.

• Positive Cervical Flexion Rotation (CFR) test for the $C1-C2$ segment.

• Deep neck flexor weakness and poor endurance.

Intervention Strategy for CGH

• Overall Strategy: Find the impairments and treat them. This typically involves moving restricted upper cervical segments, relaxing overactive/painful muscles, and improving postural muscle function.

• Intervention Components:

  • Thoracic manipulation.

  • Manual therapy and exercise targeting upper cervical mobility.

  • Local and regional soft tissue intervention.

  • Exercises to promote DNF function and postural control.

• Appropriate Treatment Sequence:

  • Choose targeted Rx based on anatomy/biomechanics (e.g., $AA$ joint vs. $OA$ joint vs. $C2/C3$).

  • Suboccipital muscle involvement almost always accompanies $AA/OA$ issues.

  • Consider stage and irritability before aggressive mechanical treatment.

  • Match manual therapy with effective HEP, such as $C1-C2$ Self-SNAG or $OA$ flexion with the head against a wall.

  • Progress to muscle endurance, postural training, and proprioception.