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Deteriro Flexores Cervicales (Mt Jull 04)

Deteriro Flexores Cervicales (Mt Jull 04)

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Published by: Jorge Campillay Guzmán on Nov 21, 2009
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05/19/2012

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www.elsevier.com/locate/math
Manual Therapy 9 (2004) 89–94
Original article
Impairment in the cervical flexors: a comparison of whiplash andinsidious onset neck pain patients
G. Jull
a,
*, E. Kristjansson
b
, P. Dall’Alba
a
a
Department of Physiotherapy, The University of Queensland, Queensland 4072, Australia
b
The Faculty of Medicine, The University of Iceland, Reykjav
ık, Iceland 
Received 22 August 2002; received in revised form 20 June 2003; accepted 30 June 2003
Abstract
There has been little investigation into whether or not differences exist in the nature of physical impairment associated with neckpain of whiplash and insidious origin. This study examined the neck flexor synergy during performance of the cranio-cervical flexiontest, a test targeting the action of the deep neck flexors.Seventy-five volunteer subjects participated in this study and were equally divided between Group 1, asymptomatic controlsubjects, Group 2, subjects with insidious onset neck pain and Group 3, subjects with neck pain following a whiplash injury. Thecranio-cervical flexion test was performed in five progressive stages of increasing cranio-cervical flexion range. Subjects’ performancewas guided by feedback from a pressure sensor inserted behind the neck which monitored the slight flattening of the cervical lordosiswhich occurs with the contraction of longus colli. Myoelectric signals (EMG) were detected from the muscles during performance of the test.The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude(normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all
o
0.05) and had significantly greater shortfalls from the pressure targets in the test stages (
o
0.05). No significant differences wereevident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy iscommon to neck pain of both whiplash and insidious origin.
r
2003 Elsevier Ltd. All rights reserved.
Keywords:
Neck flexors; Whiplash; Neck pain
1. Introduction
Neck pain is a common condition causing substantialpersonal and financial costs (C
#
ot
!
eet al., 1998;Holm- strom et al., 1992). Broadly, onset may be insidious ormay follow trauma. Pain is often persistent or recurrentin nature. Neck pain of traumatic origin following amotor vehicle crash (whiplash) often poses a particularchallenge in management. There are several influencesthat may impact on the perception of neck pain anddisability in persons with whiplash associated disorders(WAD) compared to those with an insidious onset of neck pain. These include the magnitude of the injury,psychological responses to injury and pain, socialfactors and litigation (C
#
ot
!
eet al., 2001;Radanov and Sturzenegger, 1996). There has been little investigationinto whether or not differences exist in the nature of physical impairment associated with neck pain of whiplash and insidious origins which may contributeto the greater difficulty often encountered in therehabilitation of patients with WAD.Changes in cervical flexor muscle function have beeninvestigated in neck disorders of both whiplash andinsidious origins.Vernon et al. (1992)in an initialcomparative study of neck isometric strength and flexor/extensor strength ratios, found that subjects with bothWAD and insidious onset neck pain had lesser strengththan asymptomatic subjects. There was a progressiveanterior-to-posterior muscle imbalance in the neck painsubjects, with the cervical flexors becoming relativelyweaker as compared to the extensors. This was moreapparent in subjects with WAD, suggesting that therecould be a difference in the degree of impairmentbetween these subject groups.
ARTICLE IN PRESS
*Corresponding author. Tel.: +61-7-3365-2275; fax: +61-7-3365-2775.
E-mail address:
g.jull@shrs.uq.edu.au (G. Jull).1356-689X/$-see front matter
r
2003 Elsevier Ltd. All rights reserved.doi:10.1016/S1356-689X(03)00086-9
 
Cervical flexor muscle function has also been exam-ined using the cranio-cervical flexion test (C-CFT) (Jull,2000). The cranio-cervical movement aims to assess theanatomical action of longus capitis in synergy withlongus colli, rather than that of the superficial flexors,sternocleidomastoid (SCM) and anterior scalene mus-cles, which flex the neck but not the head. The longuscolli muscle has a unique role in the support of thecervical segments and curve (Mayoux-Benhamou et al.,1994). In the C-CFT, the subject performs five incre-ments of increasingly inner range cranio-cervical flexionin a supine lying position (Falla et al., 2003a;Jull, 2000). Patients are guided to the test level by feedback from apressure unit (Stabilizer, Chattanooga, USA) which isplaced behind the neck to monitor the progressiveflattening of the cervical lordosis which results from thecontraction of longus colli (Mayoux-Benhamou et al.,1994, 1997). Performance in the test has been examinedin subjects with WAD (Jull, 2000) and cervicogenicheadache (Jull et al., 1999). The results of these studiesindicated that patients were less able to achieve and holdthe progressive positions of the test as compared to therespective control subjects. These results inferreddysfunction in the deep neck flexors, as no directmeasure of these muscles could be made. In the studyof subjects with WAD (Jull, 2000) and in a study of patients with chronic neck pain (Sterling et al., 2001),amplitudes of muscle signals (electromyography, EMG)were measured in the sternocleidomastoid (SCM) duringthe test, followingCholewicki et al.’s (1997)hypothesisthat increased activity of the superficial muscles could bea measurable compensation for poor segmental stability,or in this case of the C-CFT, poorer activation of thelongus colli. It was shown that both neck pain patientgroups had higher amplitudes of muscle signals in theSCM.There has not been a direct comparison of perfor-mance in the C-CFT between patients with neck painfrom whiplash and insidious origin. This study wasundertaken to make this comparison. A clinicallyapplicable version of the C-CFT was used.
2. Methods
 2.1. Subjects
Seventy-five volunteer subjects between the ages of 18–66 years were enrolled in the study. They comprisedthree groups, each of 25 subjects. Control subjects(Group 1) and insidious onset neck pain subjects(Group 2) were volunteers from the general anduniversity communities who responded to advertising.The control subjects were eligible for the study providedthey had no current or past history of musculoskeletalpain or injury in the neck or upper limb. Insidious onsetneck pain subjects were eligible provided that theircondition had not been caused by trauma from a motorvehicle crash. Subjects with WAD (Group 3) were thoseattending for assessment at a Whiplash Research Unit.Subjects for Groups 2 and 3 were not considered if theyhad a history of neck surgery, previous diseases affectingthe neck or throat, and rheumatic or neurologicaldisorders. Ethical clearance for the study was obtainedfrom the Medical Ethics Committee, The University of Queensland, and all subjects gave informed consent toparticipate in the study.
 2.2. Instrumentation and measurements
For Groups 2 and 3, data were collected regarding thelength of history of neck pain and subjects rated theiraverage pain intensity on a visual analogue scale (VAS),anchored with ‘no pain’ and ‘the worst pain imaginable’.
 2.2.1. Cranio-cervical flexion test
The subjects were positioned in a supine lyingposition. The pressure sensor was inserted between thetesting surface and the back of the neck and waspreinflated to a baseline of 20mmHg (Fig. 1). Subjectswere asked to perform progressive repetitions of cranio-cervical flexion to increase the pressure by 2mmHgincremental targets from 22mmHg to a maximum of 30mmHg. Each target pressure was held for 5s with a10s rest between each task. The pressure sensor wasconnected to a pressure transducer (RS components)and electrical signals from the pressure transducer wereamplified and relayed to a visual feedback device and toan Amlab data acquisition system (Associated Measure-ments Pty Ltd, Australia). The visual feedback deviceconsisted of an electronic voltmeter, marked in 2mmHgincrements from 20 to 30mmHg, and calibrated to
ARTICLE IN PRESS
Fig. 1. The cranio-cervical flexion test demonstrating the visualfeedback with the pressure sensor and measurement with surfaceEMG.
G. Jull et al. / Manual Therapy 9 (2004) 89–94
90
 
display the pressure in the pressure bag, based on thepressure transducer output. Sampling frequency forpressure measures was 1000Hz. The mean pressure thateach subject achieved over the 5s holding time of thefive test levels was calculated to determine whethersubjects had reached each prescribed level of the test.The differences between the mean pressure achieved andthe nominated target pressure for each stage werecalculated for each group.Myoelectric signals were collected from the SCMmuscles using Ag–AgCl electrodes (Conmed, USA) in abipolar configuration. Electrodes were positioned alongthe lower one-third of the muscle bellies of the SCM(Falla et al., 2002). Signals were amplified (Amlab), andpassed through a 20–500Hz bandwidth filter. They weresampled at 1000Hz. EMG data (amplitude of the signal)were analysed off-line (Matlab). The maximum rootmean squared (RMS) value was identified for each traceusing a 1s sliding window, incremented in 100ms steps.RMS values were normalized for each subject, bydividing the 1s maximum RMS from each level of thecranio-cervical flexion test by the 1s maximum RMSduring a standardized head lift. The normalized RMSdata for the left and right SCMs were averaged foranalysis.
 2.3. Procedure
Subjects received written and verbal informationabout test procedures and informed consent wasobtained. Demographic details were obtained from allsubjects and the neck pain subjects rated their pain onthe VAS.Subjects were positioned in supine lying with the headand neck in a mid position such that the face line washorizontal and an imaginary horizontal line bisected theneck longitudinally. If necessary, layers of towel wereplaced under the head to gain the position. Subjectswere fully familiarized with the C-CFT by the researcherwho was skilled in the clinical test procedure. Theyparticipated in a practice session with the pressurebiofeedback during which time the researcher correctedperformance.EMG electrodes were applied over the lower one-third of the SCM following skin preparation involvingmild abrasion with fine sandpaper and cleaning with anisopropyl alcohol swab. The subject was first required toperform a head lift by tucking their chin in and liftingthe head to just clear the bed. A 10s recording was madefor later normalization procedures. The pressure bagwas placed behind the subject’s cervical spine andinflated until a stable pressure of 20mmHg wasachieved. The researcher instructed the subject toperform the C-CFT to target 22mmHg and hold theposition steady. A research assistant operated thecomputer system. A 10s recording was made for eachstage to capture the 5s holding time. Subjects thenrested for 10s. With a similar procedure, the subjectsequentially targeted the other four levels of the test tothe maximum of 30mmHg.
 2.4. Statistical analysis
The analysis of the SCM RMS values required a logtransformation to remove the skewness in the originalmeasure. A saturated design model was fitted initiallyand non-significant terms were removed. A mixed modelANOVA was used to investigate within and betweengroup differences in the normalized RMS values for theSCM muscles for the factors of age, gender and stagesof the C-CFT. Boxplots of the pressure data indica-ted possible differences in the means for the shortfallin pressures from the designated pressure levels of theC-CFT across groups and pressure levels. Variancesbetween measurements within groups indicated thatmodels needed to include terms for this heteroscedacity.The linear effects model used to model target pressureerror included specific variance functions modellingvariance as a power of the pressure level covariate.
3. Results
The demographic details for each subject group aswell as the length of history and VAS scores for the neckpain groups are presented inTable 1. The only obviousdifference between the groups was the length of historyof the insidious onset neck pain group compared to thewhiplash group. The results of primary analyses forSCM normalized RMS values revealed significantdifferences between groups
ð
¼
0
:
001
Þ
and stages of the test
ð
¼
0
:
001
Þ
:
There were no significant effects forgender
ð
¼
0
:
51
Þ
or age
ð
¼
0
:
62
Þ
:
The analysisrevealed a strong positive linear relationship betweenSCM normalized RMS values and stage of the C-CFT,but the relationship levelled off for the whiplash groupat the highest pressure target (Fig. 2). Both the neck painand whiplash groups had significantly higher SCMnormalized RMS values than the control group at eachstage of the C-CFT (all
o
0
:
05). However there wereno significant differences in SCM normalized RMS
ARTICLE IN PRESS
Table 1Characteristics of the subject groupsControls
ð
n
¼
25
Þ
Neck pain
ð
n
¼
25
Þ
Whiplash
ð
n
¼
25
Þ
Gender (females %) 60 80 68Age (years, mean
7
SD) 39.3
7
14.0 40.3
7
9.2 36.3
7
10.2Length of history (years) 8.5
7
6.0 1.8
7
1.1Average pain (VAS 010) 6.3
7
1.5 6.2
7
2.3
G. Jull et al. / Manual Therapy 9 (2004) 89–94
91

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