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VERTIGO AND DIZZINESS

IN WHIPLASH INJURIES

Royal Belgian E.N.T. Society


Novembre 2007
Professeur Raymond BONIVER
O.R.L.

Professeur invité
à l’Université de LIEGE
Clinical spectrum of whiplash-associated disorders as
proposed by the Quebec Task Force (1995)
Grade Presumed pathology Clinical presentation
I Microscopic or multimicroscopic Usually presents to a doctor
lesion more than 24 h after trauma
Lesion is not serious enough to
cause muscle spasm
II Neck sprain and bleeding around soft Usually presents to a doctor in
tissue (articular capsules, ligaments, the first 24 h after trauma
tendons, and muscles) Nonspecific radiation to the
Muscle spasm secondary to soft head, face, occipital region,
issue injury shoulder, and arm from soft
tissues injuries
Neck pain with limited range of
motion due to muscle spasm
III Injuries to neurologic system by Presents to a doctor usually
mechanical injury or by irritation within hours after the trauma
secondary to bleeding or Limited range of motion
inflammation combined with neurologic
symtoms and signs
Clinical classification on whiplash-associated disorders
proposed by the Quebec Task Force (1995)
Grade Clinical presentationa
0 No complaints about the neck
No physical sign(s)
I Neck complaint of pain, stiffness, or tenderness

No physical sign(s)
II Neck complaint and
Musculoskeletal sign(s): decreased range of motion and point
tenderness
III Neck complaint and
Neurological sign(s): decreased or absent deep tendon
reflexes, weakness, and sensory deficits
IV Neck complaint and
Fracture or dislocation
a
Symptoms and disorders that can be manifest in all grades include deafness, dizziness, tinnitus, headache, memory
loss, dysphagia, and temporomandibular joint pain. Grades I-II are the limits of terms of reference of the Quebec Task
Force on Whiplash-Associated Disorders
Aetiology
Lesions of Soft Tissues of the Neck
Lesions of peripheral nerves

⇒ Dizziness
Aetiology
Vestibular lesions
– Benign Positional Vertigo
– Otolithic vertigo without cupulolithiasis
– Labyrinthin Concussion
– Perilymphatic fistula
– Hydrops endolymphatic delayed
⇒ Vertigo
Aetiology
Central Nervous System Lesions
– Vascular problems
± Wallenberg syndrom
– Dissection of vertebral arteries
– Trauma
– Chiropracty
– Contusion of vestibular nuclei or
vestibular central pathways
– Phobic secondary postural syndrom
⇒ Vertigo
Phobi c vert igo
The syndrome of phobic postural vertigo, described by
Brandt in 1991, is characterised by combination of
situationally triggered panick attacks including vertigo and
subjective postural and gait instability and the fear of
imminent death. Patients complain of vertigo rather than
anxiety and feel physically ill. This syndrome should be
explained by the hypohesis that an impairment of the
space constancy mechanism leads to partial uncoupling of
the efferent copy for active head movements. This triggers
phobic attacks. Allowing to Brandt it represents the third
cause of vertigo in a specialised consultation. Clinical
experience does point the existence of persons with
positional vertigo who are conditioned to be dizzy, with or
without objective signs of vertigo. At present, this syndrom
is of uncertain validity or significance as it lacks a specific
test for diagnosis.
- benign paroxysmal positioning vertigo
- immediate
- late onset : days to several weeks
- slow degeneration of the otolith
organ after labyrinth
concussion
- settling of dislodged otoconia in
the utricular cavity before
entering the semicircular canal
- time needed for several pieces
of otoconia to form a cloth
(canalolith) to become causative.
Gacek Hypot hesi s
The pathophysiological mechanism responsible for a
position-induced vestibulo-ocular response in this
disorder is neural, rather than mechanical stimulation
of the sense organ. Loss of the inhibitory action of
otolith organs on canal activation caused by
degeneration of otolith neurons (saccular, utricular) is
a possible explanation of the brief canal response
induced by the positional stimulus.
TREATMENT
1. Dizziness from soft tissues lesions or
peripheral nerves:
We refer to the chapter
« Whiplash Inury : Orthopaedic and
Rehabilitative Approach to Neck Pathology »
P. Sibilla, S. Negrini, S. Atanas
In Whiplash Injury. Diagnosis and Treatment.
Springer Verlag.
Summary of Sibilla and al. classification

Degree Lesion Treatment


1st Simple strain Soft collar, 20 days
2nd Strain Soft collar with a good containment,
20 days
3rd Serious strain Hard collar, 25/30 days
4th Compromising of Minerva in Articast, 30/40 days
mechanical stability
5th Articular dislocation Surgery
and or bony fractures
REHABILITATIVE
TOOLS
Physical Exercises
- Pain Relief - Proprioception
- Decontraction - Posture
- Streng thening - Activity of Daily Life
- Mobilisation -Thoracic and Lumbar Spine
- Normalisation - Active participation of the
Patient
Physical Therapy
- Magnetotherapy 20 x 20 min à 60 Gauss 5x/week
- Laser therapy on trigger points
- Heat : never if there is vertigo or dizziness, never ultrasound
- Electrotherapy : no
- Cold : no
Mechanical Therapy
!!! Excessive mobilisation

- Manipulation : no
- Massage : to reduce muscular contraction
- Traction : danger to damage soft tissues
- Acupuncture : on some cases.
TREATMENT
2. VERTIGO
Beni gn paro xysm al verti go

- Posterior (Hallpike manoeuver)


-Semont
- V.H.T.
- Horizontal
- Lempert
- Vanucchi
- V.H.T.
Lempert’s Manœuvers
MANOEUVERS OF THE VHT-TESTBATTERY
SEQUENCE DIRECTION DESCRIPTION
OF
MANOEUVER

change of position
from to

M1 middle sitting supine


M2 left supine left side
M3 right left side right side
M4 middle supine sitting

standing

M5 * turning to the right


M6 * turning to the left

sitting, change of position


from to

M7 right nose closed to Le knee Ri ear closed to


Ri shoulder
M8 left nose closed to Ri knee Le ear closed to
Le shoulder

sitting, movements

M9 * turning head CCW **


M10 * turning head CW ***
M11 * bending forward
M12 * from sitting to erect standing position
M13 * moving head forwards/backwards

change of position
from to

M14 left sitting to head hanging and


turned to the left
M15 left return to sitting position
M16 right sitting to head hanging and
turned to the right
M17 right return to sitting position
M18 middle sitting to head hanging in
midline
M19 middle return to sitting position
________________________________________________________________________________
* Manoeuvers where nystagmus never occurred.
** Counter-clockwise
*** Clock
Otol ithi c Pos ttraumati c
Ver ti go

V.H.T.
Labyrinthin Concussion

V.H.T.
Peri lymphati c fistul a

- Rest
- In case of failure : surgery
Hydrops

- Medical treatment
Central Vertigo

- Drugs : - Vincamine
- Piracetam
- Ginkgo biloba

- Rehabilitation by exercises
Phobi c postur al syndrome

- Psychological approach
- Posture exercises
- Physiotherapy
OUR EXPERIENCE

150 cases of whiplash with cervical


syndrome and dizziness
- 16 cases with central vestibular
dysfunction
-100 cases with postural abnormalities
(15 with TM problems)
- 30 cases with B.P.P.V.
- 4 cases of labyrinthine concussion