Whiplash-associated Disorders Research Articles

Pragmatic cluster randomised double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute non-specific neck pain: a mixed-methods protocol

IntroductionNon-specific neck pain causes pain and disability and contributes substantial socioeconomic burden internationally. Up to 50% of adults experience neck pain annually, leading to reduced the quality of life. An...

Prevalence of functional somatic syndromes and bodily distress syndrome in the Danish population: the DanFunD study.

Aims: Little is known about the prevalence and characteristics of functional somatic syndromes (FSS) such as irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), whiplash associated disorders (WAD), multiple chemical sensitivity (MCS), and bodily distress syndrome (BDS) in the general population when they are investigated simultaneously. Method: This cross-sectional study is based on the Danish Study of Functional Disorders (DanFunD) cohort consisting of 9656 adults from the general population. FSS and BDS were identified by questionnaires and characterized by age, sex, vocational training, physical health and comorbidity with physical and psychiatric disease. Results: In total, 16.3% (95% CI: 15.6-17.1) of the participants fulfilled the criteria for at least one FSS, ranging from 1.7% for WAD to 8.6% for CFS, and 16.1% (95% CI: 15.4-16.9) fulfilled the criteria for BDS. Cases had a high risk of poor self-perceived health, limitations in daily activities, and a high psychiatric comorbidity, all increasing with the number of syndromes in each individual. However, the associations differed across the various FSS. Mutual overlaps of IBS, FM and CFS were greater than could be expected by chance. Conclusions: FSS and BDS are prevalent in the adult Danish population, and cases have high risk of poor self-perceived health, limitation in daily activities, and psychiatric comorbidity. These associations were particularly strong for cases with multiple FSS and multi-organ BDS.

Clinical assessment of cervical movement sense in those with neck pain compared to asymptomatic individuals

BackgroundA simple clinical test involving subject tracing zigzag (ZZ) and figure of eight (F8) patterns with a head mounted laser device in determining cervical movement sense has proven reliability and feasibility. However, its validity in comparing individuals with and without neck pain (NP) has not been examined. MethodsSeventy-six subjects (38 NP and 38 asymptomatic subjects) performed both patterns while motion of their laser point was videoed. Independent examiners subsequently rated the videos (real-time) to record the time needed and the number of errors when completing each task. Sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-) for various cut-offs to optimise clinical interpretation were determined. Comparisons between 25 subjects with idiopathic neck pain versus 13 with whiplash-associated disorders were also undertaken. ResultsAll outcome variables except ZZ time were significantly different between individuals with NP and controls. Optimal cut-offs of 9 and 10 errors yielded LR+/LR- of 3.67/0.17 (F8) and 3.00/0.38 (ZZ). Whiplash patients performed the ZZ task faster with similar errors to those with idiopathic neck pain. ConclusionThe clinical utility of this inexpensive measure to assess cervical movement sense in people with NP is supported. Moderate LRs+ were demonstrated for number of errors for both patterns. Individuals with NP generated significantly more errors while tracing each pattern. Optimal cut offs of 9 errors for ZZ and 10 errors for F8 were established. Overall, these tests appear to be clinically suitable to determine altered cervical movement sense in those with NP.

Associations between brain morphology and motor performance in chronic neck pain: A whole-brain surface-based morphometry approach.

Changes in brain morphology are hypothesized to be an underlying process that drive the widespread pain and motor impairment in patients with chronic neck pain. However, no earlier research assessed whole-brain cortical morphology in these patients. This case-control study assesses group-differences in whole-brain morphology between female healthy controls (HC; n = 34), and female patients with chronic idiopathic neck pain (CINP; n = 37) and whiplash-associated disorders (CWAD; n = 39). Additionally, the associations between whole-brain morphology and motor performance including balance, strength, and neuromuscular control were assessed. Cortical volume, thickness, and surface area were derived from high resolution T1-weighted images. T2*-weighted images were obtained to exclude traumatic brain injury. Vertex-wise general-linear-model-analysis revealed cortical thickening in the left precuneus and increased volume in the left superior parietal gyrus of patients with CINP compared to HC, and cortical thickening of the left superior parietal gyrus compared to HC and CWAD. Patients with CWAD showed a smaller cortical volume in the right precentral and superior temporal gyrus compared to HC. ANCOVA-analysis revealed worse neuromuscular control in CWAD compared to HC and CINP, and in CINP compared to HC. Patients with CWAD showed decreased levels of strength and sway area compared to CINP and HC. Partial correlation analysis revealed significant associations between the volume of the precentral gyrus, and neuromuscular control and strength together with an association between the volume of the superior temporal gyrus and strength. Our results emphasize the role of altered gray matter alterations in women with chronic neck pain, and its association with pain and motor impairment.

Predictors for Psychological Distress 2 Months After Mild Traumatic Brain Injury.

Objective: To predict psychological distress at 2 months for patients with mild traumatic brain injury.Method: A prospective cohort study of 162 patients with mild traumatic brain injury (MTBI) admitted consecutively to an outpatient clinic at Haukeland University Hospital, Norway. Demographic data were obtained from Statistics Norway and injury characteristics were obtained from the hospital records. Sick leave data from the last year before the injury were obtained from The Norwegian Labor and Welfare Service. Self-report questionnaires were used to obtain history about earlier disease and symptom profiles. The Hospital Anxiety and Depression Scale (HAD) detecting states of depression and anxiety were used as the dependent variable in a stepwise linear regression. Pre-injury factors and injury-related factors were examined as potential predictors for HAD.Results: In the first steps we observed a significant association between HAD at 2 months and education, whiplash associated disorder (WAD), and earlier sick listed with a psychiatric diagnosis. In the final step there was an association only between HAD and self-reported anxiety and WAD. There were no associations between HAD and injury-characteristics like severity at Glasgow Coma Scale or intracranial injury.Conclusion: Patients with low education, earlier psychiatric diagnosis, self-reported earlier anxiety and WAD were more likely to develop a psychological distress after a MTBI. These findings should be taken into consideration when treating patients with MTBI.

The role of non-rigid cervical collar in pain relief and functional restoration after whiplash injury: a systematic review and a pooled analysis of randomized controlled trials.

Whiplash injury (WI) represents a common diagnosis at every emergency department. Several investigations have been conducted to compare the different medical managements for non-surgical cases. However, the role of the immobilization with a non-rigid cervical collar (nRCC) for pain management and range of motion (RoM) preservation has not been completely clarified. We performed a systematic review of the randomized control trials (RCTs) and a pooled analysis in order to investigate the role of the nRCC for pain management, scored through the visual analogue scale (VAS) and the RoM, by comparing the use of a nRCC (for 1-2weeks) with a non-immobilization protocols, regardless of the association with physical therapy (PhT). Only patients with whiplash-associated disorders grade I-II were included. Due to a certain heterogeneity across the RCTs, follow-up period time range resetting was necessary in order to pool the data. A total of 141 papers were reviewed; 6 of them matched the inclusion criteria and were admitted to the final study. Pooled analysis showed that nRCC does not improve the outcome in terms of VAS score and RoM trends along the follow-up. Moreover, VAS and RoM trends seem to further improve at long-term follow-up in non-immobilization associated with PhT group. This pooled analysis of the available RCTs shows the absence of an advantage of the immobilization protocol with a nRCC after a WI. On the contrary, non-immobilization protocols show an overall better trend of pain relief and neck mobility recovery, regardless of the association of PhT. These slides can be retrieved under Electronic Supplementary Material.

Cervical Rotator Muscle Activity With Eye Movement at Different Speeds is Distorted in Whiplash.

People with whiplash-associated disorders (WADs) report difficulty with quick head movements and cervicoocular dysfunction. Changes in coordination between eye movement and neck muscle activity may be involved. To examine whether activity of superficial and deep neck muscles increases with eye movement when the head is held in a fixed position, whether this differs between directions and speed of eye movement, and whether this is modified in WAD. Convenience case series with unmatched controls. Research laboratory. Nine individuals with chronic WAD grade II and 11 pain-free controls. Electromyography (EMG) was recorded from muscles that could act to rotate the neck to the right (right obliquus capitis inferior [OI], multifidus [MF], splenius capitis [SC], and left sternocleidomastoid [SCM]) with intramuscular or surface electrodes in 9 WAD participants and 11 pain-free controls. Eyes were rotated without head movement to track slow and medium-speed targets to the right or left, and as fast as possible (FP). Amplitude of EMG. In controls, SCM and SC EMG increased with right gaze (all P's < .03). EMG of the deep OI muscle increased in both directions (P < .001). WAD involved counterintuitive greater activity of SCM with left rotation across speeds of eye movement (SC with slow movement, P < .036), decreased OI EMG with gaze left (P < .019), and no change in MF EMG (P < .6) in either gaze direction. For FP tasks, EMG of all muscles was greater than slower speeds in controls (all P's < .0001), but not WAD (all P's > .33). Coordination between neck muscle activity and eye movements with increasing speed is modified in WAD. Contrasting changes are present in deep and superficial neck muscles with implications for neck function that may explain some common WAD symptoms. IV.

Effect of intensive inpatient physical therapy on whole-body indefinite symptoms in patients with whiplash-associated disorders

BackgroundA considerable number of patients with whiplash-associated disorders (WAD) report variable and indefinite symptoms involving the whole body, despite there being no evidence of direct injuries to organs other than the neck. However, little is known about their management or underlying mechanism. This study examined the effect of intensive physical therapy at the cervical muscles in patients with WAD reporting whole-body indefinite symptoms.MethodsA total of 194 hospitalized patients with WAD who were resistant to outpatient care by reporting whole-body indefinite symptoms between May 2006 and May 2017 were enrolled in this observational study. All patients underwent daily physical therapies by low-frequency electric stimulation therapy and far-infrared irradiation to the cervical muscles during hospitalization. Self-rated records in the medical interview sheets on 22 representative whole-body symptoms at admission and discharge were compared.ResultsThe number of symptoms was markedly decreased by the physical therapies during hospitalization. Almost all symptoms showed recovery rates of more than 80% at discharge as compared to those at admission. Although the percentage of patients reporting at least four of the 22 representative indefinite symptoms was 99.0% at admission, it decreased to 7.7% at discharge. Sixteen percent of patients recovered completely without any residual symptoms. The mean number of symptoms significantly decreased from 13.1 at admission to 2.0 at discharge. Notably, symptoms other than those in the neck or shoulder recovered to a greater extent than those in the neck or shoulder.ConclusionsThis study, for the first time, examined the management of whole-body indefinite symptoms in patients with WAD. The intensive physical therapy markedly improved the symptoms, suggesting the involvement of cervical muscles in the pathogenesis.Trial registrationUMIN000035435 (Retrospectively registered on Jan 3, 2019).

An analysis of whiplash injury outcomes in an Irish population: a retrospective fifteen-year study of a spine surgeon's experience.

Whiplash injuries result from an acceleration-deceleration injury of the cervical spine. The associated symptoms may include neck pain/stiffness; cervicogenic headaches; interscapular pain; upper limb pain, paraesthesia and weakness. Current treatment protocols recommend conservative management of low-grade whiplash. To assess changing practices over time in the management of whiplash-associated disorders in the practice of a specialist spine surgeon and to explore the impact of associated litigation on this patient cohort. The private medical records of a specialist spine surgeon over a 15-year period (1996-2011) were reviewed. Three hundred one consecutive patients were identified: 169 females and 132 males with a mean age of 37years ± 13. All were referred by primary care with potential soft tissue injury of the cervical spine following a road traffic accident. Fifty-eight percent had associated back pain. An initial conservative approach was adopted in all cases. Subsequently, 4 patients underwent surgical intervention. Ninety-three percent reported chronic neck pain > 6months after their injury. Age was the only significant predictor of chronic neck pain (adjusted OR 1.29 for every 5-year increase, p = 0.03). All were ultimately involved in litigation. The establishment of the Personal Injuries Board did not influence the litigation duration during the study period. Whiplash poses a significant societal economic burden in Ireland and was associated with prolonged symptoms including neck pain and upper limb neuropathic symptoms in this cohort. Associated low-back pain was common. Litigation was linked with presentation in all cases.

Factors influencing outcomes among patients with whiplash-associated disorder: A population-based study in Japan.

IntroductionOnly a few, large population-based studies, have reported on whiplash-associated disorder (WAD). However, none of them have investigated the influence of crash severity on WAD outcome. In the present study, we aimed to determine whether crash severity predicts outcomes among patients with no-fault government insurance for acute WAD.MethodsWe utilized data from a compulsory, no-fault government automobile liability insurance agency in Japan. Individuals involved in a car accident between April 2001 and June 2015 with residual disabilities reported at the end of the treatment between October 2014 and September 2015 were included. Crash severity was assessed based on property damage costs, size of the other vehicle (large car, medium car, small car, or two-wheeled vehicles), and collision types (rear-end collision, contact with vehicle moving in the same direction, or in the opposite direction). Outcomes included the time to claim closure and the number of treatment visits.ResultsWe analyzed data for a total of 52,251 individuals (28,571 male and 23,680 female) with a median age of 44 years (range: 2–95 years). The median time to claim closure was 220 days (range: 1–4,938 days), and the median number of treatment visits was 102 (range: 1–2,492). There was no significant association between outcomes and property damage costs or size of the other vehicle. Collision types exhibited no consistent association with outcomes. However, older age and affected body parts, in addition to the neck, were independent risk factors for delayed claim closure and a large number of visits, although, all odds ratios were low (often less than 2.0).ConclusionsThere was no obvious association of outcomes with property damage costs, size of the other vehicle, or collision types in acute WAD patients. Further studies should investigate the influence of psychological factors, compensation systems, and cultural conditions.

A cluster randomised, double-blind pilot and feasibility trial of an active behavioural physiotherapy intervention for acute whiplash-associated disorder (WAD)II

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII (neck complaint and musculoskeletal sign(s)). Effective management in the acute stage is required to prevent development of chronicity; an issue for 60% of patients. An Active Behavioural Physiotherapy Intervention (ABPI) was developed to address both physical and psychological components of WAD. The ABPI is a novel complex intervention designed through a rigorous sequential multiphase project to prevent transition of acute WAD to chronicity. An external pilot and feasibility cluster randomised double-blind (assessor, participants) parallel two-arm clinical trial was conducted in the UK private sector. The trial compared ABPI versus standard physiotherapy to evaluate trial procedures and feasibility of the ABPI for managing acute WADII in preparation for a future definitive trial. Six private physiotherapy clinics were recruited and cluster randomised using a computer-generated randomisation sequence. Twenty-eight (20 ABPI, 8 standard physiotherapy) participants [median age 38.00 (IQR = 21.50) years] were recruited. Data were analysed descriptively with a priori establishment of success criteria. Ninety-five percent of participants in the ABPI arm fully recovered (Neck Disability Index ≤4, compared to 17% in the standard physiotherapy arm); required fewer treatment sessions; and demonstrated greater improvement in all outcome measures (pain intensity, Cervical Range of Motion, Pressure Pain Threshold, EuroQol-5 Dimensions) except for the Impact of Events Scale and Fear Avoidance Beliefs Questionnaire. The findings support the potential value of the ABPI, and that an adequately powered definitive trial to evaluate effectiveness (clinical, cost) is feasible with minor modifications to procedures.

Importance of intervertebral displacement for whiplash investigations

It is often reported that the physiological rotational limits of adjacent vertebrae in the cervical spine are exceeded in rear-end accidents which play a significant role in Whiplash Associated Disorders (WAD). This paper presents the first analysis of existing experimental and computational intervertebral displacement research. Existing techniques to capture intervertebral displacement in experimental studies can be grouped into three methods: visual targets method, electronic sensors method and X-Ray method. The analysis of intervertebral displacements has led to the development of the intervertebral neck injury criterion (IV-NIC); it has also shown an upward shift of the C5C6 instantaneous axis of rotation and that the flexion changes to extension point between C2 and C4. Furthermore, it is also shown that when a computational model is validated only for the head kinematics, it should not be assumed that the model provides good neck kinematics. Lastly, current rear-impact dummies are incapable of providing true neck kinematics.

Spanish Version of the Whiplash Disability Questionnaire in Adults With Acute Whiplash-Associated Disorders

ObjectiveThe purpose of this study was to develop and validate a Spanish version of the Whiplash Disability Questionnaire (WDQ) for the Spanish population with acute whiplash-associated disorder (WAD). MethodsThis was a cross-sectional questionnaire validation study. Adults with acute WAD (grade I to III) were enrolled within 3 weeks of their injury. A blinded forward and back translation of the WDQ was made from English to Spanish, and the resulting back-translation version was compared with the original. Patients with WAD completed the Spanish version of the 13-item WDQ. The developed questionnaire was assessed using psychometric statistical analysis including correlation with the numerical rating score for pain, Northwick Park Neck Pain Questionnaire, Neck Disability Index, and 36-item Short Form Health Survey. ResultsFifty-six patients completed the questionnaire, the mean age was 33.9 years (standard deviation [SD] = 10.5), and 76.8% were women. Participants were enrolled 13.9 days (SD 4.9) after the injury, with 14.3% presenting with WAD grade I and 85.7% with WAD grade II. The mean WDQ score was 62 (SD = 31). Two factors were detected, and the factor structure remained stable after translation. Positive correlations were identified between the total WDQ score and the numerical rating score, Neck Pain Questionnaire, and Neck Disability Index results, with a strong negative correlation with the 36-item Short Form Health Survey. ConclusionThe Spanish version of WDQ is psychometrically reliable and a valid instrument to measure the disability status in patients with acute WAD within the clinic.

How are pain and traumatic stress symptoms related in acute whiplash-associated disorders? An investigation of the role of pain-related fear in a daily diary study.

Comorbidity of pain and posttraumatic stress disorder is well recognized, but the reason for this association is unclear. This study investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Participants (n = 99) used an electronic diary to record hourly ratings of pain, traumatic stress, and fear of pain (FOP) symptoms over a day. Relationships between pain, traumatic stress, and pain-related fear symptoms were investigated through multilevel models including variables lagged by 1 hour. Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain; current pain was not associated with previous traumatic stress. The relationship between traumatic stress and previous pain became negligible after controlling for FOP, except for traumatic stress symptoms of hyperarousal that were driven directly by pain. Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms. They also confirm that traumatic stress symptoms of hyperarousal are central in this relationship. Differences between this study and others that reported mutual maintenance can be understood in terms of different stages of whiplash-associated disorder and different intervals between repeated measurements. Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and FOP change over time, and whether previous experiences of traumatic stress influence these relationships.

Precollision Medical Diagnoses Predict Chronic Neck Pain Following Acute Whiplash Trauma.

The reason why some individuals develop chronic symptoms, whiplash-associated disorder, following whiplash trauma is poorly understood. We explored whether precollision pain-related diagnoses, medically unexplained symptoms, and psychiatric diagnoses are related to whiplash-associated disorder. A cohort of 719 individuals exposed to whiplash trauma and subsequently experiencing symptoms within 72 hours (whiplash-exposed cohort) and 3595 matched controls were included in this observational prospective study. At 12 months postcollision, the whiplash-exposed cohort rated their neck pain using the Visual Analog Scale. Data on health were obtained from the Danish National Patient Register for the whiplash-exposed cohort and for the controls for a 5-year period before collision. The whiplash-exposed cohort had significantly increased incidences of precollision pain-related diagnoses: χ(1)=17.42, P<0.001 and medically unexplained symptoms: χ(1)=22.2, P<0.001 but not psychiatric diagnoses: χ(1)=3.60, P>0.05 compared with controls in the 5-year period. Participants from the whiplash-exposed cohort with precollision pain-related diagnoses (odds ratio=2.46; 95% confidence interval, 1.39; 4.35) and medically unexplained symptoms (odds ratio, 1.72; 95% confidence interval, 1.04; 2.84) had significantly increased odds for neck pain at follow-up. Precollision pain and medically unexplained symptoms predict chronic neck pain following whiplash trauma. This may indicate that a sensitization process was initiated before the collision or that individuals with precollision low threshold for contacting health care services maintain this behavior postcollision. The collision may trigger existing individual vulnerabilities that constitute to be a risk factor for chronic whiplash.

Psychological Manifestations and Chronic Pain in Whiplash-Associated Disorder Mechanisms: The Whole Pie, Please.

In the last decade, as the biopsychosocial model of patient health care has expanded, there has been an increased focus on the influence of psychological manifestations on patient symptoms and health-related outcomes. This Viewpoint explores the scientific underpinnings of psychological manifestations in chronic whiplash-associated disorders (WADs)-where opinions vary widely concerning the reason for persistent symptoms and nonrecovery. It also provides an epidemiological and scientific foundation for the management of chronic WAD, incorporating the spectrum of the biopsychosocial model. J Orthop Sports Phys Ther 2019;49(3):118-121. doi:10.2519/jospt.2019.0603.

Pathophysiology behind prolonged whiplash associated disorders: study protocol for an experimental study

BackgroundThere is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls.MethodsParticipants are a sub-group (n = 30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the “butterfly test” and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n = 30).DiscussionThe study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD.Trial registrationClinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention

ObjectiveThere are few effective treatments for acute whiplash-associated disorders (WAD). Early symptoms of postinjury stress predict poor recovery. This randomised controlled trial (StressModex) investigated whether physiotherapist-led stress inoculation training integrated...

Can a Chronic BPPV With a History of Trauma be the Trigger of Symptoms in Vestibular Migraine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Whiplash Associated Disorders (WAD)? A Retrospective Cohort Study.

In patients with chronic benign paroxysmal positional vertigo (BPPV), i.e., chronic vestibular multicanalicular canalithiasis (CVMCC), abnormal signals are transmitted from diseased labyrinths via the healthy vestibular nuclei complex to their end organs. The vestibulo-thalamo-cortical reflex as proposed in vestibular migraine is just one of these reflexes. In a group of patients diagnosed with CVMCC otolith repositioning maneuvers specific for each semicircular canal (SCC) ameliorated pain and other symptoms in 90%. Increased awareness of CVMCC may reduce suffering and continuous medication. To evaluate if CVMCC can be the trigger of symptoms in vestibular migraine, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and whiplash associated disorders (WAD). Retrospective consecutive observational cohort study. Ambulatory at a private Otoneurology Centre. One hundred sixty-three patients with CVMCC and a history of trauma. Based on the symptoms (structured symptom questionnaire), the patients are post hoc sub grouped according to the criteria of the different diagnoses. Frequency of patients with CVMCC who fulfill the criteria of the different diagnoses. 98% of all patients with CVMCC fulfill the Barany Society criteria of a probable vestibular migraine; 17% fulfill the International Classification of Headache Disorders defined vestibular migraine criteria; 63% fulfill the Fukuda criteria of ME/CFS; 100% of the patients with WAD suffer from CVMCC. This survey supports the hypothesis that CVMCC can be the trigger of symptoms in vestibular migraine, ME/CFS, and WAD. The actual diagnosis the patient receives is often in accordance with the patient's dominant symptom.

Vestibular-Balance Rehabilitation in Patients with Whiplash-Associated Disorders

Whiplash associated syndrome is one of the neck disorders that is accompanied by several chronic symptoms. Balancing problems arising from common disorders and dizziness are considered as manifestations that are time-consuming to evaluate and treat. The present study aims to investigate the effect of vestibular-balance rehabilitation using a test that can be used for differential diagnosis of these lesions by comparing dizziness handicap inventory (DHI) and Smooth Pursuit Neck Torsion (SPNT) scores. This was an analytical cross-sectional study with a two-stage design. Forty patients with whiplash-associated disorders were randomly divided into control and intervention groups. SPNT test and DHI evaluation were performed for both groups. For twenty people selected randomly in the intervention group, vestibular-balance rehabilitation was performed during 12 sessions. Finally, the SPNT and DHI tests were performed again to examine and compare the results. The results of this study showed that there was a statistically significant difference between the scores of smooth pursuit neck torsion gain in the SPNT test, the total score of DHI, the functional components of this questionnaire between the control and intervention groups after the implementation of the rehabilitation, and the differences in the physical, functional, and emotional components of the questionnaires of the control and intervention groups after rehabilitation exercises. Vestibular-balance rehabilitation exercises can be an effective treatment for dizziness and improving the quality of life of a person suffering from whiplash-associated disorder, followed by the reduction in dizziness caused by disability.