Vestibular Rehabilitation in a Patient with Whiplash-associated Disorders
From: Journal of Chinese Medical Association 2006; 69(12):591–595
Whiplash injury involves hyperextension of the neck followed by flexion, and typically results from an automobile accident when a person has been hit from behind. Although the majority of people recover within weeks or months, about 12–40% will persist in
having complicated sequelae such as neck pain, stiffness, painful paresthesia of the neck and upper limbs, temporomandibular dysfunction, dizziness, tinnitus, and headaches, which are hard to elucidate and treat. These symptoms are collectively called whiplash associated disorders. Among these symptoms, dizziness may be most bothersome for the patient, and it is also most difficult to treat. As there is no specific medication for the treatment of dizziness, a special method of rehabilitation, so-called vestibular rehabilitation, has recently gained widespread attention. The concept of head, body and coordinated eye exercises
is applied for patients who suffer from motion intolerance and imbalance problems. We report a patient with whiplash injury who had all of the symptoms described above. Satisfactory results were obtained after a comprehensive multidisciplinary rehabilitation program.
Whiplash injury is notorious for its constellation of chronic symptoms that are difficult to treat. These symptoms are generally called WADs. As Rodriquez et al mentioned in their comprehensive review, Whiplash associated disorders may include neck pain, headache, dizziness, paresthesia, temporomandibular dysfunction, visual disturbance, memory impairment, concentration problems, and psychosocial distress. These symptoms may cause greater functional disability and psychologic stress than anticipated. Among these symptoms, subjective dizziness with subsequent impaired balance function may be the problem that affects patients most. It is also more difficult to evaluate and treat clinically, so deserves extra attention and discussion.
Neck pain is relatively common in whiplash-injured patients. Painful inhibition of muscles results in subsequent limited range of motion. Although the reason for neck pain may be psychiatric somatization, other explanations such as myofascial pain secondary to cervical sprain, cervical disc herniation, cervical spondylolisthesis, cervical spine fracture, and injury to the cervical zygoapophyseal facet joint are also possible reasons. The richly innervated cervical facet joints are most vulnerable during the initial neck hyperextension stage while being hit from behind, and it has been considered to be the most possible reason responsible for neck pain in whiplash-injured patients. Therefore, treatments such as local anesthetic block of the medial branch of the cervical dorsal rami which supply only the zygoapophyseal joints, percutaneous radiofrequency neurotomy for facet joint innervation, and intra-articular corticosteroid or anesthetic injection for facet joints have been suggested in the literature.
Dizziness is a frequent complaint after whiplash injury. Damage to various structures such as vestibular apparatus, brainstem, cerebellum, vertebral artery, and cervical proprioceptive receptors during whiplash injury are postulated as causes for dizziness. If neither subjective vertigo complaint nor nystagmus are present, then vestibular dysfunction is less likely. If brain imaging studies and other cerebellar function tests are normal at the same time, which is usually the case in whiplashinjured patients, cervicogenic dizziness may be the most likely explanation. During whiplash injury, extensive damage to neck muscles and joints is highly possible, which may cause proprioceptive receptor dysfunction. The abnormal proprioceptive signal from the neck conflicts with visual and vestibular signals, and a sensation of dizziness arises.
In this patient, diplopia resulting from orbital fracture may be another cause of her dizziness. However, the patient refused any orbital surgery. Therefore, treatment could only rely on a long-term vestibular rehabilitation program. The training program included: (1) head-eye coordination exercise: eye focused on a fixed or moving target while moving head from side to side; (2) visual-ocular control exercise to train smooth pursuit and saccade eye movement; (3) adaptation and habituation exercise for motionprovoked dizziness symptoms; (4) sensory substitutionpromoting exercises such as progressive challenge progressing from walking with support to walking on foam with head movement; and (5) postural strategy practicing exercises such as ankle response, hip response, stiffening response, counterbalance response, stepping response, grabbing response and rescue response. For our patient, the training program we arranged included activities such as sitting on an elastic ball with bouncing , stepping on a trampoline, and standing on a tilting board with movement in coronal and sagittal directions, which are sensory substitution-promoting and postural strategy practicing exercises. These vestibular rehabilitation programs utilize the plasticity of the central nervous system by means of adaptation, habituation and substitution to reorganize balance perception while training postural strategy in case of falling. Our patient’s balance improved after the exercises, suggesting the significant role of vestibular rehabilitation programs in improving patients’ quality of life. The risk of falling also decreased according to the DGI evaluation. The improved DGI score was compatible with the results described in a previous report.
Whiplash associated disorders are considered to be some of the most difficult problems to diagnose and treat. The symptoms are mostly chronic, often resulting in great financial and mental burdens to the patient, patient’s family and society. However, if the correct diagnosis for the symptoms can be made, some of the problems can be successfully treated. Vestibular rehabilitation program focusing on the adaptation and habituation of the subjective dizziness and imbalance sensation can be considered as an alternative treatment strategy to treat dizziness in whiplash-injured patients.
