Thoracic dysfunction in whiplash associated disorders: A systematic review

Abstract

BackgroundResearch investigating Whiplash Associated Disorder (WAD) has largely focused on the cervical spine yet symptoms can be widespread. Thoracic spine pain prevalence is reported ~66%; perhaps unsurprising given the forceful stretch/eccentric loading of posterior structures of the spine, and the thoracic spine’s contribution to neck mobility/function. Approximately 50% WAD patients develop chronic pain and disability resulting in high levels of societal and healthcare costs. It is time to look beyond the cervical spine to fully understand anatomical dysfunction in WAD and provide new directions for clinical practice and research.PurposeTo evaluate the scope and nature of dysfunction in the thoracic region in patients with WAD.MethodsA systematic review and data synthesis was conducted according to a pre-defined, registered (PROSPERO, CRD42015026983) and published protocol. All forms of observational study were included. A sensitive topic-based search strategy was designed from inception to 1/06/16. Databases, grey literature and registers were searched using a study population terms and key words derived from scoping search. Two reviewers independently searched information sources, assessed studies for inclusion, extracted data and assessed risk of bias. A third reviewer checked for consistency and clarity. Extracted data included summary data: sample size and characteristics, outcomes, and timescales to reflect disorder state. Risk of bias was assessed using the Newcastle-Ottawa Scale. Data were tabulated to allow enabling a semi-qualitative comparison and grouped by outcome across studies. Strength of the overall body of evidence was assessed using a modified GRADE.ResultsThirty eight studies (n>50,000) which were conducted across a range of countries were included. Few authors responded to requests for further data (5 of 9 contacted). Results were reported in the context of overall quality and were presented for measures of pain or dysfunction and presented, where possible, according to WAD severity and time point post injury. Key findings include: 1) high prevalence of thoracic pain (>60%); higher for those with more severe presentations and in the acute stage, 2) low prevalence of chest pain (<22%), 3) evidence of thoracic outlet syndrome, with some association to and involvement of the brachial plexus, 4) muscle dysfunction in the form of heightened activity of the sternocleidomastoid or delayed onset of action of the serratus anterior, 5) high prevalence of myofascial pain and trigger points in the scalene muscles, sternocleidomastoid and mid/lower fibres of trapezius muscle (48–65%), and 6) inconclusive evidence of altered thoracic posture or mobility.ConclusionsConsiderable evidence supports thoracic pain and dysfunction in patients with WAD, involving primarily nerves and muscles. Notwithstanding the low/very low level of evidence from this review, our findings do support a more extensive clinical evaluation of patients presenting with WAD. Additional high quality research is required to further c...

Thoracic dysfunction in whiplash associated disorders: a systematic review

“…In accordance with the protocol [22] meta-analyses would be performed where a sufficient number of studies share all of the stated characteristics; design, measure of dysfunction, severity based on QTF and stage post whiplash injury.…”

Cervico-thoracic pain and associated impairments in air force personnel: a cross-sectional study

“…We also combined pain in the cervical and thoracic regions as they often accompany each other [ 1 , 5 ]. Thoracic pain and dysfunction is also common in many cervical disorders [ 45 ]. The movement control tests in this study have shown adequate (moderate to almost perfect) inter-rater agreement but lower (fair to substantial) test-retest agreement, which should be considered in follow-up situations [ 25 ].…”

Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations

“…Exercise has shown to be a useful approach in 50 to 90% of all TOS cases [ 6 ]. Although there is much variation within and between individuals, symptoms of TOS generally improve with exercise and other physical therapy techniques (e.g., manual therapy or manual adjustments) [ 21 , 60 , 61 , 62 , 63 ]. In a general exercise session, emphasis on proper scapular function during upper-body movements, breathing techniques, and head and pelvis alignment during various tasks is essential for treating TOS [ 36 , 58 , 64 ].…”

“…Repeated trauma to the head or neck, postural dysfunction, extended duration in compromising shoulder positions, pregnancy, edema, anatomical deviations, hypertrophied muscles (e.g., scalenes), boney growths, and muscle weakness are all theorized to be contributing factors to TOS [ 2 , 4 , 9 , 11 , 12 , 13 , 18 ]. The most commonly presented cause of TOS appears to be an abrupt flexion-extension motion (e.g., whiplash) at the atlantoaxial joint and other joints between the cervical vertebrae, which can lead to symptoms present with both vTOS and nTOS [ 2 , 9 , 16 , 21 ]. This whiplash motion can result in instability at the atlantoaxial joint, causing the surrounding musculature to shorten, in order to compensate for the laxity in the joint.…”