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Referred Neck Pain and Headaches, Balance, Visual Disturbance and Dizziness 

Here in North Sydney we treat people daily with a wide spectrum of headaches ranging from less severe tension headaches to severe debilitating migraines, vertigo and nausea. Our treatments are directed at the cervical and thoracic spines and their accompaning muscles and fascia. Frequently, we also investigated the pelvis and low back as these can have a major influence on posture.

Some people come to us suffering from dizziness and balance disturbances not associated with BPPV. At least 3 systems contribute to our sense of balance; these include the upper cervical spine of the neck, the ears and eyes. As such, each system can compensate for some of the deficits in the other systems (also known redundancy). However, generally, the brain interprates information from these 3 systems using transcerebral and cerebellar correlations. When for example, neck pathology presents itself, it may result in excessive nociceptive (pain) input and/or reduced proprioceptive (sense of position) input. In these cases we use conventional treatments to the neck to reduce muscle spams and pain, combined with avant-guard techniques using laser pointers on the head, blindfolds and relocation exercises, occulo-motor tracking and stability tasks, as well as virtual reality training with the WiiFit to attain optimal outcomes for brain correlation.

Please read on for more information on

- Vertigo

- Whiplash

Headaches may arise from

  • neurological causes (eg Migraine)
  • malignancies
  • problems with blood flow
  • stress and tension
  • biomechanical problems (dysfunctions) of the cervical and thoracic spine

Cervicogenic headache may occur due to dysfunction at the C1/2/3 levels.  Such dysfunction may refer pain directly to the scalp and eyes via the greater and lesser occipital nerves.

Cervicogenic headache may also occur due to muscle spasms, reduced vertebral artery blood flow from as low as the first rib, adverse neural tension from 0/C1, C5/6, T6

Alternatively, cervicogenic headache may occur due to excessive nociceptive and mechanoceptive bombardment of the neurones in the spinal cord (WDR = wide dynamic range neurones, NS = nociceptive specific neurones).  Overflow from the WDR and NS neurones into the Trigeminal nerve (Cranial nerve V) can exacerbate the frequency and duration of migraines.  (See below)

The locus coeruleus is a cluster of neurones in the brainstem whose function is to reduce excessive neuronal activity in both the spinal cord (descending modulation) and in the cerebral cortex. see below

peripheral sympathetic nervous system and WDR hypersensitivity

link to neurophysiology and PET scan of cortex

Pain summary

Link to Upper Cervical Spine Instability


Dizziness and Vertigo may also accompany headaches. These may be due to

  • Benign Paroxismal Positional Vertigo which underlies a problem with the crystals in the inner ear
  • Vertebral Artery compromise
  • Sympathetic Nervous System dysfunction
  • A mismatch between vestibular, occular and proprioceptive input
Headaches & Migraines

Chronic neck and shoulder pain affects up to 18% of the population (Guez et al 2003). According to these researchers only 1/4 are due to trauma. These conditions are usually accompanied by pain and stiffness as well as impaired neck mobility. It has been estimated that up to one in five headaches are of musculoskeletal origin (Jull et al 2007a). Impairments have included a mismatch between efference copy and the afference weighting of information (Djupsjoebacka 2008) suggesting both peripheral and cortical processing affecting the chronicity of the dysfunction.

Investigations into people with persisting post concussion symptoms (PCS) applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control.

Pathology includes

  • upper trapezius myalgia with increased [glutamate], [serotonin] and [interleukin] concentrations (Falla 2008)
  • disturbed oxidative metabolism "moth eaten" fibres
  • impaired intramuscular circulation
  • increased proportion of type IIc fibres (i.e. reduced endurance fibres)
  • increased fatigue
  • decreased conduction velocity
  • connective tissue infiltration

Dysfunction includes

  • activation of A-delta and C-fibres
  • physical deconditioning leading to early fatigue resulting in impaired sensorimotor control (Karlberg et 1991)
  • reduced acuity of muscle spindle proprioceptive input. Deep muscles of the cervical spine have a very high density of muscle spindles (Bakker & Richmond 1982)
  • muscle fatigue reducing the quality of proprioceptive information (Pederson et al 1998, Johansson et al 1995)
  • impaired function of the deep cervical muscles (Jull 2000)
  • impaired proprioceptive input from deep cervical muscles
  • impaired ability of the CNS to utilize cervical proprioceptive input
  • proprioception (Jull et al 2007b)

-> altered feedforward strategies due to variation in efference copy with conflicting afferent input

- > conflict of inputs from visual, vestibular and somatosensory sources (Treleaven et al 2003)

-> task dependent changes in pain adaptation of motor responses using redundant strategies with potential overloading affects on some body parts and underloading affects on other parts (Falla 2008)

-> hyperalgesia and potential allodynia

Examination includes

  • active repositioning tests to assess muscle and joint proprioception (efferent-afferent mismatch) (Lee et al 2006)
  • passive repositioning using blindfolds (joint proprioception) - discrimination threshold and constant error
  • smooth pursuit eye tracking (Treleaven et al 2005a)
  • deep neck flexor muscle strength and endurance
  • trapezius and levator scapulae muscle activity
  • passive joint moblizations
  • passive and active ROM
  • postural sway (Treleaven et al 2005b)
  • shoulder strength and endurance
  • shoulder acuity and repositioning with cognitive-behavioural aspects of kinesiophobia (Djupsjoebacka 2008)
  • psychometric evaluation (Neck Disability Index)


Cervical Headache : the relationship of upper cervical spine (O-C3) dysfunction and the trigeminal nerve.

The International Headache Society (IHS) classification of headache is based on clinical phenomenology which assumes that a common presentation defines a valid pathological entity. Migraine and cervicogenic headaches (CH) have a number of common features which need to be appreciated when discussing the role of Spinal Manipulative Therapy (SMT) in migraine headache management.

The structures supplied by the sensory division of the first 3 cervical nerves include " the joints and ligaments of the upper 3 cervical segments, their posterior and anterior muscles, the sternocleidomastoid and trapezius muscles, and the dura mater of the posterior cranial fossa" (Bogduk 1983). Relays in the trigeminal nucleus have been implicated in referred headache from these structures (Bogduk 1992). Physical irritation of both the greater occipital nerve (GON) and the C2 and C3 roots may cause hemicranial symptoms (Pfaffenrath, Dandekar, Pollman 1987) similar to migraine (Anthony 1989).

The cell bodies in the trigeminal ganglion innervate the large cerebral arteries and dura mater (Liu-Chen, Mayberg, Moskowitz 1983). Periodic failure of the locus coereleus and raphe nuclei to suppress activity in the C2-C3 segments in the trigeminal nucleus of the spinal cord is postulated to cause migraine (Goadsby 1993).

Unfortunately, the quality of CH vary greatly and don't adequately distinguish them from migraine. CH tend to increase in frequency and are more easily provoked as the lesion progresses (Edeling 1982). However, migraine rarely expresses itself more than 10 headache days per month (Olesen 1993). Unlike CH, the distribution of symptoms in migraine are usually (75%) unilateral with side shifts (Sjaastad, Stovner 1993). Prior to 1986 a number of patients fulfilling the IHS criteria of CH also fulfilled the criteria of migraine (Sjaastad, Stovner 1993). This questions whether Maitland (1986, p330), Parker, Pryor, Tupling (1980), Parker,Tupling, Pryor (1978), and Kelly (1978) were using SMT for the treatment of migraine or CH. Vernon, Steinman, Hagino (1992) describe cervicogenic dysfunction, including hypomobility in the upper cervical spine in patients with "migraine". However studies suggest different pathogenic mechanisms between CH and migraine (Bovim, Sand 1992). Differential diagnostic problems arise when they coexist (Olesen 1993).

Gawel and Rothbart (1992) hypothesise that plasticity in the sensory pathways allows leakage of pain-generating activity in ever increasing numbers of neural networks until a point is reached where the cervicotrigeminal relay is involved. Cervical spine dysfunction does not in itself cause migraine but may contribute to its expression (Kidd, Nelson 1993). Conceptually, SMT treatment of inputs into these networks may disrupt this overactivity (see Zusman 1992, 1994 for review). Clinically, manipulative physiotherapists believe that overcoming movement abnormality relieves associated symptoms (Kelly 1983). Clearly, the exact sources of pathology need to be established. Jull, Bogduk, and Marsland (1988) consider SMT accurate in the diagnosis of cervical zygapophysial joint disorders. Thorough physical and subjective examination (Maitland 1986) and the use of a pain behaviour diary may implicate the 'nature and stage' of each headache disorder.

Until further research is carried out, the history (Bogduk, Corrigan, Kelly, Schneider, Farr 1985), and knowledge of IHS criteria in the classification of headaches, are crucial in deciding which patients presenting with "migraine" are appropriate for SMT. Ultimately, SMT management should assist medical practitioners in establishing a possible cervical component in a "migraine" sufferer who is unresponsive to pharmacological intervention.

More recent evidence suggests a major role for the re-establishment of proprioception in chronic neck and shoulder pain. Elements of motor learning and cognitive behavioural therapy should be included in treatment regimes. Interventions which enhance proprioceptive acuity include

  • body awareness training (Kadi et al 2000) eg Tai Chi, Alexander Technique, Dance therapy, etc
  • exercises involving coordinated rapid eye, head, neck and arm movements (Fitz-Ritson 1995)
  • Feldenkrais therapy (Lundblad et al 1999)
  • multimodal treatment involving exercises to improve balance, neck co-ordination, and occulomotor control (Taimela et al 2000)
  • proprioception to improve eye & head movement (Jull et al 2007) - occulomotor reflexes
  • low intensity endurance exercise regime for the deep craniocervical flexors for postural pertubation (Falla et al 2007, Jull et al 2007)
  • high intensity exercise to challenge the neck flexors is requird to reduce the fatiguability of the sternocleidomastoid and anterior scalene muscles and improve the strength of the cervical muscles (Falla et al 2007)
  • joint mobilizations, taping, trigger point therapy & dry needling, soft tissue massage, EMG biofeedback training in combination with the above.

Exercises should be cognitively challenging with progressions of difficulty, ultimately containing unpredictable task variations as well as changes in context in which the task is performed (Jarus 1994).

Cervical Proprioception

  • Clinical aspects of proprioceptive dysfunction have not been researched extensively (Kristjansson 2005)
  • Proprioception is a complex neurophysiological pathway which plays a small but important role in motor control (Gandevia & Burke 1992)
  • The cervical spine has great mobility at the expense of mechanical stability and a close neurophysiological connection to the vestibular and occular systems (Gimse et al 1996)
  • Perception drives the motor responses. Motor strategies and 'feed forward' preparatory responses are instigated by the CNS to drive the PNS. The CNS stores sensory perceptions in memory. However, sensory conflict may arise when incoming disturbed proprioceptive information is unexpected leading to altered 'efference-afference copy'
  • This hierarchical model has been criticised as it does not explain reactions to novel tasks, nor can the memory bank store all the information needed for complex co-ordinated motor tasks required to solve for the control of multiple 'degrees of freedom' problem proposed by Bernstein (1967)
  • Treatments built into hierarchical ways of thinking (Knott & Voss 1968) have been criticised for being too passive because therapeutic interventions were modelled on facilitation and inhibition rather than function training (Shumway-Cook & Woollacott 2001)
  • Systems theories examine the functioning of the whole, where self organisation occurs based on principles of physics whereby constraints within an organism, a task and the environment determine which movement strategies are best for each individual as a whole (Shumway-Cook & Woollacott 2001) - integration of neuro-musculo-skeletal with vestibular, occular and immune.
  • Clinically, treatment needs to be functionally meaningful and task dependent to appeal to the clients perceptions and cognitions.


  • When the vertebrates evolved in the ocean, the whole body, including the head, formed a spindle-like unity to enable fast swimming. Spatial orientation was served by peripheral vestibular and visual systems
  • About 350million years ago when vertebrates climbed onto the land, to be able to survive, their head had to be able to move freely on the rest of their body
  • The first rudimentary head on neck motion was a nodding action occurring at 0/C1
  • However, this wasn't enough and development of the dens axis enveloped by the ring of the atlas followed (Wolff 1998)
  • Last major development took place at C2/3 which facilitated coupling of movements
  • These bony developments were accompanied by distinct development of the musculature of the upper cervical spine to orient the head sensors in space
  • A network of mechanoreceptors were developed to provide information of the head in regard to the rest of the body

The Cervical Spine and the Postural Control System

  • the vestibular, visual and somatosensory systems
  • The semicircular canals used to determine changes in the rate of motion, angular velocity
  • The otoliths containing the utricular and saccular maculae provide information on linear velocity and gravity (head tilt)
  • Convergence occurs in the vestibular nuclear complex (VNC) via the vestibular nerve and cerebellum
  • The vestibulo- and reticular-spinal tracts provide impulse propagation to the trunk & limbs
  • The upper cervical mechanoreceptors have indirect inputs into these descending tracts

Visual System & Audition

  • Over 1/3 of the brain in primates is devoted to vision (Stein & Glickstein 1992)
  • The visual postural system consists of 2 movement - smooth pursuit, saccade, opticokinetic
  • The vestibular-ocular reflex (VOR) stabilizes images on the retina
  • The position and movement of the head in relation to the rest of the body and eye movements is regulated by the VOR and the much weaker cervico-ocular reflex (COR) where the latter acts on the extra-ocular muscles.
  • However, in dysfunctional conditions the COR becomes more active and can be used for differential diagnosis of upper cervical spine proprioception (Neuhuber 1998, Tjell 1998)

The somatosensory subsystem

  • Upper cervical spine has an abundance of mechanoreceptors, esp. from the gamma muscle spindles (nuclear bag and nuclear chain fibres) of the deep segmental muscles (Richmond & Bakker 1982), these impulses converge in the central cervical nucleus (CNN)
  • The cervical mechanoreceptors have direct inputs to the VNC via the DRG at the C2 and C3 levels which contrasts to inputs from lower spine segments which tapper off to indirect inputs.
  • Inputs from lower spinal segments converge onto the cuneatus nuclei and travel from there to the cerebelllum (Neuhuber 1998)
  • The CNN has important connections to the VNC. The lateral VNC is the origin of the powerful lateral vestibulospinal tracts which controls muscle tone in the trunk and extremeties (Tjell 1998)
  • The cervico-collic reflex (CCR) is mediated through these pathways and probably the medial vestibolospinal tract via the VNC (Peterson et al 1985). The CCR is stimulated by cervical movements and dampens the activity of the VOR and VCR stimulated by the semi-circular canals

The nociceptive system

  • The nociceptive system in the upper cervical spine projects onto many cranial afferents of which the trigeminal nucleus and the tractus solitaritus nuclear complex (Vagal nerve) are the most important ones.
  • Neuroanatomical research indicates connections from the upper cervical spine to the limbic system (Feil & Herbert 1995; Neuhuber 1998)
  • Coordination of movement is mainly the function of the cerebellum, where all spinal and brain stem reflexes directly or indirectly converge (Stein & Glickstein 1992)
  • Linear Vestibulocollic Reflex (VCR)
  • Little is known about the otoliths
  • The otoliths are stimulated by linear accelerations of the head and their inputs have been found to modify both eye and head stabilizing responses (Schor et al 1985)
  • Otolith contributions to compensatory eye and neck responses increased with stimulus frequency, but the otolith system alone is unable to produce perfect compensation (Boral & Lacour 1982)
  • ? Convergence of canal and otolith input on vestibulospinal neurons combine to provide reflexes to linear and angular acceleration ? (Uchino et al 2000)
  • ? Otoliths may have a distinct functional affect during locomotion providing compensatory head pitch movements by the angular VCR during walking and the linear VCR during running ? (Hirasaki et al 1999)

Multimodal Control

  • The reflexes appear to be predominant in the frequency of natural locomotion (1.5-2Hz) (Hirasaki et al 1999) and their function is to damp oscillations of the head at higher frequencies (Keshner et al 1999)
  • Voluntary responses are observed as anticipatory torques in the neck muscles or responses controlled by the occulomotor reflex
  • Above 1Hz mechanical factors (inertial, stiffness and viscoelasticity) become important
  • The relative importance of the VCR and CCR for head-neck stabilization is probably dependent upon the degrees of freedom and the postural requirements of the task (Keshner 2005)

Motor Control

  • Complex biomechanical linkage with 20 pairs of muscles capable of performing similar actions -> therefore suggesting some redundancy in the system
  • Overall the number of independently controlled muscle elements exceeds the number of degrees of freedom of neck motion -> the extent of functional variability depends upon the task being studied
  • Head represents 7% body weight, yet has 20 different muscles directly linking the skull in either side of midline to the vertebral column
  • Motions of the head are primarily directed towards orienting and stabilizing the position of the eyes and head in space
  • CNS programmes neck muscles in specific directions rather than an infinite variety of muscle patterns
  • Muscles organised in layers - outer layer connects skull with the shoulder girdle - deeper layer links the skull with the vertebra
    - deepest layer consists of muscles that link the cervical and thoracic vertebrae
  • The layer of muscles linking the skull to the vertebrae form the long dorsal (splenius capitis, semispinalis capitus and longissimus capitis) and a long ventral (longus capitus) muscle. - > act as a sleeve for the cervical vertebrae eg rotation
  • Splenius cervicis, Semispinalis cervicis, longissimus cervicis & longus colli lie deeper, have a small moment arm - > proprioceptive function
  • Suboccipital muscles produce extension at the atlanto-occipital joint.

Neck muscle morphometry

  • Each muscle differs in it's relative content of fast and slow twitch fibres, angles of pennation, sarcomere length, sites of origin and insertion and the mechanics of action across the individual joints
  • Unlike limb muscles where there is a distinct tendonous attachment to bones, many neck muscles had very little tendons at their ends.
  • Instead of distinct tendons, many neck muscles have a complex architecture of internal tendons and aponeuroses. (Kamibayashi & Richmond 1998)

Functional Synergies

  • One solution to controlling the degrees of freedom (Bernstein 1967) is to organise movement around synergistic muscle torques (Buchanan et al 1989)
  • In cats, dissociation between deep and superficial neck muscle activation suggests different neural controllers (Richmond et al 1992)
  • Separation of two groups of muscles, one producing the forces necessary to move the head and another to align the head with the terminal target would assist the head-neck controller in meeting multiple criteria or goals (Thomson et al 1994)
  • A single action can be accomplished through the activation of agonists and antagonists where the control parameter appears to be the required force vector rather than the specific force lever arm of any particular muscle (Macpherson 1988, 1991) - therefore the specific direction of motion is important

Directional tuning of muscles

  • Each muscles preferred direction is unique and consistent amongst subjects (flexion for sternocleidomastoid, ipsilateral flexion for splenius capitis and extension for semispinalis capitis. Trapezius was tuned toward lateral flexion but had the lowest activation and the greatest variability)
  • Rotation shifted the maximal activation vectors away from the moment arm direction due to the observation that none of these muscles produce a unique axial rotation torque (Keshner 2005)
  • A likely control parameter for the CNS to employ in the selection of which muscle to employ may be contingent upon it's ability to generate a maximal mechanical advantage (Keshner et al 1997)
  • Posture affecting the plane of motion of the muscles length and pulling direction may have a greater influence on its contribution than mechanical efficiency (Runciman & Richmond 1997)
  • Orientation of the C/S (ie perpendicular or horizontal to earth) was a significant variable in determining the ROM, amplitude and timing of the neck muscles (Statler & Keshner 2003)

Neural Control of the Cervical Spine

  • Vestibulocollic (VCR) and cervicocollic (CCR) reflexes, respond reactively to accelerotory and proprioceptive stimuli to maintain the orientation of the head in space (VCR) and the head on trunk (CCR).
  • Voluntary responses are those for tracking and acquiring exteroceptive (visual, auditory and olfactory) information and can be used either anticipatorily or pursuit actions
  • The normal repertoire of movement responses emerges from combinations of input and output signals (Keshner 2005)
  • Vestibulospinal pathways have monosynaptic and disynaptic connections with cervical motor neurons
  • Cervical proprioceptive inputs have significant influence on the vestibulospinal signals (Gdowski & McCrea 2000) and together with the reticulospinal neurones have a major influence on orientation and posture through convergence of afferent input which initiates a series of interspinal reflexes
  • The VCR alone is not sufficient for purposeful head stabilization in a dynamic environment (Keshner 2005) suggesting that other inputs such as the reticulospinal are also involved.
  • Gdwoski & McCrea suggest correct alignment of the head and trunk requires ascending somatosensory inputs. The CCR arises from a stretch of the neck musculature as would occur when turning the body with a fixed head position. This reflex is more complex than a monosynaptic reflex, with evidence of presynaptic inhibition in the CCR response (Banovetz et al 1995)

Neck muscle activation patterns

  • Each head motion is executed by a specific muscular pattern that is not repeated in any other direction
  • Motor solutions to voluntary head tracking need constant adjustment whereas the VCR and CCR probably only need to stabilize specific cervical joints.

Cervical Vertigo

  • Dizziness is the third most common reason to seek medical advice in the USA (Kroenke & Mangelsdorff 1989)
    1.8% in young adults to 30% in elderly (Sloane et al 2001)
  • Up to 80-90% of patients suffering chronic whiplash report vertigo & dizziness (Oosterveld et al 1991)

4 categories of cervical vertigo
- Vertigo : "sensation of irregular or whirling motions, either of oneself or of external objects"
- Near-syncope
- Disequilibrium
-Light headedness (40-50% of attacks are vertigo)

Differential Diagnosis with

  • Vertigo (canalolithiasis and cupulolithiasis)
    -Prolonged spontaneous - positional vertigo (BBPV) -recurrent attacks
  • Meniere's Disease
  • Vestibular Neuritis
  • Labyrinthitis
  • Periplymphatic Fistula
  • Bilateral Vestibular Dysfunction
  • Central causes
  • Vestibular Schwannoma
  • Arnold-Chiari Malformation
  • Vertiginous Migraine
  • Psychogenic Dizziness
  • Mal de debarquement syndrome
  • Pharmacological

Cervical Vertigo

  • 'spinning of the head' rather than spinning of the patient, light headedness, tipsy feeling, as a consequence of 'noise ' in the PNS
  • Usually worse in the morning and tappers during the day
  • Associated with neck movements but also with tracking an object or driving a car (Hulse & Holzl 2000)
  • Tend to increase in intensity over time as mechanoreceptors are non-adaptive and their threshold decreases over time if left untreated (Neuhuber 1998)
  • Some people don't perceive dizziness however they have overall increased muscle tone which may explain why some people go on to develop fibromyalgia
  • In long-standing cases the plasticity of the CNS (Sessle 2000) may make them treatment resistant to traditional manual therapy and techniques employing virtual reality training become important (WiiFit balance exercises), yoga, Tai Chi, etc
  • Visual disturbances although common are not widely accepted due to the lack of verification using conventional opthalmologic instruments (Hulse 1998) – these people complain of blurred vision, reduced visual field, grey spots appearing in the visual fields, temporary blindness, disordered fusion, whole words or whole sentences 'jump', double vision but not true diplopia (as with VBI), and reading problems (Hulse 1998)
  • Existence of cervical vertigo is controversial as otoneurological examination are frequently normal
  • Incidence appears to be highest in the 30-50 year old and more common in females
  • The diagnosis of cervicogenic dizziness is based on history, examination, and vestibular function tests
  • Vascular hypothesis - Vertebral artery vasospasms due to close relationship with the sympathetic nerve trunk
    However this would be accompanied by serious neurological symptoms such as diplopia, dysarthria, ataxia & motor symptoms
    The vertebral artery is at risk in artherosclerosis.
    • Degenerative changes in the uncinate processes of the low C/S projecting osteophytes laterally, and/or subluxating superior articular processes (Bogduk 1986)
    • Full rotation of the C1/2
    • Deep fascial bands of cervical muscles crossing the artery, anomalous course of the artery between fascicles of either longus colli or scalenus anterior (Bogduk 1986)
  • Neurovascular hypothesis
    • Sympathetic Nervous System
    • C3/4 osteophytes and irritation of superior cervical ganglion ((Tamura 1989)
    • Direct irritation of sympathetic ganglia within fascia of anterior cervical muscles after whiplash
    • Erroneous proprioceptive signalling due to gamma reflexogenic activation of muscle spindles (Johansson & Sojka 1991)
    • However SNS blocks induces vertigo, tendency to fall, horizontal nystagmus & tinnitus, instead of diminishing the symptoms (Barre 1926, Lieou 1928 in Heikkila 2005)
  • Somatosensory hypothesis :
    • Disturbed afference – efference copy due to
      • Abnormal sensory input from neck proprioceptors
      • Vestibulo-occular reflex (VOR) stabilizing the visual field
      • Vestibulocollic reflex (VCR) stabilizing the head position
      • Cervicooccular (COR) proprioceptive reflex - helper reflex if the labyrinths have been damaged (Botros 1979), co-operates with the VOR for clear vision – originates in neck and joint proprioceptors
      • Cervicocollic (CCR) proprioceptive reflex – stabilizes the neck and protects from over-rotation and coutneracts the COR, probably generated by the gamma muscle spindles of the deep neck muscles (Hirai et al 1984)
      • Vestibulospinal reflexes – appropriate tone for the neck and body muscles for the purpose of balance
    • Impaired kinaesthetic performance was found in people with dizziness/vertigo of cervical origin which may be as a result of lesioning or functional impairment of muscular and articular receptors, or by alteration in afferent integration and tuning (Heikkila et al 2000; Wyke 1979, Taylor & McCloskey 1988)
    • Altered kinaesthetic sensitivity has been implicated in functional instability of joints and their predisposition to re-injury, chronic pain and degenerative joint disease (Revel et al 1991, Hall et al 1995)
    • Postural control and voluntary eye movements were impaired during cervical restriction with a collar (Karlberg et al 1991)
    • Smooth pursuit and saccade abnormalities have been reported in people whiplash (mild – due to altered C/S proprioception {Oosterveld et al 1991}, severe – due to medullary lesions {Hildings et al 1989}), and in people suffering from fibromyalgesia with dysaesthesia (Rosenhall et al 1987)
    • 62% of whiplash patients had at least 1 smooth pursuit abnormality at 2 years follow-up (Heikkila & Wenngren 1998)
    • Smooth pursuit was correlated with active ROM function of the C/S (Heikkila & Wenngren 1998; Karlberg et al 1991)
    • Vertigo was reported in 85% of whiplash subjects (Oosterveld et al 1991)
    • Whiplash subjects had less accurate ability to relocate their head in space after active displacement that turned their head away from the reference position (Heikkila & Astrom 1996) – esp. vertical mov'ts -> correlates with hyperflexion/extension injury

Signs & Symptoms of Cervical Vertigo

  • Correlating symptoms of imbalance with neck dysfunction
  • Cervical vertigo is characterised by a feeling of unsteadiness when standing and walking rather than rotatory vertigo (Brandt 1991)
  • Accompanied by pain – occipital, temporal, temporomandibular to orbital or forehead region
  • Tenderness on cervical palpation
  • Dizziness and nausea may be provoked by palpation of the lateral mass of the atlas (Scherer 1985)
  • Blurred vision, photophobia, direction-fixed, directional changing positional nystagmus, tinnitus, low frequency hearing loss
  • Imbalance may occur during the Unterberger stepping test
  • Correlating subjective findings (mechanism of onset, history of duration, frequency, area, and intensity) with physical and functional impairment is important in making a diagnosis and monitoring progression
  • Questionnaires
    • Activities Specific Balance Confidence Scale (ASBCS) (Powell & Myers 1995) & Dizziness Handicap Inventory (Tesio et al 1999)
    • Dynamic Gait Index (Shumway-Cook & Woollacott 2001) & Berg Balance Test (Berg et al 1992)
  • Cranial and carotid pulse and assessment for varicose veins
  • Complete neurological examination in all patients presenting with undiagnosed disorder of equilibration
  • Gait and balance and spontaneous nystagmus
  • Clinical test for Sensory Interaction in Balance (CTSIB) 'foam & dome test' - quiet standing eyes open/eyes shut, and again on foam for 15-30secs each (Shumway-Cook & Horak 1986) -
  • Posturography + vibration to the cervical extensors (illusion of lengthening) (Karlberg et al 1996) - measures the force applied by the patients feet
  • Assess dynamic visual activity – smooth pursuit neck torsion (SPNT) test, saccade tests, relocation error testing
  • VBI testing – positive predictive validity is zero, negative predictive value ranged from 63 – 97% (Cote et al 1996)
  • Unterberger stepping and Romberg quiet standing tests
  • Cervical Range of Motion testing ; extension stimulates the utricles
  • Adverse neural tension testing
  • Muscle and Joint Palpation – passive accessories, passive physiological
  • Shoulder, Scapula and thoracic spine
  • Head fixed body rotation manoeuvre - COR & CCR is activated without activation of the semicircular canals
  • Relocation testing using light on the head and moving into flexion/extension, and rotation - see above

Physical Assessment

  • Visual Disturbances
    • Smooth Pursuit Neck Torsion Test (SPNT) (Rosenhall et al 1996)
    • Tests the reflex interaction between smooth pursuit system and the proprioceptive system of the cervical spine
    • Velocity of eye movements relative to target object – net gain is calculated; abnormal result is reduced gain in the direction in which the head is rotated
    • When the body is rotated beneath a stationary neck a nystagmus can be induced
      e.g. when the trunk is rotated left, the head is in relative right rotation, the COR helps the VOR to stimulate eye movements to the left in this position, but for teleologic reasons, in order to look forward, the saccadic system moves the eyes to mid point. The VOR with the aid of an overactive COR moves the eyes again to the left inducing a right-directional nystagmus (Tjell 1998, Tjell & Rosenhall 1998)
  • Dix – Hallpike manoeuvre for BPPV
    The patient is in long sitting with the head rotated 45degrees to the side to be tested, then the patient is moved quickly into supine with the head in 30degrees of extension over a pillow under the rib cage, during which the eyes are observed for nystagmus for the posterior semicircular canals
    85% of BPPV are upward rotating due to the posterior semicircular canals
  • Cervicocephalic kinaesthetic sensibility (position sense + movement sense)
    "kinaesthesia is a sensation which detects and discriminates between the relative weight of body parts, joint positions, and movements, including direction, speed and amplitude" (Newton 1982) -> the qualities that are supposed to be the result of proprioception
    • Target matching is used to relocate the natural head posture (NHP) or to actively relocate a set point in range (Kristjansson et al 2003) in the transverse and saggital planes
    • Studies have demonstrated reduced relocation accuracy in whiplash patients (Heikkila & Wenngren 1998) but variable results in insidious neck pain (Kristjansson et al 2003)
    • 60% sensitivity and 80% specificity (Kristjansson – unpublished work 2002)
    • Movements on the transverse plane stimulate mainly the semicircular canals, those in other planes stimulate the utricular otoliths which are sensitive to gravitational changes (Taylor & McCloskey 1990)
    • Slow movements test cervical proprioception due to the inertia of the cupula in the semicircular canals
    • An important aspect of proprioception is moment-to-moment feedback from tracking fast and unpredictable movements -> 'the fly' computer program with a Fastrak device is used for such determination (Kristjansson et al 2003, 2004)


  • Positive affects have been reported for manipulative treatments (Cronin 1997, Galm et al 1998; Hulse et al 2000)
  • Both acupuncture and manipulation reduced dizziness/vertigo, neck pain and improved head repositioning error (Heikkila et al 2000)
  • Postural training with a significant eye-neck coordination component (Revel et al 1994) and vestibular component (Yardley et al 1998) have been shown to improve posture and dizziness
  • Multimodal approach advocated (Bracher et al 2000)
  • Recruitment of deep cervical flexors in neutral head and shoulder position (Jull 2000)
  • Loss of cervical lordosis in chronic whiplash patients (Kristjansson & Jonsson 2003) due to weak deep cervical flexors of the upper cervical spine (Jull 2000) and deep cervical extensors of the lower cervical spine (Kristjansson 2005)
  • Adequate movement control through range of motion
  • Determine whether global or segmental (upper, mid, low) stability has been lost
    • If segmental then try to move areas below and above the unstable segment keeping the latter stable – cognitive control
    • Next step is to recruit global and local stabilizers which most effectively move the dysfunctional segment under active control in a specific direction – the patient can be taught to only move the decontrolled segment through controlled ROM or move the whole cervical spine
    • The patient is specifically taught to control inner range and to move eccentrically from inner range to mid range and in some cases outer range (depending upon functional task which requires reinstating) (Kristjansson 2005)
    • There has been little research to the effectiveness of treatment strategies aimed at improving neuromuscular control and head carriage in the cervical spine
    • Revel et al (1994) conducted an 8 week eye-neck co-ordination exercise and awareness of movement with significant improvements in neck pain
      Olafsdottir & Helgadottir (2001) conducted an 'awareness through movement' Feldenkreis program. After 4weeks significant improvements in NHP was detected (5.22deg + 1.79 vs 3.32 + 1.27 after treatment), additionally significant improvements in the Northwick Park Disability Index occurred using a 100mm VAS (Leak et al 1994)
  • Virtual reality systems to accommodate the need for 'systems' treatment eg. WiiFit, etc
  • Shock absorbing through the use of a trampoline
  • Eye-head coordination
  • Moving the eye balls with eyes open and shut,
  • visual tracking tasks with the head still,
  • gaze stability exercises whilst moving the head slowly and later progression to rapid movements,
  • keeping the gaze stability whilst moving in phase with the patients head in sitting, standing and walking, moving the trunk or varying the surface whilst maintaining the gaze on a fixed target
  • Balance exercises
  • Tandem stance on varying surfaces with eyes open/shut
  • Walking on the spot with eyes shut
  • Walking with saggital and transverse plane movements of the head and neck,
  • walking a distance and turning rapidly and walking back,
  • standing on a balance board making various head movements progressing to tracking a moving object,
  • walking on a treadmill detecting movements in the periphery without looking,
  • walking blindfolded
  • Task dependent exercises
  • Repeat the movement that makes one dizzy
  • General endurance exercise

Cognitive VOR training

  • Adaptation – resetting or retuning the VOR
      • Particularly good for unilateral lesions (hypofunction)
      • Must incorporate movement of the head and visual input
      • Takes time – requires 1-2 minutes practice with error signal
      • Context specific –need a wide range of frequencies i.e. head velocities and variety of positions - no distraction
    • Gaze Stabilization
    • Eye exercises – head still
    • Smooth pursuit – follow a moving object
    • Saccade – gaze redirection between 2 objects
    • Head exercises for VOR
    • Move head whilst focusing on stationary object 2m away
    • Eye-head exercises
    • Move eyes and head between 2 stationary objects (target must be something legible)
  • Substitution (useful for bilateral loss)
    • Physiological/Behavioural mechanisms
      • Sensory re-learning to change/substitute sensory strategies during functional tasks
      • Can bias strategies away from vertigo side or towards it use and drive compensatory processes
      • Body scan - teach client to attend to various inputs and switch back and forth to those
      • Remove or alter some inputs during a task e.g. eyes open/shut, foam, vibration, head tilts
      • Behavioural strategies as coping mechanisms
      • Learn how to move without triggering symptoms (if adaptation and habituation don't work)
      • Learn how to lessen the symptom experience via education, relaxation strategies
  • Habituation
    • Habituate repeated exposure to noxious stimulus to bring about neural changes to reduce sensitivity to the stimulus
    • Identify the source of conflicting sensory information i.e. vestibular, visual, somatosensory
    • Design movements based on those reproducing symptoms (1-4 movements, 2-3x each, 2-5x day)
    • Performed quickly enough through sufficient range to reproduce mild to moderate symptoms – increase this as habituation increases
    • Rest between each movement to allow symptoms to subside (approx. 1 minute)
    • May take up to 4weeks to notice changes
    • Do exercise for up to 2months intensively then gradually reduce them
    • Precautions in elderly with choice of movement


Physical and psychological factors predict outcome following whiplash injury

Pain Journal, 114, 141-148

Michele Sterling, Gwendolen Jull, Bill Vicenzino, Justin Kenardy and Ross Darnell
Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03?1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.

Development of motor system dysfunction following whiplash injury

Pain, Volume 103, Issue 1, Pages 65-73 (May 2003)

Michele Sterling, Gwendolen Jull, Bill Vicenzino, Justin Kenardy, Ross Darnell

Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the superficial neck flexors (EMG) during a test of cranio-cervical flexion) as well as a measure of fear of re-injury (TAMPA) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury. Subjects were classified at 3 months post injury using scores on the neck disability index: recovered (30). Motor system function was also measured in 20 control subjects. All whiplash groups demonstrated decreased ROM and increased EMG (compared to controls) at 1 month post injury. This deficit persisted in the group with moderate/severe symptoms but returned to within normal limits in those who had recovered or reported persistent mild pain at 3 months. Increased EMG persisted for 3 months in all whiplash groups. Only the moderate/severe group showed greater JPE, within 1 month of injury, which remained unchanged at 3 months. TAMPA scores of the moderate/severe group were higher than those of the other two groups. The differences in TAMPA did not impact on ROM, EMG or JPE. This study identifies, for the first time, deficits in the motor system, as early as 1 month post whiplash injury, that persisted not only in those reporting moderate/severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms.

The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash

Manual Therapy, Volume 11, Issue 2, May 2006, Pages 99-106

Julia Treleaven, Gwendolen Jull, Nancy LowChoy

Cervical joint position error (JPE) has been used as a measure of cervical afferent input to detect disturbances in sensori-motor control as a possible contributor to a neck pain syndrome. This study aimed to investigate the relationship between cervical JPE, balance and eye movement control. It was of particular interest whether assessment of cervical JPE alone was sufficient to signal the presence of disturbances in the two other tests. One hundred subjects with persistent whiplash-associated disorders (WADs) and 40 healthy controls subjects were assessed on measures of cervical JPE, standing balance and the smooth pursuit neck torsion test (SPNT). The results indicated that over all subjects, significant but weak-to-moderate correlations existed between all comfortable stance balance tests and both the SPNT and rotation cervical JPE tests. A weak correlation was found between the SPNT and right rotation cervical JPE. An abnormal rotation cervical JPE score had a high positive prediction value (88%) but low sensitivity (60%) and specificity (54%) to determine abnormality in balance and or SPNT test. The results suggest that in patients with persistent WAD, it is not sufficient to measure JPE alone. All three measures are required to identify disturbances in the postural control system.

MRI study of the cross-sectional area for the cervical extensor musculature in patients with persistent whiplash associated disorders (WAD)

Manual Therapy, Volume 13, Issue 3, June 2008, Pages 258-265

James Elliott, Gwendolen Jull, Jon Timothy Noteboom, Graham Galloway

Cervical muscle function is disturbed in patients with persistent pain related to a whiplash associated disorder (WAD) but little is known about neck extensor muscle morphometry in this group. This study used magnetic resonance imaging to measure relative cross-sectional area (rCSA) of the rectus capitis posterior minor and major, multifidus, semispinalis cervicis and capitis, splenius capitis and upper trapezius muscles bilaterally at each cervical segment. In total, 113 female subjects (79 WAD, 34 healthy control; 18–45 years, 3 months–3 years post-injury) were recruited for the study.
Significant main effects for differences in muscle and segmental level were found between the two groups (P<0.0001) as well as a significant group * muscle * level interaction (P<0.0001). The cervical multifidus muscle in the WAD group had significantly larger rCSA at all spinal levels and in contrast, there were variable differences in rCSA measures across levels in the intermediate and superficial extensor muscles when compared to the healthy controls (P<0.0001). There were occasional weak, although statistically significant relationships between age, body mass index (BMI), duration of symptoms and the size of some muscles in both healthy control and WAD subjects (P<0.01).

It is possible that the consistent pattern of larger rCSA in multifidus at all levels and the variable pattern of rCSA values in the intermediate and superficial muscles in patients with WAD may reflect morphometric change due to fatty infiltrate in the WAD muscles. Future clinical studies are required to investigate the relationships between muscular morphometry, symptoms and function in patients with persistent WAD.

In vivo study of nerve movement and mechanosensitivity of the median nerve in whiplash and non-specific arm pain patients Pain, Volume 115, Issue 3, Pages 248-253 (June 2005)

Jane Greening, Andrew Dilley, Bruce Lynn

Chronic pain following whiplash injury and non-specific arm pain (NSAP, previously termed diffuse repetitive strain injury) present clinicians with problems of diagnosis and management. In both patient groups there are clinical signs of altered nerve movement and increased nerve trunk mechanosensitivity. Previous studies of NSAP patients have identified altered median nerve movement at the wrist. The present study uses high frequency ultrasound imaging to examine changes to median nerve movement and clinical examination to assess altered mechanosensitivity of the median nerve. Longitudinal median nerve movement was measured in the forearm during maximal inspiration in nine post-whiplash patients with chronic neck and arm pain and eight controls subjects. Eight NSAP patients and seven controls were also studied. Transverse median nerve movement at the proximal carpal tunnel during 30° wrist extension to 30° flexion was also measured. A clinical examination of nerve trunk allodynia was performed in all subjects. Longitudinal nerve movement in the forearm was reduced by 71% in the post-whiplash patients and by 68% in NSAP patients compared to controls. In the whiplash patients the pattern of transverse median nerve movement at the proximal carpal tunnel was significantly different to controls (patient mean=2.57±0.80mm (SEM) in a radial direction; control mean=0.39±0.52mm in an ulnar direction). Signs of neural mechanosensitivity (i.e. painful responses to median nerve trunk and brachial plexus pressure and stretch) were apparent in both patients groups. Change in nerve tension and neural mechanosensitivity may contribute to symptoms in whiplash and NSAP patients.

Reduced reactivity and enhanced negative feedback sensitivity of the hypothalamus-pituitary-adrenal axis in chronic whiplash-associated disorder

Pain, Volume 119, Issues 1-3, 15 December 2005, Pages 219-224

Jens Gaab, Susanne Baumann, Angela Budnoik, Hanspeter Gmünder, Nina Hottinger, Ulrike Ehlert

Dysregulations of the hypothalamus–pituitary–adrenal (HPA) axis have been discussed as a physiological substrate of chronic pain and fatigue. The aim of the study was to investigate possible dysregulations of the HPA axis in chronic whiplash-associated disorder (WAD). In 20 patients with chronic WAD and 20 healthy controls, awakening cortisol responses as well as a short circadian free cortisol profile were assessed before and after administration of 0.5 mg dexamethasone. In comparison to the controls, chronic WAD patients had attenuated cortisol responses to awakening, normal cortisol levels during the day, and showed enhanced and prolonged suppression of cortisol after the administration of 0.5 mg dexamethasone. Dysregulations of the HPA axis in terms of reduced reactivity and enhanced negative feedback suppression exist in chronic WAD. The observed endocrine abnormalities could serve as a systemic mechanism of symptoms experienced by chronic WAD patients.

Systemic Immune Response in Whiplash Injury and Ankle Sprain: Elevated IL-6 and IL-10

Clinical Immunology, Volume 101, Issue 1, October 2001, Pages 106-112

Jouko Kivioja, Volkan Özenci, Luciano Rinaldi, Mathilde Kouwenhoven, Urban Lindgren, Hans Link

Whiplash injury and whiplash-associated disorders (WAD) are significant problems of modern society. Numerous attempts have been made to characterize the nature of whiplash injury. Whether the immune system is involved during the disease process is not known. In a prospective study, using enzyme-linked immunospot (ELISPOT) assays, we examined numbers of blood mononuclear cells (MNC) secreting pro- (IFN-?, TNF-a, IL-6) and anti-inflammatory (IL-10) cytokines in patients with WAD and, for reference, patients with ankle sprain and multiple sclerosis and healthy subjects. An immune response reflected by elevated numbers of TNF-a- and IL-10-secreting blood MNC was observed in patients with WAD examined within 3 days compared to 14 days after the whiplash injury. The patients with WAD examined within 3 days after the injury had also higher numbers of IL-6 and IL-10 secreting blood MNC compared to healthy subjects. The alterations of cytokine profiles observed in WAD were also observed in patients with ankle sprain when examined within 3 days after trauma. In contrast, there were no differences for cytokine profiles between patients with WAD examined 14 days after the whiplash injury and healthy subjects. Relatively minor trauma like WAD and ankle sprain are associated with a systemic dysregulation in numbers of cells secreting pro- as well as anti-inflammatory cytokines.

Women experience greater heat pain adaptation and habituation than men

Pain, Volume 145, Issue 3, Pages 350-357 (October 2009) 

Javeria A. Hashmi, Karen D. Davis

It is not clear how males and females cope with pain over time and how sensory and emotional qualities fluctuate from moment to moment, although studies of pain at discrete time points suggest that women are more pain sensitive than men. Therefore, we developed a new broader-based pain model that incorporates a temporally continuous assessment of multiple pain dimensions across sensory and affective dimensions, and normalized peak pain intensity to unmask sex differences that may otherwise be confounded by inter-individual variability in pain sensitivity. We obtained continuous ratings of pain, burning, sharp, stinging, cutting, and annoyance evoked by repeated prolonged noxious heat stimuli in 32 subjects. Strikingly, females reported more pain than males at the outset of the first exposure to pain, but then experienced less pain and annoyance than males as a painful stimulus was sustained and with repeated stimulation. Patterns of pain and annoyance attenuation in women resembled the attenuation of sharp, stinging and cutting sensations, whereas patterns of pain and annoyance in men resembled burning sensations. Taken together, these data demonstrate a prominent sex difference in the time course of pain. Notably only females demonstrate adaptation and habituation that allow them to experience less pain over time. These findings suggest a sexual dichotomy in mechanisms underlying pain intensity and annoyance that could involve specific quality-linked mechanisms. Importantly, temporal processing of pain differs between males and females when adjusted for sex differences in pain sensitivity. Our findings provide insight into sex differences in tonic and possibly chronic pains.

Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries

Pain, Volume 145, Issue 3, Pages 325-331 (October 2009)

Michael J.L. Sullivan, Pascal Thibault, Maureen J. Simmonds, Maria Milioto, André-Philippe Cantin, Ana M. Vellya

The present study assessed the role of pain and pain-related psychological variables in the persistence of post-traumatic stress symptoms following whiplash injury. Individuals (N=112) with whiplash injuries who had been admitted to a standardized multidisciplinary rehabilitation program were asked to complete measures of pain, post-traumatic stress symptoms, physical function and pain-related psychological variables at three different points during their treatment program. The findings are consistent with previous research showing that indicators of injury severity such as pain, reduced function and disability, and scores on pain-related psychological were associated with more severe post-traumatic stress symptoms in individuals with whiplash injuries. Contrary to expectations, indicators of pain severity did not contribute to the persistence of post-traumatic stress symptoms. Univariate analyses revealed that self-reported disability, pain catastrophizing and perceived injustice were significant determinants of the persistence of post-traumatic stress symptoms. In multivariate analyses, only perceived injustice emerged as a unique predictor of the persistence of post-traumatic stress symptoms. The results suggest that early adequate management of pain symptoms and disability consequent to whiplash injury might reduce the severity of post-traumatic stress symptoms. The development of effective intervention techniques for targeting perceptions of injustice might be important for promoting recovery of post-traumatic stress symptoms consequent to whiplash injury.

Influences on the fusimotor-muscle spindle system from chemosensitive nerve endings in cervical facet joints in the cat: possible implications for whiplash induced disorders.

Thurnberg et al (2001) Pain, 91, 15-22

  • bradykinin was injected into the C1 and C2 facet joints
  • this resulted in increased activity in static fusimotorneurones leading to enhanced dorsal neck muscle activity
  • this was abolished by local anaesthetic into the same facet joints
  • thus a reflexogenic connection between nerve receptors in the cervical joint and the dorsal cervical muscles was established
  • it was hypothesised that this may lead to alterations in proprioception, motor coordination, and regulation of muscle stiffness.
  • additionally, balance and vestibular problems were considered a conceptual possibility due to this alteration in neuronal activity
  • chronicity, due to the build up of lactic acid and other inflammatory substances from lack of blood flow due to muscle stiffness is a likely scenario

Randomized controlled trial of exercise for chronic whiplash-associated disorder

Stewart et al (2007), Pain, Volume 128, Issue 1, Pages 59-68

Whiplash-associated disorders are common and incur considerable expense in social and economic terms. There are no known effective treatments for those people whose pain and disability persist beyond 3 months. We conducted a randomized, assessor-blinded, controlled trial at two centres in Australia. All participants received 3 advice sessions. In addition the experimental group participated in 12 exercise sessions over 6 weeks. Primary outcomes were pain intensity, pain bothersomeness and function measured at 6 weeks and 12 months. Exercise and advice was more effective than advice alone at 6 weeks for all primary outcomes but not at 12 months. The effect of exercise on the 0–10 pain intensity scale was -1.1 (95%CI -1.8 to -0.3, p=0.005) at 6 weeks and -0.2 (0.6 to -1.0, p=0.59) at 12 months; on the bothersomeness scale the effect was -1.0 (-1.9 to -0.2, p=0.003) at 6 weeks and 0.3 (-0.6 to 1.3, p=0.48) at 12 months. The effect on function was 0.9 (0.3 to 1.6, p=0.006) at 6 weeks and 0.6 (-0.1 to 1.4, p=0.10) at 12 months. High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months. In the short-term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash. Exercise is more effective for subjects with higher baseline pain and disability.

Habituation of the early pain-sensitivity respiratory response in sustained pain.

Kato et al (2001) Pain, 91, 57 - 63

  • respiratory rate appears to be habitually high in the chronic pain state (from 13.2Hz to 17.7Hz)
  • the pre Boetzinger brainstem complex appears to be the target for pro-nociception and anti-nociception input
  • this may be significant in terms of the scalene muscles and thoracic outlet syndrome, thoracic spine posture and mobility; or in the case of diaphragmatic breathing, the lumbothoracic stability and rhythm
  • additionally, alterations in sympathetic nervous system activity may be expected


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peripheral sympathetic nervous system and WDR hypersensitivity

link to neurophysiology and PET scan of cortex

What we do for headaches


Last update : 21 February 2017


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  • Sun 15 Oct 2017

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,  Uploaded : 18 October 2017 Read More
  • Mon 09 Oct 2017


    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. By December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower academic classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several lower limb Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one from the AFL academy had followed up on his recovery (or in this case lack of recovery).  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic. Stopped going to school for 7 weeks due to another head impact, but this time at Basketball. Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  One of the known risk factors for Sport Related Concussion (SRC) is a history of concussion. Although, most adults recover from concussion after 10 days, there is evidence to suggest ongoing abnormailities in the brain can pursist well beyond 10 days (Prichep et al 2013, J Head Trauma Rehabil, 28, 4, 266-273). Thus, with the above described symptoms and potential motor control problems, further complications of PCS also appear to be altered proprioception, an increased risk of musculoskeletal injury which in turn can lead to SRC. The following are the results from soccer players. Nordstrom et al (2014, BMJ Sports Med, 48, 19, Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Disconcertingly, highly trained young individuals can find even exercises in bed extremely demanding in the presence of sport related concussion (SRC). Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people,whereby 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320), wheerby some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill. Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Anatomical considerations : Extensive anatomical connections between the eyes, neck and vestibular system (Wallwork et al 2007, JOSPT, 37, 10, 608-612) allow sensory information from neck proprioceptors to be processed together with vestibular information which, via the lateral vestibulo-spinal tract, affect the control of postural muscles such as the deep trunk muscles  (Hain 2011, Neuro-Rehabilitation, 29, 2, 127-141).  Psychological considerations : The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Physiotherapy Assessment : Current history One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting strong deficits, despite these being 'somewhat good' previously. Significantly, during the acute phase of SRC, rugby union and rugby league players have been seen with alterations of both balance strategies and motor control of the trunk (Hides et al 2017, Musculoskeletal Sci Pract, 29, 7-19).  Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error (RPE) using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate and cognitively demanding. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some of the autonomic dysfunction observed.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football (soccer) head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Trunk muscles : Researchers have found that a history of SRC had an increased possibility of having altered size and contraction of their trunk muscles, incuding smaller multifidus, larger quadratus lumborum muscles, and asymmetrical contraction of their transverse abdominis muscles, whereby an increased thickness and resting tone of the right anteroloateral abdominal muscle has been observed (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). In this case, by the second incident (Basketball impact), the subject was 15 years of age and 193cm in height. Apart from being very tall for his age he also has joint hypermobility. Combinations of SRC, growth spurt and hypemobility may have had a greater impact on his motor performance making secondary trauma more likely? A 3-6 increased risk of future SRC has been reported in the literature in cases of concussion (Abrahams et al 2014, Br J sp Med, 48, 2, 91-97). In our subject, using the laser repositioning error described above, marked inability to reposition the neck from the left was seen. This concurs with the findings in Australian Football Players (AFL), where a mean of 4.5 degrees of joint position error was reported on the left hand side (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). This is noteworthy, as our subjects initial concussion took place during AFL, with the subsequent concussion occurring in Basketball. It should also be remembered that this subject presented to physiotherapy for an ankle injury some 6 months after the initial concussion. Lower limb kinematic exercising ability, emphasising global balance and kinematic 'inverse dynamics' muscular energy strap transfer prinicples, demonstrated strength and balance deficits within the following prgramme. It should be noted that this regime places emphasis on repatitive loading; hence 3 x 40 reps. Interestingly, an investigation comparing lower limb (LL) and back exercises (lumbar extension LE and lumbar stabilisation LS) for runners with chronic low back pain reported  greater improvement in self-rated running capability and knee extension strength in the LL group vs LE and LS groups greater increase in running step length in LL and LE groups and similar reductions in running induced pain and improvement in back muscles across all three exercise groups. (Cai et al 2018, Med Sc Sp EX, 49, 12, 2374-2384) Extrapolation of these results to the current clinical setting suggests the importance of lower limb dynamic stability in cases of concussion. Moreover, recognition of these deficits may have prevented the second incidence of concussion? Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Updated : 10 February 2018. Original : 17 November 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

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Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected