Northwestern University Department of Physical Therapy and Human Movement Sciences Feinberg School of Medicine 645 North Michigan Avenue Suite 1100 Chicago, Illinois 60611
j-elliott@northwestern.edu
James ("Jim") is an Assistant Professor in the Department of Physical Therapy and Human Movement Sciences in the Feinberg School of Medicine at Northwestern University in Chicago, Illinois. He completed his Doctoral Thesis (2007) in Health and Rehabilitation Science at The University of Queensland, Brisbane, Australia on Magnetic Resonance Imaging of the Cervical Spine Muscles in Chronic Whiplash Injury.
From 2008 – 2010 he was a Post-Doctoral Research Fellow at The University of Queensland in the National Health and Medical Research Council Clinical Centre of Research Excellence in Spinal Pain, Injury and Health (CCRE-Spine) and the Centre for National Research on Disability and Rehabilitation Medicine (CONROD), focussing on prognostic factors of outcomes following whiplash injury.
Currently, Jim is continuing his work into developing new measures for assessing patients with acute spinal trauma.
Abstract: STUDY DESIGN: Retrospective investigation of muscle changes in patients suffering from chronic whiplash-associated disorders (WAD). OBJECTIVES: To quantitatively compare the presence of muscle alterations (fatty infiltrate [MFI] and cross-sectional area [CSA]) in the anterior musculature of the cervical spine in a cohort of chronic whiplash patients (WAD II) and healthy control subjects across muscle and cervical segmental level. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging can be regarded as the gold standard for muscle imaging. There is little knowledge about in vivo features of anterior neck muscles in patients suffering from chronic WAD and how muscle structure differs across the factors of muscle, vertebral level, age, self-reported pain and disability, body mass index, and duration of symptoms. METHODS: Reliable magnetic resonance imaging measures for MFI and CSA were performed for the anterior cervical muscles bilaterally in 109 female subjects (78 WAD, 31 healthy control; 18-45 years, 3 months to 3 years postinjury). The measures were performed on all subjects for the longus capitis and colli and the sternocleidomastoid muscles. RESULTS: The WAD subjects had significantly larger MFI and CSA for the anterior muscles compared to healthy control subjects (all P < 0.0001). In addition, the amount of MFI varied by both cervical level and muscle, with the longus capitis/colli having the largest amount of fatty infiltrates at the C2-C3 level (P < 0.0001). MFI was inversely related to age, self-reported pain/disability, and body mass index but directly proportional to duration of symptoms. CONCLUSION: There is significantly greater MFI and CSA in the anterior neck muscles, especially in the deeper longus capitis/colli muscles, in subjects with chronic WAD when compared to healthy controls. Future studies are required to investigate the relationships between muscular morphometry and symptoms in patients suffering from acute and chronic WAD.
Abstract: The patient was a 32-year-old woman diagnosed with grade III spondylolisthesis at the age of 18. While the patient had not experienced back pain in recent years, she anticipated a recurrence of symptoms during her final trimester of pregnancy. Lumbar magnetic resonance imaging was used to confirm the presence of grade IV spondylolisthesis. J Orthop Sports Phys Ther 2010;40(5):324. doi:10.2519/jospt.2010.0407.
Abstract: OBJECTIVE: To evaluate the activity of neck extensor muscles during different extension exercises with muscle functional magnetic resonance imaging (mfMRI). DESIGN: Cross-sectional. SETTING: University laboratory. PARTICIPANTS: Healthy subjects (N=11; 7 men, mean age +/- SD, 34+/-5.6y; 4 women, mean age +/- SD, 23.3+/-5.2y; group mean age +/- SD, 30.1+/-7.5y). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: mfMRI measures of T2 relaxation were made for the multifidus (Mul), the semispinalis cervicis (SCe), the semispinalis capitis (SCa), and the splenius capitis (SpC) at C2-3, C5-6, and C7-T1 in response to 2 head/neck orientations: craniocervical neutral (CCN) and craniocervical extension (CCE). Subjects performed three 1-minute repetitions of each condition at 20% maximum voluntary contraction. RESULTS: Significant shifts were observed in all muscle groups at the C5-6 and C7-T1 levels after both conditions (P=.04) except the SpC muscle at C5-6 with CCN (P=.17). T2 shifts in the SCa were significantly greater in response to CCE than CCN at C2-3 (P=.03) and C5-6 (P=.02). Similarly, CCE resulted in larger shifts than CCN in the Mul/SCe at C7-T1 (P=.003). No segmental differences were observed between exercises for SpC (P=.25). CONCLUSIONS: The results of this study provide some preliminary insight into the impact of craniocervical orientation on the differential response of the deep and superficial cervical extensor muscles during the performance of cervical extensor exercises.
Abstract: STUDY DESIGN: Cross-sectional. OBJECTIVE: To develop a new magnetic resonance imaging (MRI) measure for the diffusive properties of the healthy cervical multifidus and to determine the inter- and intra-rater reliability of the measurement. BACKGROUND: Diffusion Weighted MRI (DWI), via calculation of the apparent diffusion coefficient (ADC), provides a representation of microscopic movements of water molecules in human tissues and may be useful to assess structural changes in neck muscle as has been observed following whiplash. The optimal imaging parameters however, have not been established. METHODS: A DWI measure was developed and for the basic examination, the right cervical multifidus muscle at the C5 level was studied. A total of 6 asymptomatic volunteer subjects (3 females and 3 males) underwent a single DWI scan. Inter- and intra-rater agreement was evaluated using Bland & Altman Plots and intraclass correlation coefficients. RESULTS: Mean ADCb0-b50 and ADCb50-250 were significantly different from one another (p = 0.03). The plots confirmed the agreement of raters for ADC of the right cervical multifidus at C5. CONCLUSIONS: A quantitative and reliable DWI measure of cervical multifidus ADC has been described. There appears to be a fast and slow component ADC for the healthy multifidus suggesting changes in extra- and intra-cellular volume. Further comparative study is needed to quantify ADCs in the neck muscles in patients with traumatic whiplash. J Orthop Sports Phys Ther 2010, Epub 1 September 2010. doi:10.2519/jospt.2010.3423.
Abstract: The objective was to determine whether any measurable changes in sensory responses, kinesthetic sense, cervical motion, and psychological features were related to established fatty infiltration values in the cervical extensor musculature in subjects with persistent whiplash. It is unknown if fatty infiltrate is related to any signs or symptoms. Data on motor function, Quantitative Sensory Testing, psychological and general well-being, and pain and disability were collected from 79 female subjects with chronic whiplash. Total fat values were created for all subjects by averaging the muscle fat indices by muscle, level, and side from our MRI dataset of all the cervical extensor muscles. Results of this study indicate the presence of altered physical, kinesthetic, sensory, and psychological features in this cohort of patients with chronic whiplash. Combined factors of sensory, physical, kinesthetic, and psychological features all contributed to a small extent in explaining the varying levels of fatty infiltrate, with cold pain thresholds having the most influence (r (2) = 0.28; P = 0.02). Identifying and relating quantifiable muscular alterations to clinical measures in the chronic state, underpin some clinical hypotheses for possible pathophysiological processes in this group with a chronic and recalcitrant whiplash disorder. Future research investigations aimed at accurate identification, sub-classification, prediction, and management of patients with acute and chronic whiplash is warranted and underway.
Abstract: SYNOPSIS: The development of chronic pain and disability following whiplash injury is common and contributes substantially to personal and economic costs related with this condition. Emerging evidence demonstrates the clinical presence of alterations in the sensory and motor systems, including psychological distress in all individuals with a whiplash injury, regardless of recovery. However, individuals who transition to the chronic state present with a more complex clinical picture characterized by the presence of widespread sensory hypersensitivity, as well as significant posttraumatic stress reactions. Based on the diversity of the signs and symptoms experienced by individuals with a whiplash condition, clinicians must take into account the more readily observable/measurable differences in motor, sensory, and psychological dysfunction. The implications for the assessment and management of this condition are discussed. Further review into the pathomechanical, pathoanatomical, and pathophysiological features of the condition also will be discussed. LEVEL OF EVIDENCE: Level 5.J
Abstract: SYNOPSIS: There is irrefutable evidence of an association between mechanical neck pain (MNP) and dysfunction of the muscles of the cervical spine. A myriad of impairments have been demonstrated that include changes in the physical structure (cross-sectional area, fatty infiltration, fiber type), as well as changes in behavior (timing and activation level), of the cervical muscles. Such changes suggest an impaired capacity of the cervical muscles to generate, sustain, and maintain precision of the required levels of torque needed for optimal function. In the context of physical support, these changes potentially have deleterious consequences for the cervical region, which relies heavily on its muscles for mechanical stability. While interventions focused on the retraining of cervical muscle function have shown favorable responses in alleviating MNP, the development of best practice strategies for the assessment and management of cervical muscle dysfunction is still a work in progress. One obstacle in researching the efficacy of cervical muscle training is that, as yet, we do not possess the capacity to optimally measure and classify those patients most likely to respond to different methods of training that would enrich clinical practice. While gains in this area are emerging, the ability of a clinician to best identify the need and implement the most appropriate method of training cervical muscle function is still largely dependent on a comprehensive examination of the patient that considers all aspects of the patient's disorder and functional requirements. LEVEL OF EVIDENCE: Level 5.
Abstract: 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.
Abstract: AIM: To investigate the presence of fatty infiltrate in the cervical extensor musculature in patients with insidious-onset neck pain to better understand the possible pathophysiology underlying such changes in chronic whiplash-associated disorders (WAD). MATERIALS AND METHODS: A sample of convenience of 23 women with persistent insidious-onset neck pain (mean age 29.2+/-6.9 years) was recruited for the study. Magnetic resonance imaging (MRI) was used to quantify fatty infiltration in the cervical extensor musculature. Quantitative Sensory Testing (QST; pressure and thermal pain thresholds) was performed as sensory features are present in chronic whiplash. Self-reported pain and disability, as well as psychological distress, were measured using the Neck Disability Index (NDI) and the General Health Questionnaire-28 (GHQ-28), respectively. RESULTS: Measures were compared with those of a previous dataset of chronic whiplash patients (n=79, mean age 29.7+/-7.8 years). Using a classification tree, insidious-onset neck pain was clearly identified from whiplash (p<0.001), based on the presence of MRI fatty infiltrate in the cervical extensor musculature (0/102 individuals) and altered temperature thresholds (cold; 3/102 individuals). CONCLUSION: Fatty infiltrates in the cervical extensor musculature and widespread hyperalgesia were not features of the insidious-onset neck pain group in this study; whereas these features have been identified in patients with chronic WAD. This novel finding may enable a better understanding of the underlying pathophysiological processes in patients with chronic whiplash.
Abstract: The Orthopaedic Section of the American Physical Therapy Association presents this second set of clinical practice guidelines on neck pain, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.
Abstract: OBJECTIVES: To quantify differences in the size/shape of the oropharynx between female subjects with whiplash and controls. DESIGN: Retrospective cohort. METHODS: A total of 113 subjects (79 whiplash, 34 controls) were included. T1-weighted MRI was used to measure 1) cross-sectional area (CSA [mm(2)]) and 2) shape ratios for the oropharynx. Reliability data were established. RESULTS: Whiplash subjects had significantly smaller oropharynx CSAs (P < 0.001) and shape ratios (P < 0.001) compared with healthy controls. Self-reported levels of pain and disability and duration of symptoms were not associated with size and shape of the oropharynx in whiplash subjects (P = 0.75 and P = 0.99, respectively). Age and BMI did influence the size (P = 0.01) and shape of the oropharynx (P < 0.001) in the whiplash subjects, but only 20 to 30 percent of the variance could be explained by these factors. CONCLUSION: Significant difference in the size and shape of the oropharynx was noted in subjects with chronic whiplash compared with controls. Future studies are required to investigate the relationships between oropharynx morphometry and symptoms in patients with chronic whiplash.
Abstract: Interest in rehabilitative ultrasound imaging (RUSI) of the posterior paraspinal muscles is growing, along with the body of literature to support integration of this technique into routine physical therapy practice. This clinical commentary reviews how RUSI can be used as an evaluative and treatment tool and proposes guidelines for its use for the posterior muscles of the lumbar and cervical regions. Both quantitative and qualitative applications are described, as well as measurement reliability and validity. Measurement of morphological characteristics of the muscles (morphometry) in healthy populations and people with spinal pathology are described. Preliminary normal reference data exist for measurements of cross-sectional area (CSA), linear dimensions (muscle depth/thickness and width), and shape ratios. Compared to individuals without low back pain, changes in muscles' size at rest and during the contracted state have been observed using RUSI in people with spinal pathology. Visual observation of the image during contraction indicates that RUSI may be a valuable biofeedback tool. Further investigation of many of these observations is required using controlled studies to provide conclusive evidence that RUSI enhances clinical practice.
Abstract: The use of ultrasound imaging by physical therapists is growing in popularity. This commentary has 2 aims. The first is to introduce the concept of rehabilitative ultrasound imaging (RUSI), provide a definition of the scope of this emerging tool in regard to the physical therapy profession, and describe how this relates to the larger field of medical ultrasound imaging. The second aim is to provide an overview of basic ultrasound imaging and instrumentation principles, including an understanding of the various modes and applications of the technology with respect to neuromusculoskeletal rehabilitation and in relation to other common imaging modalities.
Abstract: Magnetic Resonance Imaging (MRI) can be regarded as the gold standard for muscle imaging; however there is little knowledge about in vivo morphometric features of neck extensor muscles in healthy subjects and how muscle size alters across vertebral segments. It is not known how body size and activity levels may influence neck muscle cross-sectional area (CSA) or if the muscles differ from left and right. The purpose of this study was to establish relative CSA (rCSA) data for the cervical extensor musculature with a reliable MRI measure in asymptomatic females within a defined age range and to determine if side-side and vertebral level differences exist. MRI of the cervical spine was performed on 42 asymptomatic female subjects within the age range of 18-45. The rCSA values for the cervical extensor muscles were measured from axial T1-weighted images. We found significant side-side rCSA differences for the rectus capitis posterior minor, major (P < 0.001), multifidus (P = 0.002), and the semispinalis cervicis/capitis (P = 0.001, P < 0.001). There were significant vertebral level differences in rCSA of the semispinalis cervicis/capitis, multifidus, splenius capitis, and upper trapezius (P < 0.001). Activity levels were shown to impact on the size of semispinalis cervicis (P = 0.027), semispinalis capitis (P = 0.003), and the splenius capitis (P = 0.004). In conclusion, measuring differences in neck extensor muscle rCSA with MRI in an asymptomatic population provides the basis for future study investigating relationships between muscular atrophy and symptoms in patients suffering from persistent neck pain. Clin.
Abstract: This study analyses the differences in the relative cross-sectional area (rCSA) of several cervical extensor muscles, assessed by magnetic resonance imaging (MRI), between patients with chronic tension-type headache (CTTH) and healthy controls. MRI of the cervical spine was performed on 15 CTTH females and 15 matched controls. The rCSA values for the rectus capitis posterior minor (RCPmin), rectus capitis posterior major (RCPmaj), semispinalis capitis and splenius capitis muscles were measured from axial T1-weighted images using axial MR slices aligned parallel to the C2/3 intervertebral disc. A headache diary was kept for 4 weeks in order to substantiate the diagnosis and record the pain history. CTTH patients showed reduced rCSA for both RCPmin and RCPmaj muscles (P < 0.01), but not for semispinalis and splenius capitis muscles, compared with controls. Headache intensity, duration or frequency and rCSA in both RCPmin and RCPmaj muscles were negatively correlated (P < 0.05): the greater the headache intensity, duration or frequency, the smaller the rCSA in the RCPmin and RCPmaj muscles. CTTH patients demonstrate muscle atrophy of the rectus capitis posterior muscles. Whether this selective muscle atrophy is a primary or secondary phenomenon remains unclear. In any case, muscle atrophy could possibly account for a reduction of proprioceptive output from these muscles, and thus contribute to the perpetuation of pain.
Abstract: STUDY DESIGN: Cross-sectional investigation of muscle changes in patients suffering from persistent whiplash-associated disorders (WAD). OBJECTIVES: To quantitatively compare the presence of fatty infiltrate in the cervical extensor musculature in a cohort of chronic whiplash patients (WAD II) and healthy control subjects across muscle and cervical segmental level. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging (MRI) can be regarded as the gold standard for muscle imaging; however, there is little knowledge about in vivo features of neck extensor muscles in patients suffering from persistent WAD and how fat content alters across the factors of muscle, vertebral segments, age, self-reported pain and disability, compensation status, body mass index, and duration of symptoms. METHODS: A reliable MRI measure for fatty infiltrate was performed of the cervical extensor muscles bilaterally in 113 female subjects (79 WAD, 34 healthy control; 18-45 years, 3 months to 3 years post injury). The measure was performed on all subjects for the rectus capitis posterior minor and major, multifidus, semispinalis cervicis and capitis, splenius capitis, and upper trapezius. RESULTS: The WAD subjects had significantly larger amounts of fatty infiltrate for all of the cervical extensor muscles compared with healthy control subjects (all P < 0.0001). In addition, the amount of fatty infiltrate varied by both cervical level and muscle, with the rectus capitis minor/major and multifidi at C3 having the largest amount of fatty infiltrate (P < 0.0001). Intramuscular fat was independent of age, self-reported pain/disability, compensation status, body mass index, and duration of symptoms. CONCLUSION: There is significantly greater fatty infiltration in the neck extensor muscles, especially in the deeper muscles in the upper cervical spine, in subjects with persistent WAD when compared with healthy controls. Future studies are required to investigate the relationships between muscular alterations and symptoms in patients suffering from persistent WAD.
Abstract: BACKGROUND: Several authors have postulated that cervical instability is a major cause of traumatic spinal pain. OBJECTIVE: The purpose of this prospective case series study (n = 6) was to determine if proliferant injections have an effect on cervical translation as measured by a blinded reader. DESIGN: This study was a prospective case series. Study participants were selected from patients seen for the primary complaint of Motor Vehicle Collision related neck pain in a private sub-specialty pain clinic. METHODS: Flexion and extension views were obtained by standard radiographs taken with a C-Arm fluoroscope under Valium sedation. Patients with more than 2.7 mm of absolute cervical translation and at least 50% reduction of cervical and referred pain with a two day rigid cervical immobilization test were admitted into the study. Participants underwent 3 prolotherapy injections at all sites that demonstrated translation. The difference in means between pre-test and post-test measurements (flexion translation, extension translation, and pain VAS scores) were assessed by a Wilcoxon signed ranks test (alpha = 0.05). RESULTS: The mean post-test VAS score (M= 3.83, SD=2.3, t=2.889) was significantly less (p=0.04) than the mean pre-test VAS score (M=5.75, SD=1.94). The correlation between difference in mean extension at C2-3 and C5-6 and difference in mean extension was significant (rho=0.89, p=0.02 and rho=0.85, p=0.03 respectively). Difference in mean flexion at C3-4 and C4-5 was significantly correlated with difference in mean flexion (rho=0.88, p=0.02 and rho=0.941, p <0.01 respectively). CONCLUSIONS: The results of this study demonstrate statistically significant correlations between proliferant injections, a reduction of both cervical flexion and extension translation, as well as a reduction in pain VAS score. Since patients with traumatic cervical instability have few viable treatment options other than surgical fusion, cervical proliferant injections under C-Arm fluoroscope may be a viable treatment option.
Abstract: AIM: To establish a simple method to quantify muscle/fat constituents in cervical muscles of asymptomatic women using magnetic resonance imaging (MRI), and to determine whether there is an age effect within a defined age range. MATERIALS AND METHODS: MRI of the upper cervical spine was performed for 42 asymptomatic women aged 18-45 years. The muscle and fat signal intensities on axial spin echo T1-weighted images were quantitatively classified by taking a ratio of the pixel intensity profiles of muscle against those of intermuscular fat for the rectus capitis posterior major and minor and inferior obliquus capitis muscles bilaterally. Inter- and intra-examiner agreement was scrutinized. RESULTS: The average relative values of fat within the upper cervical musculature compared with intermuscular fat indicated that there were only slight variations in indices between the three sets of muscles. There was no significant correlation between age and fat indices. There were significant differences for the relative fat within the muscle compared with intermuscular fat and body mass index for the right rectus capitis posterior major and right and left inferior obliquus capitis muscles (p=0.032). Intraclass correlation coefficients for intraobserver agreement ranged from 0.94 to 0.98. Inter-rater agreement of the measurements ranged from 0.75 to 0.97. CONCLUSION: A quantitative measure of muscle/fat constituents has been developed, and results of this study indicate that relative fatty infiltration is not a feature of age in the upper cervical extensor muscles of women aged 18-45 years.
Abstract: BACKGROUND: The need exists for more definitive clinical signs indicative of abnormal central pain processing following a whiplash injury. Our observations have identified the presence of allodynia in the thoracic spine in patients with neck pain following whiplash injury. The evaluation of allodynia in the thoracic spine in a whiplash injured population may assist in the clinical diagnosis of patients believed to be suffering from central nervous system hypersensitivity. OBJECTIVE: To evaluate for the presence of allodynia in a cohort of patients with whiplash injury. METHODS: Thirty-one patients with whiplash injuries were evaluated in this prospective study for the presence of allodynia in the thoracic spine. Thoracic vertebrae were marked by the initial evaluating clinician and a Wartenberg pinwheel was utilized to identify areas of hypersensitivity in the thoracic dermatomes. Patients were instructed to give no verbal clues, so only visual clues, as determined by the clinician, were assessed. A second clinician, blinded to the initial examination results, repeated the examination in the same fashion. RESULTS: Thoracic allodynia was identified in 70.97% of the observed population. There was a high level of agreement between observers (Kappa coefficient of agreement, 0.8039; 95% CI, 0.7465, 0.8613; P < 0.05). There was no predilection for a particular thoracic dermatome. CONCLUSION: Thoracic allodynia was identified as a common, interrater-reliable, objective physical examination finding in this whiplash cohort.
