Welcome to BrainHub Podcast where you will discover the top news and tips on keeping your brain healthy.
Hello and welcome to the BrainHub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinic in Sydney.
Matthew: Good day Carlo, how are you doing?
Carlo: Great Matthew, excuse my rusty voice this morning after two weekends of presenting seminar content it’s a little husky today.
Matthew: Yes, I was going to ask you a little bit about that, you have been doing some seminars for practitioners on the treatment of vestibular disorders, that’s, for those who aren’t practitioners the balance system within the body, do you want to tell us a little bit about how that went?
Carlo: Yeah, thanks Matt, we were fortunate that we presented to approximately a hundred practitioners in Sydney and Melbourne over two day weekend, we explored vestibular system and how important it’s to many clinical conditions that practitioners see in their office. We went through an examination and management of people suffering from a range of balance conditions like vertigo, cervical dizziness and other vestibular or balance based conditions.
Matthew: I know, I was at the Melbourne one and I found it to be extremely interesting and the feedback that I believe you got from a lot of people was that the seminars were very well received so hopefully you will doing a lot of those soon.
Carlo: Yeah, thanks Matt, we had very favourable comments from a lot of the practitioners and really pleasant to hear they are experience in their own clinic and how they have translated some of the content that we have covered into obtaining favourable patient outcome which is only one of the goals that we set out in putting this on and we have just announced that we are hitting over to Perth so those people in WA who would have also heard of this seminar series.
Matthew: Yeah that’s great, I am sure we are going to talk a little bit more about vestibular dysfunction and so forth in coming episodes, this is obviously our fourth episode and so far we have looked at the effects of concussion on the brain and how to prevent concussion, how to improve recovery through pre-season screenings and so on and in our last episode we talked about how sugar can have a negative impact on the brain. So if you haven’t had a chance to listen to those episodes be sure to visit brainhub.com.au/blog and you can find all those episodes there. Alternatively if you subscribe on iTunes or Stitcher be sure that you won’t miss any episodes that way. If you like the show be sure to leave us a four or five star review on iTunes, it gives us some nice feedback, it gives us a nice warm fuzzy feeling but also helps others find our podcast as well. So it’s really great for them, it’s really for us and hopefully you get a nice feeling out if it as well. So it could be wonderful if you could. This month we are going to be talking about whiplash, whiplash might seem like an odd topic, there was a great deal of information and awareness raised in the 1980s and 1990s about the effects on the neck and the long term damage that it can cause but the increase in there in that knowledge on brain function has meant that we have discovered impacts on the brain that really weren’t appreciated before. So Carlo, do you want just to give us some background about whiplash and what it’s and what makes it such an important injury?
Carlo: Yes, thanks Matt, most of us as you have mentioned historically we think of whiplash as being a neck related injury, technically it’s referred to as an acceleration or deceleration or a hyperflexion-hyperextention injury. Basically what that means is that we have got this big mass, this ball namely our skull sitting on this thin and fragile structure namely our neck and whenever there is a stop start shearing force on the body as if we were tackled or involved in a car accident this big mass just gets flung forwards and backwards or in sideways at times and it has been shown that because of the acceleration deceleration type movement a lot of the muscular musculoskeletal structures within the neck and the ligaments, the muscles, the disk and in severe cases even the bones themselves can be damaged both in acutely so when the injury happens there is a sprain, strain, sometimes even a fracture of those areas. We have seen in practice and many people have seen in practice that over a long period of time those injuries whether they are small bingos or large motor vehicle accidents can actually lead to other mechanical spinal degeneration based injuries, arthritis and other conditions like that. So we see the effects of it, we see the effects on the neck as a mechanical influence on the upper back and suddenly we need to be aware of those type of injuries.
Matthew: Yes indeed, I know the trigger for these injuries is often quite small as well, I remember reading something that as little as sort of ten kilometres an hour can trigger some sort of whiplash injury in the neck.
Carlo: You are exactly correct, small low speeds have been shown to have the basis of early stages of whiplash disorders and interestingly people think of whiplash, you know, your head has to hit a steering wheel or has to hit the pillar for it to be considered a whiplash and that’s not the case. Even pushing someone from behind or in a little dodging car bingo from behind people can often experience whiplash associated symptoms from such a small innocuous based incident.
Matthew: Indeed, that sort of puts a bit of dump going to the fanfare and jumping in the dodging cars.
Carlo: I guess another thing is that our neck fortunately has the capacity to protect itself, we are not as fragile as it may be but these reflexes can only operate at a certain speed and a lot of these injuries that the body sustains is basically too fast for those protective reflexes to occur. So the neck is somewhat susceptible and as I mentioned small instances can contribute to lasting problems.
Matthew: Yes, now we know of course that the neck and the rest of the spine and other tissues of the neck have a big impact on the brain the logical conclusion is that because of these neck injuries that it’s going to affect the brain function, do you want to tell us a little bit about how the brain relates to whiplash and so forth?
Carlo: Yeah, definitely. Obviously if there is a head trauma associated with the whiplash, your head hits the steering wheel or the pillar or you have been tackled and your head hits the floor there can no doubt be concussion or mild traumatic brain injury components but that aside injury to the neck whether it be from a traumatic injury like a whiplash or even we are noticing now from poor posture or degeneration of the neck has an influence on the brain. I subscribe to a lot of the research performed by a group of physiotherapists based at University of Queensland and led by physiotherapist Julie Treleaven, she has really shown how when there is a dysfunction in the neck the joints in the neck and the muscles in the neck it not only gives you neck pain but it actually has strong influences to other parts of the brain and can cause symptoms. So basically the information from the neck fires up into the brain and influences the balance senses of our brain, it influences eye movement, it influences the autonomic parts of our brainstem and these are the parts that the heart rate, blood pressure, gut function, respiration originates from, the neck and influence areas of the brain that have regulation on our emotions, fear, anxiety, as well as posture. So with these connections what they are finding now is if the neck is disturbed through a whiplash injury then people can suffer from a range of symptoms and they include dizziness and steadiness, headaches, visual changes, they have trouble following a moving target or they have troubles reading and they can have auditory problems, they might have some hearing difficulties as well, they may have cognitive difficulties like poor memory, they are unable to focus and have concentration, they may have fatigue, may have sleep disturbances. So what we find is someone who has had whiplash based injury such as a car accident or sporting injury will typically complain of a number and sometimes all of these symptoms to various grades. It’s really important that we as clinicians or even as patients or someone who suffer this that we don’t simply look at the neck, whilst it’s important and that area needs to be attended to and there is a number of people that can do so but I guess what we are seeing now is a that unless you start assessing and managing these other connected symptoms and signs you are not going to get to the root of the problem and persistence in symptoms can be there.
Matthew: I suppose that kind of links in that one of the big problems in the past with whiplash has been the tendency to sort of develop chronic pain syndromes from it. I suppose that ties in with what you are saying in terms of you have the secondary effects within the brain that need to be addressed as well. Can you dive in a little bit more about the chronic pain aspects and why that’s the case and how the management of whiplash has changed because you see a number of people with whiplash in your clinic, don’t you?
Carlo: That’s true, yeah, a good portion of our patients have suffered whiplash whether be in the sport field or motor vehicle accidents, we have got practitioners and doctors that tend to send clients to us because of the more complete aspect of what we do and going back to your question about chronicity, I find that chronic pain from whiplash really can come from several angles one of which I have touched on that the practitioner may not look at the full picture. They simply look at ok you suffered a neck injury so let’s manage the neck function and whilst this certainly needs to happen it’s certainly not the only thing, because of those connections between the neck, the eyes, the balance system and other parts of the brain your assessment really should involve all movement analyses. It really should involve measuring balance and posture, you should look at vestibular or inner ear function, we often test memory and cognitive capacity because people find that they have got brain fog, they don’t have that capacity to focus on their task, they are quite sleepy, their performance at work suffers. So we measure these things, we also look at blood pressure, heart rate and other things that gives us a good snapshot or window of function to how their body is going. So unless you address these and once you identify them obviously the management should be based upon those findings and unless you can address that as part of your rehabilitation plan then chronicity of pain will tend to happen because you manage their neck they may feel better but unless you are addressing these other things the pain will return or dysfunction will return and it’s that dysfunction that actually contributes to chronic pain. So my strong advice to people with whiplash based problems is really find someone to look across all those aspects which is well researched and there is evidence to show that they are linked. And another aspect that can contribute to chronic pain and something that we see with people with dizziness and that can include cervicogenic or neck related dizziness is fear and anxiety. A lot of people who have had these injuries are fearful of getting into a car or fearful that their balance is not right and that can cause further problems. So we often work with psychologists or other practitioners that may use an assortment of therapies, cognitive behaviour therapy that can help manage people’s expectations, people’s fear and anxiety and unless sometimes you address those things no matter how good you are with your manual therapy or rehabilitation therapy those symptoms can persist and form further chronic problems. So we often encourage people, we work with a team of other elite practitioners who can help us on these things. So basically be broad with your scope, understand the connection between the neck and other parts of the brain and ensure that your therapists involve that and secondly ensure that you are working with people who can help from a cognitive, behavioural and even on an emotional perspective.
Matthew: Yes, I think gone are the days of people being told that it’s all in your head, it used to be a very common thing and unfortunately there probably still are some practitioners out there who tend to think of that but those who are at the forefront of this research and the forefront of practice really do understand that it’s an aspect that’s involving someone’s emotionality and that it’s valid as any physical symptoms that the patient has.
Carlo: Very much so and sometimes you could clear up any physical symptoms that may have happened a result of the injury but if the patient still lives in that fear, anxiety or sensitised world then that would still perceive symptoms irrespective of what actually has happened or is happening. So at times you really need a collective approach.
Matthew: Exactly, I remember when we were studying neurology that one of the things that our teacher said was that you don’t actually have to have any pain in the limb for example, you can feel pain in your finger but it doesn’t mean that that’s where the pain is, all it means is that you are perceiving pain in your brain, that it doesn’t actually have to be anything wrong with your finger. And that isn’t to say that you are just imagining it, it’s that there are problems within the brain and that needs to be dealt with just as much.
Carlo: Very much so, I describe to the patients those things have been really wired in your brain, there is no more inputs and outputs and how we interpret things has been skewed for whichever reason, there is many reasons for that probably another podcast in its own but things are really wide and what we need to do is help change that. Neuroplasticity which is how the brain changes based upon its environment is both a good thing and can be a negative thing as well. So having a practitioner that understands that’s really important. So I would strongly encourage any patient or a parent of a patient who has experienced altered sensations and altered perceptions of pain as well as whiplash injuries then they would certainly seek care from someone who is open and understanding of these underlying processes. Medication is not the answer here, standardised very segmental therapy on an area where pain is believed to be is not the answer, you need a more global way of thinking and managing these sorts of concerns.
Matthew: Well at Brain Hub we do offer assessment for whiplash as well as a variety of other conditions. So if you are based in Australia and you would like some advice the telephone number is 1300770197 or you can visit our website which is brainhub.com.au and there is full contact details available there. Otherwise Carlo was there anything else you wanted to add.
Carlo: No, no, I think for practitioners who want to know more about this Brain Hub has just concluded Sydney and Melbourne seminars, we are about to hit over to Perth and probably other states throughout the year, the information has been recorded and will be available at some other stage for practitioners to be well versed in what we have just discussed. For patients that have suffered these sorts of issues, as Matt said, contact the website or our phone number and we will put you into contact with the best people to help overcome some of these concerns.
Matthew: Great, well thank you very much for listening and until next time take care.
Thanks for listening to the BrainHub Podcast, for more information and to subscribe visit brainhub.com.au.
1: Coppieters I, Malfliet A. Chronic Whiplash-Associated Disorders:
Reorganization of the Brain? EBioMedicine. 2016 Aug 9. pii:
2: Treleaven J, Peterson G, Ludvigsson ML, Kammerlind AS, Peolsson A. Balance,
dizziness and proprioception in patients with chronic whiplash associated
disorders complaining of dizziness: A prospective randomized study comparing
three exercise programs. Man Ther. 2016 Apr;22:122-30.
3: Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in
post-concussion syndrome. Phys Sportsmed. 2015 Jul;43(3):274-84.
4: Yokota J, Shimoda S. [Neuro-otological Studies of Patients Suffering from
Dizziness with Cerebrospinal Fluid Hypovolemia after Traffic Accident-associated
Whiplash Injuries]. Brain Nerve. 2015 May;67(5):627-34.
5: Takasaki H, Treleaven J, Johnston V, Van den Hoorn W, Rakotonirainy A, Jull G.
A description of neck motor performance, neck pain, fatigue, and mental effort
while driving in a sample with chronic whiplash-associated disorders. Am J Phys
Med Rehabil. 2014 Aug;93(8):665-74.
6: Craton N, Leslie O. Is rest the best intervention for concussion? Lessons
learned from the whiplash model. Curr Sports Med Rep. 2014 Jul-Aug;13(4):201-4.
7: Treleaven J, Takasaki H. Characteristics of visual disturbances reported by
subjects with neck pain. Man Ther. 2014 Jun;19(3):203-7.
8: Nijs J, Meeus M, Cagnie B, Roussel NA, Dolphens M, Van Oosterwijck J, Danneels
L. A modern neuroscience approach to chronic spinal pain: combining pain
neuroscience education with cognition-targeted motor control training. Phys Ther.
9: Roitman P, Gilad M, Ankri YL, Shalev AY. Head injury and loss of consciousness
raise the likelihood of developing and maintaining PTSD symptoms. J Trauma
Stress. 2013 Dec;26(6):727-34.
10: Bexander CS, Hodges PW. Cervico-ocular coordination during neck rotation is
distorted in people with whiplash-associated disorders. Exp Brain Res. 2012
11: Treleaven J. Dizziness, unsteadiness, visual disturbances, and postural
control: implications for the transition to chronic symptoms after a whiplash
trauma. Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S211-7.
12: Treleaven J, Jull G, Grip H. Head eye co-ordination and gaze stability in
subjects with persistent whiplash associated disorders. Man Ther. 2011
13: Evans RW. Persistent post-traumatic headache, postconcussion syndrome, and
whiplash injuries: the evidence for a non-traumatic basis with an historical
review. Headache. 2010 Apr;50(4):716-24.
14: Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator.
Headache. 2010 Apr;50(4):699-705.
15: Treleaven J. A tailored sensorimotor approach for management of whiplash
associated disorders. A single case study. Man Ther. 2010 Apr;15(2):206-9.
16: Elliott J, Sterling M, Noteboom JT, Treleaven J, Galloway G, Jull G. The
clinical presentation of chronic whiplash and the relationship to findings of MRI
fatty infiltrates in the cervical extensor musculature: a preliminary
investigation. Eur Spine J. 2009 Sep;18(9):1371-8.
17: Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck
pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009
Dr Carlo Rinaudo (Chiropractor and PhD candidate) is the clinic director of Brain Hub, a clinic in Sydney focussed on helping people with dizziness and vertigo conditions, poor balance, whiplash and concussion symptoms.
The clinic and its practitioners use a range of modalities to help assess and manage these conditions and/or symptoms. Vestibular rehabilitation therapy and other brain-based therapies are primarily utilised, along with standard Chiropractic and physical therapy techniques.
The growing evidence showing support for the management of these conditions comes primarily from the physical therapy and clinical neuroscience fields, rather than chiropractic specific. Fortunately, Dr Rinaudo with post-graduate training both in Australia and from overseas is experienced to translate this knowledge into clinical practice. Additionally, he is currently undertaking a PhD from the University of New South Wales (UNSW) and Neuroscience Research Australia (www.neura.edu.au) in Vestibular Therapy, more specifically clinical trials on how to help people with dizziness and vertigo conditions. He is working alongside leading researchers and Neurologists in the field. Additionally, the benefits expected from his PhD research will be used to further validate the use of vestibular rehabilitation therapy for other related conditions like whiplash and concussions.
Dr Rinaudo is a frequent speaker at national events, as well as lecturer in the field of vestibular rehabilitation and dizziness conditions to other health practitioners.