Trapped in the neutral zone: another symptom of whiplash-associated disorder?

Instability of the cervical spine following whiplash trauma has been demonstrated in a number of studies. We hypothesized that, in patients with whiplash-associated disorder, rotation of the head would be accompanied by an earlier onset of neck muscle activity to compensate for intrinsic instability. The aim of the study was to examine the range of motion (RoM) of the cervical spine and the onset and activity of the sternocleidomastoid (SCM) muscles during axial rotation, in healthy control subjects and in patients with chronic whiplash-associated disorder. Forty-eight control subjects (42% male) and 46 patients (33% male) with chronic whiplash-associated disorder (symptoms lasting longer than 3 months) were examined. Cervical axial RoM differed significantly (P = 0.0001) between the groups, with the whiplash patients showing lower values (83 degrees +/- 30 degrees) than the healthy controls (137 degrees +/- 19 degrees). The whiplash patient group showed no evidence of the predicted earlier activation of SCM muscles. Many patients never reached the point in the RoM where SCM muscle activity rises steeply, as it does in the healthy controls (the 'elastic zone'), and their movements remained mostly within the region of low muscle activity (the 'neutral zone'). The whiplash patients appeared either unable or unwilling to drive the cervical spine into this region of high muscle activity, possibly because they were restricted by existing pain or fear of pain.