chronic neck pain: only one of the many consequences of whiplash

CHRONIC NECK PAIN: ONLY ONE OF THE MANY CONSEQUENCES OF WHIPLASH

THE INJURY THAT KEEPS ON GIVING….  WHIPLASH

When we think of WHIPLASH INJURIES, we automatically think of injuries to the neck.  While this is certainly true (CHRONIC NECK PAINis the number one long-term sequelae of WHIPLASH ACCIDENTS), there can be far-reaching consequences that go beyond the neck — in many cases, all over the body.  Follow along today as I show you how Whiplash Associated Disorders (WAD) are tearing people up in epidemic numbers all over the world,

The title of a 2012 study from Department of Physical Therapy at the University of Alberta sums the whole mess up nicely — If They Can Put a Man on the Moon, They Should be Able to Fix a Neck Injury: Explaining Pain Beliefs About WAD.  Unfortunately, research is say that this is far from the case, and as I showed you THE OTHER DAY, it’s unfortunate that experts say we aren’t much further along at solving this puzzle than were 30 years ago.

• AS MANY AS 50% OF THE PEOPLE INJURED IN A WHIPLASH-TYPE ACCIDENT PROGRESS TO CHRONIC:  Earlier this year, BMJ Publishing wrote, “The pain and stiffness from whiplash usually go away in a few days or weeks.”  While they did admit that, “symptoms can sometimes last a lot longer,” what does “longer” really mean?  A 2013 PLoS One study on INFLAMMATION and the relationship to whiplash (The Course of Serum Inflammatory Biomarkers Following Whiplash Injury….) said, “Widespread hyperalgisa, morphological muscle changes and psychological distress are common features of WAD.  Whiplash associated disorders (WAD) are a common and costly health problem for western society. Many (up to 50%) of those injured transition to chronicity and current management approaches for both acute and chronic WAD are only modestly effective.” More recently, last October’s issue of the Journal of Orthopedic and Sports Physical Therapy (JOSPT) revealed that, “It is generally accepted that up to 50% of those with a whiplash injury following a motor vehicle collision will fail to fully recover. Twenty-five percent of these patients will demonstrate a markedly complex clinical picture that includes severe pain-related disability, sensory and motor disturbances, and psychological distress. To date, no management approach (eg, physical therapies, education, psychological interventions, or interdisciplinary strategies) for acute whiplash has positively influenced recovery rates.” This stat is repeated over and over again in the peer-reviewed scientific literature.  And while it isn’t totally true (our TESTIMONIAL PAGE would take issue), it’s true in far more cases than it should be.  And unfortunately……

• THE LONGER IT GOES ON, THE WORSE THE PROGNOSIS:  In October of last year, JOSPT ran another study in a series on whiplash called Recovery Pathways and Prognosis After Whiplash Injury.  The authors concluded that, “Recovery from a whiplash injury is varied and complex. Three distinct patterns of predicted recovery (trajectories) have been identified using disability and psychological outcome measures. These trajectories are not linear, and show that recovery, if it is going to occur, tends to happen within the first 3 months of the injury, with little improvement after this period.” Not only is this scary, but helps prove the earlier point; that unfortunately……

• WE ARE NOT GETTING BETTER AT TREATING IT:   A different study from still the same issue of JOSPT verified all of this when the author began his study (Whiplash Continues its Challenge) by saying, “There have been many advances in the management of neck pain disorders, but a personal frustration as a clinician and researcher in the field is that the incidence of full recovery following a whiplash injury as a result of a motor vehicle crash has not increased and, subsequently, the rate of transition to chronic neck pain has not lessened.”   Much of this has to do with the fact that…..

• STANDARD IMAGING IS RELATIVELY WORTHLESS FOR SHOWING THE REASON(S) BEHIND MANY OF THE COMMON SYMPTOMS OF WHIPLASH INJURIES — BUT THERE IS A PROMISING NEW TECHNOLOGY OUT THERE:  After talking about the same things we’ve already discussed thus far, Dr. James Elliot, a professor of Physical Therapy as Northwestern University’s PT & Human Movement Sciences department said of a study he was working on a few years ago, “Very rarely, if ever, do we have any available imaging findings – with radiography, with CT, with MRI – to accurately identify the lesions that would potentially point to the injury responsible for a person’s ongoing symptoms.”  While this is certainly true, Diagnostic Ultrasound is increasingly being used (at least on THE RESEARCH SIDE OF MEDICINE) to image injured soft tissues (HERE is a cool example).   Two recent studies — one from last August’s Science Reports that dealt with women and Whiplash, the other from the October 2015 issue of the same journal — concluded that, “Tools to assist in the diagnosis of WAD and an increased understanding of neck muscle behaviour are needed. We examined the multilayer dorsal neck muscle behaviour in nine women with chronic WAD versus healthy controls during the entire sequence of a dynamic low-loaded neck extension exercise, which was recorded using real-time ultrasound movies with high frame rates. The WAD group showed more shortening during the neck extension phase in the trapezius muscle and during both the neck extension and the return to neutral phase in the multifidus muscle. For the first time, a novel non-invasive method is presented that is capable of detecting altered dorsal muscle strain in women with WAD during an entire exercise sequence…   Skeletal muscles actively contract and produce force in response to control signals from the central nervous system, leading to mechanical changes in the muscles. Ultrasound enables quantitative descriptions of these mechanical changes and allows non-invasive investigation of different muscle layers in real time and in vivo. Ultrasound analysis measures deformation (mechanical muscle changes, such as elongations and shortenings of the muscle) and deformation rate (how fast the deformation occurs) simultaneously in the superficial and deep neck muscle layers.”  This radically improves our understanding of FASCIAL ADHESION as related to…..

• WHIPLASH AND INJURIES TO THE NECK MUSCLES:  Sometimes I think the medical community can be too smart for their own good; to the point where they are missing the forest for the trees.  Case in point, a scientific article published for lay people just last month (Whiplash Pathology: Does Knowledge Change Clinical Practice?) from Physical Therapist, Chris Worsfold’s site, Pain in the Neck: Notes From a Neck Pain Clinic.  Worsfold says (cherry picked, as are all quotes on this post), “muscle injury occurs in whiplash injury – but it’s rare...”  After telling readers that muscle damage is seen in only about one percent of MRI’S, he goes on to say of specialized blood tests used to detect enzymes released as the result of muscle tearing; “Blood tests can reveal elevated creatine kinase levels after muscle trauma and this often correlates with the degree / severity of the muscle injury. The researchers could find no evidence of muscle damage following whiplash injury; further evidence that frank muscle injury is rare.”  Worsfold is correct here — “frank” (gross) muscle injuries are rare in Whiplash Injuries.  However, I am convinced that the vast majority of what we refer to as muscle strains, muscle pulls, or muscle tears, are anything but (HERE).  In light of YESTERDAY’S POST, concerning Diagnostic Ultrasound and FASCIA, I think it safe to say that muscles are involved in these sorts of injuries.  Proof of that are the numerous studies showing…

• THE MUSCLES OF PEOPLE INJURED IN WHIPLASH ACCIDENTS TURN TO FAT:  I showed this in a very recent post, and because there are lots and lots of studies on this topic (“Fatty Infiltration“), I am not covering it in any more depth.  Suffice it to say that it’s bad, and will not only affect the ranges of motion of your neck (cervical spine) but will be adversely affected by these same ROM’s, leading to rampant spinal decay.  Which begs the question…….

• HOW IMPORTANT IS CERVICAL RANGE OF MOTION IN PEOPLE RECOVERING FROM WHIPLASH?   On the surface, this question is a no-brainer.  I’ve shown you repeatedly what abnormal ranges of motion (HERE) and subsequent DIMINISHED PROPRIOCEPTION lead to.  No matter how you slice it, the end result is going to be some sort of PHYSICAL DEGENERATION.  Let me show you another reason ROM of the Cervical Spine is such a big deal.  Sixteen years ago, three Danish MD / Ph.D’s (all of them neurologists associated with the Pain Research Centre at Aarhus University Hospital) published a study in the journal Neurology called Handicap After Acute Whiplash Injury, in which they looked back a year later at the factors that made Whiplash Injuries worse.  “Exposure to a whiplash injury implies a risk for development of chronic disability and handicap.  In a 1-year prospective study of persons with acute whiplash injury and control subjects who had acute ankle distortion, pain intensity, number of nonpainful neurologic complaints, cervical mobility, workload during extension and flexion of the neck, and results of psychometric assessment were recorded.  After 1 year, 7.8% persons with whiplash injury had not returned to usual level of activity or work. The best single estimator of handicap was the cervical range-of-motion test, which had a sensitivity of 73% and a specificity of 91%. Accuracy and specificity increased to 94% and 99% when combined with pain intensity and other complaints.”  Think about this for a moment; of all the crazy neurological issues that neurologists deal with day in and day out, the number one predictor of crappy outcomes and poor recovery was poor ROM of the cervical spine — something you can test on your own (HERE).   Just remember that this issue of muscle injury helps explain why…….

• WOMEN ARE MORE LIKELY TO BE INJURED THAN MEN:  Although many people (mostly insurance companies) have been saying for years that this is the result of female susceptibility to DEPRESSION and other psychological issues, a study from the November 2015 issue of Pain Practice (Sex Differences in Patients with Chronic Pain Following Whiplash Injury: The Role of Depression, Fear, Somatization, Social Support, and Personality Traits) failed to bear this out by concluding, “Except for emotional support in problem situations and social companionship, psychosocial factors do not differ between men and women with chronic WAD. These findings imply little to no risk for sex bias in studies investigating psychosocial issues in patients with chronic WAD“.  Studies from HERE and HERE respectively concluded that elderly females are the most common group with permanent injuries, and that all our mathematical Whiplash models so far have been based on males.  As of late last summer there is now an advanced model based on females and the differences in their tissues and musculoskeletal structure.  And while women are more commonly injured, both males and females injured injured in MVA find that…..

• TRIGGER POINTS ARE MORE COMMON IN WHIPLASH VICTIMS:  After reading my numerous posts on TRIGGER POINTS, this bullet is not tough to grasp.  A study from Pain Medicine (Myofascial Trigger Points in Patients with Whiplash-Associated Disorders and Mechanical Neck Pain) said that, “Manual examination of suboccipital, upper trapezius, levator scapula, temporalis, supraspinatus, infraspinatus, deltoid, and sternocleidomastoid muscles, was done to search for the presence of both active or latent muscle trigger points.  The mean number of active muscle trigger points was significantly greater in the WAD group than in the mechanical neck pain group.”  This is because…..

• CHRONIC PAIN FROM WHIPLASH IS DIFFERENT THAN OTHER KINDS OF CHRONIC PAIN:  There are so many studies on this topic; suffice it to say that they agree almost unanimously — Whiplash is a different sort of animal than run-of-the-mill injuries, and leave behind a different footprint, with a different sort of pain.  It’s not just a “SPRAINED ANKLE” in the neck as some are fond of saying.  One of the many reasons may be…..

• WHIPLASH AFFECTS MUSCLES THAT HAVE MYODURAL BRIDGES:  Everyone has heard of an epidural.  There are three layers of dura, which are the tough, fascia-like membranes that cover the spinal cord.  Careful anatomy dissections have recently revealed that there are fascia-like “BRIDGES” of connective tissue between the muscles and the dura.  In other words, the numerous tiny suboccipital muscles (the deep muscles that lay directly underneath the base of the skull) have what amounts to attachments to the cord itself.  This is at least part of the reason that stress of various sorts leads to muscle tension, which leads to CERTAIN KINDS OF HEADACHES, ultimately affecting the brain itself (HERE).  And when the brain ain’t happy, ain’t nobody happy!  For a short video on MYO-DURAL BRIDGES, take a look at the provided link.

WHIPLASH AND NEUROLOGICAL DAMAGE

• GENERAL NEUROLOGICAL PROBLEMS:  This, folks, is where things start getting interesting.  Whiplash has the potential to foul your neurological systems up in ways that, as you’ve already seen, we are only beginning to scratch the surface of.  Last October’s issue of Frontiers in Neurology (An Attempt of Early Detection of Poor Outcome after Whiplash) by eleven French researchers did a good job of spelling this out.  “The whiplash problem has generated no less than 566 review articles on whiplash since 1964, which summarize 3,266 papers since 1952.  Although the majority of acute patients with whiplash-associated disorders (WAD) show no visible physical damage to the neck, up to 50% of them develop chronic pain. Whiplash injury would rather induce peripheral sensitization (hypersensitivity of the peripheral nociceptors) and central sensitization (hyper excitability of the central nervous system), which could persist for months and even years past the acute phase of the whiplash. Indeed, recent reviews pointed to clinical signs to evaluate WAD, which suggest a role of central sensitization in chronic whiplash associate disorders: persistent pain complaints, local and widespread hyperalgesia, referred pain, allodynia, decreased spinal reflex thresholds, inefficient diffuse noxious inhibitory control activation, and enhanced temporal summation of pain.  70% of chronic whiplash patients (CWP) complain of dizziness and unsteadiness within 1 week of their trauma, and 40% of acute whiplash patients (AWP) report dizziness and 10% of them develop later otological symptoms, such as tinnitus, deafness, and vertigo.  Reduced cervical mobility, disturbed kinesthesia and altered neck muscles activity are often present at the acute stage and they persist over time in the moderate/severe whiplash groups of patients. Several reviews also point to dysfunctions of postural control in CWP. On the sensory side. Vestibular deficits may be at play because some AWP and CWP exhibit nystagmus, abnormal gain of the vestibulo-ocular, vestibulo-collic and cervico-ocular reflexes, and abnormal values of the vestibular evoked potentials.  The clinical syndromes of whiplash patients can also result from abnormal neck somatosensory information. In particular, the sensitivity of the neck muscles spindle could be affected by ischemic or inflammatory events and degenerative changes. Furthermore, being at the convergence of the somatosensory, vestibular, and visual systems on several central nervous system (CNS) structures, abnormalities of one of more of these subsystems can lead to the oculomotor, cephalic, and postural syndrome.”  I completely realize you may not have gotten this whole thing, but suffice it to say that none of it is fun.  It can all be summarized by the following points.

• WHIPLASH AND CONCUSSIONS / MTBI:   Back in October, JOSPT published a paper (Whiplash Injury or Concussion? A Possible Biomechanical Explanation for Concussion Symptoms in Some Individuals Following a Rear-End Collision) where researchers reviewed data from football helmet impacts and the force generated on the head from MVA.  The authors found, “a potential biomechanical link between whiplash injury and concussion, and advances our understanding of how head restraint interaction during a rear-end crash may cause an injury more typically associated with sports-related head impacts.”  Interesting, because numerous studies have shown that a properly adjusted head restraint (headrest) is the best method of preventing whiplash (middle of the restraint at the middle of the ear).  The worst force in this study was when the head restraint was positioned too low, allowing the neck to be “fulcrumed” over it during rear end impacts.  The Forensic Engineering Expert Witness Blog actually wrote a very interesting (short) post on this study just a couple of weeks ago called Concussion and Whiplash Injury.  If you want to see why concussions have the potential to be a freaky problem, READ THIS CRAZY story about the downfall and demise of Elvis Presley.

• WHIPLASH IS RELATED TO BOTH PSYCHOLOGICAL / MENTAL STRESS:  After initially looking at over 2,500 studies and settling on about 1% of that number that actually met their criteria, researchers writing in last September’s issue of BMJ Open (Psychological Impact of Injuries Sustained in Motor Vehicle Crashes) tried to correlate things like PTSD, DEPRESSION, and psychological distress, to the Whiplash Injury.  The authors concluded that, “Elevated psychological distress was associated with motor vehicle crash related injuries with a large summary effect size in WAD, medium to large effect size in spinal cord injury and small to medium effect size in mild traumatic brain injury. Increased psychological distress remains elevated in spinal cord injuries, mild traumatic brain injuries, and WAD for at least 3 years post-crash.”  And we’ve already seen where MTBI is related to WAD as well.

• WHIPLASH SUFFERERS TEND TOWARD SYMPATHETIC DOMINANCE:   Seeing what we’ve seen so far, we can’t be surprised that Whiplash sufferers frequently end up with SYMPATHETIC DOMINANCE, including it’s number one diagnostic sign — LOW HEART RATE VARIABILITY.  This was confirmed by a study published in the November 2015 issue of Pain Practice (Lower Resting State Heart Rate Variability Relates to High Pain Catastrophizing in Patients with Chronic Whiplash-Associated Disorders).  The study itself is not very exciting unless you understand the concept of Sympathetic Dominance — living in a constant state of “fight or flight” adrenal arousal.  It’s no wonder this sort of stress burns out the adrenal glands, leading to “ADRENAL FATIGUE” that many refer to as FIBROMYALGIA.

• WHIPLASH CAN CAUSE PROBLEMS SWALLOWING AND BREATHING:  Even though I am not going to go into the crazy complicated neurological pathways that explain it, a 2015 study published in Brain: Structure & Function (Neck Muscle Afferents Influence Oromotor and Cardiorespiratory Brainstem Neural Circuits) concluded that, “Whiplash associated disorders (WAD) and cervical dystonia, which involve disturbance to the neck region, can often present with abnormalities to the oromotor [chewing, swallowing, speaking, etc], respiratory and cardiovascular systems.”  And here’s the rub; if you you don’t have a someone examining you that understands functional problems and is aware of studies like this, you can forget about these problems being logically and systematically related back to your accident.

• IT CAUSES PROBLEMS WITH EYE MOVEMENTS, WHICH ARE INDICATIVE OF BIGGER PROBLEMS:   Last October’s issue of BMC Musculoskeletal Disorders published a study called Eye Movements in Patients with Whiplash Associated Disorders: A Systematic Review.  Although there are some big words here, for anyone dealing with this junk, it’s helpful to realize your problem is not only not in your head, it’s relatively common.  “Many people with Whiplash Associated Disorders (WAD) report problems with vision.  Seventy percent of patients complain of pain, dizziness and unsteadiness, while 50% report problems with vision. These problems with vision comprise concentration problems during reading, sensitivity to light, visual fatigue, and eye strain.  Such oculomotor problems in WAD patients could be related to cervical sensorimotor disorders. This may be because of the complexity of the cervico-oculomotor system, that includes not only the central nervous system but also the proprioceptive system of the cervical spine.”  I hope you grasped the importance of this last sentence in relationship to PROPRIOCEPTION of your neck. “Eye movement control depends on eye position in the head and on the position of the head in space. Head position is determined by integration of several sub-systems such as the vestibular system, visual information and proprioceptive system of the cervical spine. Disturbed afferent cervical information is related to nystagmus, dizziness and deficits in balance. The principal source of cervical afferent information is formed by mechanoreceptors in the upper cervical spine. Specifically in the deep upper cervical muscles (i.e. m. obliquus capitis superior and inferior, m. longus colli), the density of muscle spindles is extremely high compared to other muscles in the body. Muscle spindles are part of the sensorimotor system. In patients with WAD sensorimotor control is disturbed.  The majority of studies in this review confirm the possibility of eye movement impairments in WAD patients”  Sometimes these problems are intimately related to something called “Centralization” (HERE and HERE).  Speaking of which……

• WHIPLASH CAN LEAD TO CENTRAL SENSITIZATION:  CENTRAL SENSITIZATION is the granddaddy of CHRONIC (TYPE III) PAIN.  This is the kind of pain that continues to play on a loop long after the injury itself has healed.  The December issue of JOSPT said that, “Central Sensitization (CS) dominates the clinical picture in a subgroup of the musculoskeletal pain population,” and that we need to be, “applying modern pain neuroscience to clinical practice implies, recognizing those patients having predominant CS pain, and accounting for CS when designing the treatment plan in those with predominant CS pain.”  This, however, is extremely tough to do as more or “better” drugs have not proven effective.  It’s also why (after discussing it with my patients) I sometimes take THIS APPROACH when I’m not sure whether or not their problem is Type III Pain.  A study done at the University of Queensland said four years ago next month that, “There is compelling evidence for central hyperexcitability in chronic WAD. This should be considered in the management of chronic WAD.”  The Belgian authors of a study published in the May 2015 edition of Pain Physician (Cognitive Performance Is Related to Central Sensitization and Health-related Quality of Life in Patients with Chronic Whiplash-Associated Disorders and Fibromyalgia) concluded that, “A growing body of research has demonstrated that impaired central pain modulation or central sensitization (CS) is a crucial mechanism for the development of persistent pain in chronic whiplash-associated disorders (WAD) and fibromyalgia (FM) patients. Furthermore, there is increasing evidence for cognitive dysfunctions among these patients. In addition, chronic WAD and FM patients often report problems with health-related quality of life (QoL).  In conclusion, this paper has demonstrated significant cognitive deficits, signs of CS, and reduced health-related QoL in chronic WAD and FM patients compared to healthy individuals. Significant relations between cognitive performance and CS as well as health-related QoL were demonstrated.”  Bad stuff, and in my estimation, the best way to avoid it (certainly not a foolproof) is to live an ANTI-INFLAMMATORY LIFESTYLE.

• GREATEST PREDICTORS OF LONG TERM PROBLEMS FROM WHIPLASH:  Remember how just a bit ago I showed you that a group of neurologists determined diminished neck ranges of motion to be the best predictor of long-term WAD-related problems?  A Japanese study from PLoS One that’s not quite two years old said this.  “Whiplash-associated disorders (WAD) are the most common injuries that are associated with car collisions in Japan and many Western countries.  Based on the results of this analysis, we found that female sex, the severity of the collision, poor expectations of recovery, victim mentality, dizziness, numbness or pain in the arms, and lower back pain were significantly associated with a poor recovery from WAD.“

• WE KNOW WHIPLASH LEADS TO DEPRESSION; WHAT ABOUT “BURNOUT”?   Earlier this year, I wrote a post about burnout (HERE).  Despite the fact that PubMed Health (Depression: What is Burnout?) says no one has “officially” defined it yet, it is loosely defined as, “exhaustion, alienation from work-related activities, and reduced performance“.   A five year old study from the International Journal of Rehabilitation Research (Burnout in Patients with Chronic Whiplash-Associated Disorders) concluded that, “A high proportion of burnout was found in the patient group (87%). The results indicate the possible clinical importance of burnout in relation to chronic WAD.”  It’s not surprising when you realize how much pain has the ability to consume every waking thought — you essentially become your pain (HERE).

• WHIPLASH, TEMPOROMANDIBULAR DISORDERS, AND FACE PAIN:  The Swedish Dental Journal published a study called Frequent Jaw-Face Pain in Chronic Whiplash-Associated Disorders, in which they concluded, “Chronic Whiplash-Associated Disorders (WAD) presents with frequent pain in the neck, head and shoulder regions…  In contrast to healthy subjects, a majority of the WAD patients (88%) reported frequent pain in the jaw-face, in addition to frequent pain in the neck (100%), shoulders (94%), head (90%) and back (72%). The WAD patients also reported stiffness and numbness in the jaw-face region, and frequent general symptoms such as balance problems, stress and sleep disturbances. The result suggests that frequent pain in the jaw-face can be part of the spectrum of symptoms in chronic WAD.”  The Journal of Orofascial Pain (Temporomandibular Disorder Pain after Whiplash Trauma: A Systematic Review) concluded similarly.  After “A systematic literature search of the PubMed, Cochrane Library, and Bandolier databases was conducted from January 1966 through October 2012, the search identified 125 articles. The reported median prevalence of temporomandibular disorder (TMD) pain after whiplash trauma was 23%.  For patients with a combination of TMD pain and WAD, treatment modalities conventionally used for TMD, such as jaw exercises and occlusal splints, had less of an effect compared to TMD patients without a whiplash injury. The poorer treatment outcome suggests that TMD pain after whiplash trauma has a different pathophysiology compared to TMD pain localized to the facial region.”  In other words, the issue could very well be neurological and not simply physical.  For more on SKULL AND FACE PAIN, just click the link.

• WHIPLASH AFFECTS BALANCE:  I’m not even going to go down this road because numerous studies have already mentioned it.  Suffice it to say that balance issues, whether from CERVICAL VERTIGO or from other sources, are a significant problem in people suffering from WAD.

• WHIPLASH CAN LEAD TO OCCULT CORD DAMAGE:  Engineers, physicians, and researchers from Chicago and Miami, teamed up to bring us this 2015 offering (Potential Associations Between Chronic Whiplash and Incomplete Spinal Cord Injury) in the journal Spinal Cord Series and Cases.  After studying individuals who met criteria, the authors reported, “reduced spinal cord motor tract integrity, increased fatty infiltration of the neck and lower extremity muscles and significantly impaired voluntary plantarflexor muscle activation. The lower extremity structural changes and volitional weakness in chronic WAD were comparable to participants with incomplete spinal cord injury.”  The point of showing you this is not because it’s common, but because it’s yet another of the myriad of neurological symptoms of WAD that are routinely misunderstood, overlooked, or just plain ignored.

CURRENT STANDARDS OF CARE FOR TREATING PEOPLE WITH WHIPLASH

As far as the governments standards for treating people with chronic WAD are concerned, it’s important to realize from what we discussed already, the word chronic, by it’s very definition, means your problem is at least three months old.  Research tends to show that neither standard conservative care (chiropractic, therapy, massage, exercise, modalities, acupuncture, etc) nor non-conservative care (drugs, surgery, RFA’s, guided injections, etc) are going to help much.  That’s not me saying this, that’s what the research shows over and over and over again.  Some of these guidelines seem to reflect this idea — that after three months of unresolved whiplash you are essentially SOL.

• According to the October issue of JMPT (The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline), treatment for chronic WAD should involve, “multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD — Neck Pain Associated Disorders); multimodal care or practitioner’s advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD).”  Notice here that all forms of treatment are active.  While this is grand on many levels, it may be guilty of missing at lest part of the “PHASE I” boat.

• Two months later, the December issue of Canada’s Spine Journal (Which Interventions are  Cost-Effective for the Management of Whiplash-Associated and Neck Pain-Associated Disorders?) came up with this gem. “Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD.”  It would take me awhile to really unwind this enough to decipher it completely, but suffice it to say that it’s another one of the studies touting “ADVICE” to be the equivalent of (or even superior to) action.

• Same group, same month (Are Manual Therapies, Passive Physical Modalities, or Acupuncture Effective for the Management of Patients with Whiplash-Associated Disorders or Neck Pain and Associated Disorders?).  “Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, low-level laser therapy (LLLT) and ultrasound) are not effective and should not be used to manage neck pain.”  Got to say that I am a believer in LLLT for any number of things, and with the cost coming down all the time, these creatures have become affordable to the general public.

• Again, same group, same time (Are Psychological Interventions Effective for the Management of Neck Pain and Whiplash-Associated Disorders?) only this time they were looking at psychological interventions.  “We did not find evidence for or against the use of psychological interventions in patients with recent onset NAD or WAD. We found evidence that a progressive goal attainment program may be helpful for the management of persistent WAD and that Jyoti meditation may benefit patients with persistent NAD.“

• Two years ago, PLoS One published The Effectiveness of Conservative Management for Acute Whiplash Associated Disorder (WAD) II: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.  In it they determined that, “Conservative intervention was more effective for pain reduction at 6 months and 1-3 years, and improvement in cervical mobility in the horizontal plane at <3 months compared with standard/control intervention. Active intervention was effective for pain alleviation at 6 months and 1-3 years compared with passive intervention.  Behavioural intervention was more effective than standard/control intervention for pain reduction at 6 months, and improvement in cervical movement.   This rigorous systematic review found that conservative and active interventions may be useful for pain reduction in acute WADII management in the medium-long term. Additionally, improvement of cervical movement in the horizontal plane short term could be promoted by the employment of a conservative intervention. The employment of a behavioural intervention (e.g. act-as-usual, education and self-care including regularly exercise) may be an effective treatment in reducing pain and improving cervical mobility in patients with acute WADII in the short-medium term.”  The problem with this study and others like it is that ultimately, “The level of evidence from this systematic review is evaluated as low/very low according to GRADE.“

I love looking at STANDARDS OF CARE, but am not convinced they are always in the patients best interest.  And as you see, they don’t always agree with each other, with the evidence used to create them sometimes being poor or biased.  To see how I go about dealing with individuals struggling with chronic WAD in my clinic, HERE is a quick overview. 

Although this is certainly not always the case with acute WAD, with chronic, long-term WAD, you will know in a single treatment whether my approach is going to help (HERE).  My thought processes fall back on a few different things.  Firstly, if you look at the material pertaining to healing times on my COLLAGEN SUPER-PAGE, you’ll see that at three months there’s still a long way to go as far as complete healing / remodeling is concerned.

Secondly, the common theme in these guidelines seems to be that things that increase ROM of the C-Spine (manipulation, mobilization, massage, exercises, stretches, etc, etc) were largely beneficial in every study that pertained to the physical body.  This is nothing new and has been shown by the medical community for decades. 

The year I got married (1996), the most renowned whiplash researchers on the planet (Gargan & Bannister) published a study in the journal Injury called Chiropractic Treatment of Chronic Whiplash Injuries.  When you read their conclusions, you need to note that the patients were “chronic” — the group that the medical community essentially says nothing will help, so HERE’S YOUR DRUGS. Now run along and have a nice day.

“Forty-three percent of patients will suffer long-term symptoms following ‘whiplash’ injury, for which no conventional treatment has proven to be effective. A retrospective study was undertaken to determine the effects of chiropractic in a group of patients who had been referred with chronic ‘whiplash’ syndrome. The severity of patients’ symptoms was assessed before and after treatment using the Gargan and Bannister classification. 93% improved following chiropractic treatment. The encouraging results from this retrospective study merit the instigation of a prospective randomized controlled trial to compare conventional with chiropractic treatment in chronic ‘whiplash’ injury.” 

DOES THE FACT YOU’VE HIRED A LAWYER HAVE ANY BEARING ON THE OUTCOME OF YOUR INJURY?

“According to rehabilitation expert-professionals, an injury compensation (IC) can lead to distress, by creating a (conscious or unconscious) conflict of interests within a patient between striving for compensation on one hand, and recovery on the other hand. Patient characteristics can either attenuate or worsen IC-related distress.

Reliable and valid tools need to be developed to assess the influence of IC on health, disability and rehabilitation, and to limit the negative effects. Rehabilitation professionals can discuss the possible unintended effects of IC with their patients to clarify their current situation.” The conclusions of a six month old study (How does injury compensation affect health and disability in patients with complaints of whiplash? A qualitative study among rehabilitation experts-professionals) from the journal, Disability and Rehabilitation

The medico-legal arena seen hovering behind the scenes of the “Whiplash Injury” has become an industry unto it’s own, with no question more hotly debated than the one raised by the title of this section.  After combing through lots of studies on the subject (there are dozens), I find it to be a wash — as many yeses as nos.  While it’s true that the majority of studies used to show that pending litigation had no effect on outcomes, this is no longer the case. 

My guess is that much of this is due to the idea promoted by a bumper sticker I saw recently; Hit Me: I Need The Money! — an idea being driven home by the NUMEROUS ATTORNEY’S OFFICES springing up everywhere.  I would also assume that some of this discrepancy could be ascertained by looking at who funded said studies.  Was it funded by an association of treating practitioners (AMA, ACA, APTA, AOA, etc).  Was it funded by an insurance company?  Trust me when I tell you it makes a difference (HERE). 

Without going into details or attempting to provide legal advice, when my family was in THIS ACCIDENT almost a dozen years ago, I settled the claim (it was actually multiple claims) myself using THIS DIY TOOL.  Also, no matter what is wrong with you, you’ll do better if you are not living in a state of perpetual SYSTEMIC INFLAMMATION.  To see a template of what can be done to start breaking the chains of the pain, dysfunction, and distress you are in, take a look at THIS SHORT POST.

And if you or someone you love or care about suffers from the effects of a whiplash injury, be sure to like, share or follow on FACEBOOK.