Whiplash Type Injury / Whiplash Associated Disorder.
Chiropractic treatment has been a great source of relief for many people who have suffered from whiplash. What exactly is whiplash and how does chiropractic help?
What is Whiplash?
Whiplash is a description of how the injury has been sustained. It is not a disease and not in itself a diagnosis. Rather it is a descriptive term that describes the mechanism of injury. Anytime the spine is unexpectedly moved in one direction and then it rebounds in the opposite direction there is the possibility of developing a whiplash type injury. It can happen in a backwards and forwards direction or it can be in a side to side motion. Of course whiplash type injuries are not limited to motor vehicle accidents alone; Sports injuries, knocks falls and slips can all produce a whiplash type injury. The term “whiplash type injury” is used to describe any injury mechanism where there is sudden excessive extension followed by an immediate excessive flexion of the neck that results in damage to the muscles, ligaments and tendons. We now know that whiplash type injuries frequently do not result from just excessive extension or excessive flexion (extension and flexion beyond normal limits of motion), but rather an extremely rapid extension and flexion that causes the damage.
What part of the spine is damaged in whiplash?
Most whiplash sufferers have misaligned vertebrae in their spine. Whiplash type injuries usually involve a combination of nervous system, muscles, joints and connective tissue damage. There are different degrees of whiplash type injuries and in order to decide the appropriate treatment, it is important to understand the mechanics of how whiplash type injuries occur.
How does a whiplash injury occur?
There are many different potential causes of whiplash type injury but one of the most common causes is the result of a motor vehicle accident where your body goes through an extremely rapid and intense acceleration and deceleration. In this instance all four phases of a whiplash type injury occur very quickly. During each phase there are different forces acting on the body that can cause injury, and with such a violent and forceful movement, damage to the vertebrae, nerves, discs, muscles, and ligaments of your neck and spine can be significant. The following is a description from Meridel Gatterman in her book “Chiropractic management of spine related disorders pages 230-231).
“In rear end collisions, even with a high seat back or head restraint, the neck is thrown into extension in proportion to the distance between the occupants head and the supporting structure. As the victims torso is forced backwards into the seat back, the head and neck initially remained fixed while the vehicle moves forward.”
“This initial inertia of the head followed by extension of the cervical spine at the end of this rearward translation.” This means that whilst the seat is moving forward whilst the head is still moving backwards. This shearing force in the neck is what causes most of the damage in whiplash type injuries. Many of the bone, joint, nerve, disc and TMJ injuries that we see clinically occur during this phase.
“After deflecting off the seat back or head restraint, the head rebounds forward, forcing the neck into flexion. In cars without head restraints or with head rests in a low position hyperextension occurs. If the headrest is not high enough then it may act as a fulcrum over which the neck pivots. As you move forward in your seat, any slack in your seat belt is removed and the restraint becomes tight.
“As the neck recoils forward hyperflexion is stopped by the chin hitting the chest.” This is where a lot of the injuries that are sustained in an accident can happen.” It causes a severe flexion in the neck putting tremendous strain on muscles, ligaments, and misaligning vertebra. If your head hits the windshield or steering wheel then you may suffer a concussion, or more severe brain injury.
Symptoms of Whiplash
Symptoms of whiplash
There are a number of common symptoms associated with whiplash. These symptoms include some or all of the following:
Most patients suffering from whiplash complain of some form of neck pain. This is a very common symptom and it may be either localised or it may refer into the head, down the arm or into the mid back region.
It is quite common for patients suffering a whiplash type injury to suffer from headaches. These often originate in the neck and refer into the head and are termed a cervicogenic headache. They are usually of a dull aching nature but can also be sharp. They may be localised in the back of the neck or refer into the front of the head.
Low Back Pain
Low back pain is a common complication of a whiplash injury. This can be the result of twisting in the restraint/ seatbelt and from rapid bending or twisting of the spine.
Whiplash type injuries can manifest in a wide variety of ways. The exact nature of the symptoms will vary depending on the patient’s direction of impact, speed of the vehicles involved, as well as sex, age and physical condition. Each case will be different. It is not uncommon for signs and symptoms to come on after a period of time, sometimes with a delay of days or weeks. This can often be because inflammation can take 24 to 72 hours to develop. It is not uncommon for some injuries to go unnoticed for weeks or months.
People often make the mistake of thinking that because there may be very little damage to the car that they can’t be injured. In fact even small accidents can cause whiplash, especially if you are not aware there is an impending accident about to happen and are unprepared. Often when there is no visible damage to the car it might mean that more of the impact force has been transferred to the occupant of the car. Whatever the situation be sure to be checked by your chiropractor as soon as possible after an accident to assess you for whiplash type injuries.
Diagnosis of whiplash type injuries:
Your Back to Health Chiropractor will conduct a thorough history of what exactly has caused the whiplash type injury. This will include questions on :
The nature of the accident
The exact location of the pain
Exacerbating and relieving factor
Types of pain
Referral of pain
Family history etc
You will then be offered an in depth physical examination which will look at all of the following factors:
General posture and flexibility
Palpation may reveal muscle tenderness and tightness in the neck muscles and suboccipital
There may be reduced active and passive range of motion
Orthopedic tests may be positive
Muscle tests to determine the extent of weakness
Neurological assessment if required
X-rays of the spine may be conducted depending on the extent of your problems and the examination findings
Your Chiropractor will discuss with you exactly what examinations will be appropriate and will require your consent before undertaking an examination. Once a diagnosis has been confirmed then specific treatment options can be discussed.
Chiropractic Treatment for Wiplash
Chiropractic Management and Treatment Whiplash Type Injuries:
Chiropractic care is a useful way of treating whiplash. There are a number of different treatment modalities that your Back to Health chiropractor might consider.
The main treatment a chiropractor would provide would be gentle spinal adjustments and or manipulation to the spine as required to reduce inflammation and irritation to the nervous system.
Massage, stretching and strengthening exercises for neck muscles are based on the specific muscles that are involved.
Relative rest. It is important in the initial phase of treatment to reduce exercise and movements that aggravate the problem to minimum and reduce inflammation, whilst at the same time continuing with other activities that do not affect the condition such as swimmming and other low impact aerobic activities. this is a concept often termed relative rest.
Ice can be applied to the neck to reduce the inflammation. This can be a frozen gel pack or simply a home made ice pack. It is recommended to use the ice for no longer than 10 minutes and to wrap it in a towel so as the ice is not directly in contact with the skin.
1)”Chiropractic Management of Spine Related Disorders.”. Meridel I Gatterman pp 231.
Reimbursement for Treating Crash Victims: Deconstructing the Objections
By Arthur Croft, DC, MS, MPH, FACO
Many, if not most whiplash victims treated by chiropractors either fully recover or at least are left with relatively manageable conditions. What’s more, the cost of treatment rarely exceeds $10,000 and is usually much less.
In contrast, patients who are treated through more traditional channels frequently are passed from doctor to doctor without much success and without managerial continuity. Failing to recover with medication and a brief series of physical therapy treatments, most patients quietly give up and live with their pain.
Those with more severe complaints often are passed off to pain clinics and subjected to a number of diagnostic blocks. After this is usually a series of epidural steroid injections, often to cervical and lumbar regions. Eventually a discogram is performed, which identifies a surgical lesion and surgery is undertaken. With disturbing frequency, the first surgery fails and a second is undertaken; sometimes a third.
crash victims – Copyright – Stock Photo / Register Mark
The final cost is stunning. In my region of the country (San Diego, Calif.), when all is said and done, the diagnostics blocks will (depending on the number of levels, etc.) typically cost about $14,000. The epidural steroids will be a bit more, especially when cervical and lumbar injections are given. The discogram will be in the $16,000-and-up range, depending on the number of levels. And in my experience, surgeons tend to charge extravagant fees in litigated cases, often in excess of $75,000.
I can’t tell the reader how often this happens, and it is not my intention to deride the medical community. I am certainly not asked to see the success stories, so I see a biased caseload. But the exemplar described above is common enough that I deal with them on nearly a daily basis. Frequently, these folks have not received any chiropractic care.
Because chiropractors provide an efficacious treatment and at a reasonable cost, taking an active part might be seen as a virtual moral imperative. Getting paid simply requires a little information. This editorial offers some of that, and some suggestions for coping with the insurance industry.
The single most frequently cited justification by auto insurers for refusing to honor medical bills for treatment is that injuries are unlikely, uncommon or impossible in collisions in which the property damage is under $1,000 or so. This is, in fact, the basis of the MIST (minor impact, soft tissue) strategic business model applied by Allstate and other injurers. Health care providers and their patients face these policy-based denials more often than not when the responsible insurer is third party.
risk curve – Copyright – Stock Photo / Register Mark
The risk curve is cubic, rising sharply up to the point where structural damage begins to occur, then dropping off due to the additional ride-down provided to the occupants, and then climbing again as crash speed increases. (Graph is for illustrative purposes only and does not reflect exact risk percentages or speeds.) Initially, we should recognize that there are two levels on which this problem can be approached. First, insurance coverage is supposed to be predicated on the premise that when some event (such as an auto collision resulting in injuries) occurs, medical benefits for treatment will be paid. It is not predicated on the probability of such an event occurring.
If I should ever be so unlucky as to be struck by lightning or bitten by a shark, I certainly wouldn’t expect Blue Cross to deny medical coverage based on the prior odds of those things happening. Yet that is, in essence, what insurers are basing their denial upon in PI cases. The tacit extension, of course, can only be that the patient is lying about their injuries.
The other level, which is probably the easiest to work with, concerns the factual basis for the insurer’s claims. Is it true that injuries are unlikely, uncommon or impossible under the conditions of minimal or near-zero property damage? Surprisingly, no. And it’s counterintuitive, of course. In fact, at the transition where property damage begins to occur in slightly higher-speed collisions, the risk for injury actually dips down. (See graph, which is for illustrative purposes only, above.)
A general understanding of collision mechanics goes a long way to explain this seeming paradox. Without delving into too much depth here, the vehicle is relatively stiff in lower-speed ranges: it does not undergo crush or mechanical deformation here. Much of the kinetic energy of the collision is used to accelerate the vehicle and its occupant.
When the speed of the crash is high enough that the bumper energy absorber, bumper reinforcing bar, struts, or even frame elements are damaged, two things happen: (1) the kinetic energy used to deform these structures is no longer available to accelerate the vehicle; and (2) the duration of the collision is increased. And, since acceleration is equal to the change in velocity (delta V) divided by the time of the change in velocity (delta T), a relatively longer collision pulse translates into less acceleration.
I should add that this paradoxic risk curve inversion occurs only at the transitional speed range (about 8-12 mph) between no damage and initial damage speeds. As the collision speeds continue to increase beyond 20 mph, the risk curve will again begin to climb, even as the property damage becomes more severe. (See graph.)
How do we know this? In an important study of whiplash injuries undertaken by the Insurance Institute for Highway Safety (IIHS), investigators found that the largest group had little or no damage to the rear-struck victims’ cars.1 I later looked at the entire English biomedical and engineering literature, beginning in the year 1970, for studies comparing crash severity (as measured by any reasonable metric) to any of three dependent variables: acute injury risk, severity of risk or the risk for poor outcome in low-velocity collisions.2 In this large meta-analysis, which had never before been undertaken, we applied standard methods of best-evidence synthesis and reported that there was no evidence for correlation.
Two clinico-epidemiological studies also shed important light on the question. Jakobsson, et al.,3 used pre-installed accelerometers in a fleet of vehicles to conduct a natural experiment and reported that the mean delta V at which whiplash injuries occurred was about 5 mph. More recently, a series of nearly 100 rear-impact whiplash injury cases were evaluated by looking at medical records and by conducting detailed reconstructions of the crashes in order to determine the delta V. The mean delta V in this study was 4 mph.
Human-subject crash testing has been conducted by a number of groups over the years.4-9 A careful reading of these studies reveals that in nearly all cases, no property damage was said to have occurred. This is actually by design, because in order to be able to draw conclusions about crash variables that we intentionally change from one crash test to the next (e.g., position of occupant, crash speed, head restraint position), it is imperative that the crash conditions which are not intended to be variable do not vary.
So, for example, if successive crash tests were causing progressive property damage, the mechanical property of the vehicle would be changing due to strain softening. This would confound the results, making interpretation difficult, if not impossible.
In the crash tests that I conducted over the course of eight years, we rarely observed any structural damage in rear-impact, bumper-to-bumper impacts at closing speeds of less than 10-12 mph, and in many cases we ran three or more tests without producing damage. So, collectively, we have a report from IIHS confirming that injuries are common in zero- or near-zero-damage rear-impact crashes; we have other independent studies that provide a mean delta V for rear-impact injury collisions of 4-5 mph; and we have several independent published crash-test studies confirming the fact that collisions producing speed changes in this range don’t typically result in property damage.
In conclusion, there is no published evidence to support the claimed correlation between the three categories of risk and property damage in terms of low-speed, rear-impact collisions. There is, however, published evidence that there is no correlation.2 Practitioners faced with letters of denial from insurance companies have a number of options. They could offer to provide the claims person with this information. They could also inquire as to the source of the claims person’s misinformation concerning risk and probability based on property damage. They could explain this to their patient so as to reassure them. And if the case is being litigated, they could provide this information to the attorney.
I will discuss human risk factors in another editorial; these also should always be considered when considering risk because, as it turns out, human factors are much more deterministic than crash metrics.
Chapline JF, Ferguson SA, Lillis RP, Lund AK, Williams AF. Neck pain and head restraint position relative to the driver’s head in rear-end collisions. Accid Anal Prev. 2000;32(2):287-297.
Croft AC, Freeman MD. Correlating crash severity with injury risk, injury severity, and long-term symptoms in low velocity motor vehicle collisions. Medical Science Monitor, 2005;11(10):RA316-321.
Jakobsson L, Norin H, Bunketorp O. In-depth study of whiplash associated disorders in frontal Impacts: influencing factors and consequences. Paper presented at the International IRCOBI Conference on the Biomechanics of Impact, Sept. 18-20, 2002; Munich, Germany.
Croft A, Haneline M, Freeman M. Differential occupant kinematics and forces between frontal and rear automobile impacts at low speed: evidence for a differential injury risk. Paper presented at: International Research Council on the Biomechanics of Impact (IRCOBI), Sept. 18-20, 2002; Munich, Germany.
Croft AC, Philippens MMGM. The RID2 biofidelic rear impact dummy: a validation study using human subject in low speed rear impact full scale crash tests. Neck injury criteria (NIC). Paper presented at the 2006 SAE World Congress, April 3-6, 2006; Detroit, Mich.
McConnell W, Howard R, Guzman H. Analysis of human test subject kinematic responses to low velocity rear end impacts. SAE Tech Paper Series. 1993;930889:21-30.
McConnell W, Howard R, Poppel J. Human head and neck kinematic after low velocity rear-end impacts: understanding “whiplash.” Paper # 952724; presented at the 39th Stapp Car Crash Conference, 1995.
Szabo T, JB. W, Anderson R. Human occupant kinematic response to low speed rear-end impacts. SAE Tech Paper Series, 1994;940532:23-35.
Szabo T, Welcher J. Dynamics of low speed crash tests with energy absorbing bumpers. SAE Tech Paper Series, 1992;921573:1-9.
Do “whiplash injuries” occur in low-speed rear impacts?
Castro WH1, Schilgen M, Meyer S, Weber M, Peuker C, Wörtler K.
A study was conducted to find out whether in a rear-impact motor vehicle accident, velocity changes in the impact vehicle of between 10 and 15 km/h can cause so-called “whiplash injuries”. An assessment of the actual injury mechanism of such whiplash injuries and comparison of vehicle rear-end collisions with amusement park bumper car collisions was also carried out. The study was based on experimental biochemical, kinematic, and clinical analysis with volunteers. In Europe between DM 10 and 20 billion each year is paid out by insurance companies alone for whiplash injuries, although various studies show that the biodynamic stresses arising in the case of slight to moderate vehicle damage may not be high enough to cause such injuries. Most of these experimental studies with cadavers, dummies, and some with volunteers were performed with velocity changes below 10 km/h. About 65% of the insurance claims, however, take place in cases with velocity changes of up to 15 km/h. Fourteen made volunteers (aged 28-47 years; average 33.2 years) and five female volunteers (aged 26-37 years; average 32.8 years) participated in 17 vehicle rear-end collisions and 3 bumper car collisions. All cars were fitted with normal European bumper systems. Before, 1 day after and 4-5 weeks after each vehicle crash test and in two of the three bumper car crash tests a clinical examination, a computerized motion analysis, and an MRI examination with Gd-DTPA of the cervical spine of the test persons were performed. During each crash test, in which the test persons were completely screened-off visually and acoustically, the muscle tension of various neck muscles was recorded by surface electromyography (EMG). The kinematic responses of the test persons and the forces occurring were measured by accelerometers. The kinematic analyses were performed with movement markers and a screening frequency of 700 Hz. To record the acceleration effects of the target vehicle and the bullet vehicle, vehicle accident data recorders were installed in both. The contact phase of the vehicle structures and the kinematics of the test persons were also recorded using high-speed cameras. The results showed that the range of velocity change (vehicle collisions) was 8.7-14.2 km/h (average 11.4 km/h) and the range of mean acceleration of the target vehicle was 2.1-3.6 g (average 2.7 g). The range of velocity change (bumper car collisions) was 8.3- 10.6 km/h (average 9.9 km/h) and the range of mean acceleration of the target bumper car was 1.8-2.6 g (average 2.2 g). No injury signs were found at the physical examinations, computerized motion analyses, or at the MRI examinations. Only one of the male volunteers suffered a reduction of rotation of the cervical spine to the left of 10 degrees for 10 weeks. The kinematic analysis very clearly showed that the whiplash mechanism consists of translation/extension (high energy) of the cervical spine with consecutive flexion (low energy) of the cervical spine: hyperextension of the cervical spine during the vehicle crashes was not observed. All the tests showed that the EMG signal of the neck muscles starts before the head movement takes place. The stresses recorded in the vehicle collisions were in the same range as those recorded in the bumper car crashes. From the extent of the damage to the vehicles after a collision it is possible to determine the level of the velocity change. The study concluded that, the “limit of harmlessness” for stresses arising from rear-end impacts with regard to the velocity changes lies between 10 and 15 km/h. For everyday practice, photographs of the damage to cars involved in a rear-end impact are essential to determine this velocity change. The stress occurring in vehicle rear-end collisions can be compared to the stress in bumper car collisions.
The Healing of Injured Soft Tissues
In this months issue we’re going to touch on area of patient treatment that has undergone enormous leaps and bounds in our understanding over the last decade. An area I will refer to as “Post-Traumatic Soft Tissue Injury”.
Even with recent breakthroughs in understanding the physiology of repair (and possibly because of these RECENT breakthroughs) there is a considerable amount of misunderstanding regarding soft tissue injury and its repair.
The most common (almost knee-jerk) misconception is that injured soft tissue will heal in a period of time between four and eight weeks.
Frequently it is claimed that injured soft tissues will heal spontaneously, leaving no long-term residual damage, and that treatment is not required. This type of information is extremely misleading and confusing to both doctor and patient alike.
Published articles and books concerning the healing of injured soft tissues (Oakes 1982; Roy and Irving 1983; Kellett 1986; Buckwalter/Woo 1988, Majno 2004) indicate that the time frame for such healing is approximately one year.
Needless to say the difference between a recovery time of 4-8 weeks and 12 months dramatically impacts both clinical practice and expected outcomes.
Healing Takes Place In Three Specific Phases. Soft Tissue Healing Phase #1 Acute Inflammatory Phase.
This phase will last approximately 72 hours. During this phase, after the initial injury, an electrical current is generated at the wound, called the “current of injury.”
This “current of injury” attracts fibroblasts to the wound (Oschman, 2000).
During this phase there is also initial bleeding and continual associated inflammation of the injured tissues. Because of the increasing inflammatory cascade during this period of time, it is not uncommon for the patient to feel worse for each of the first three days following injury.
Because there is disruption of local vascular supplies, there is insufficient availability of substrate (glucose, oxygen, etc.) to produce large enough quantities of ATP energy to initiate collagen protein synthesis to repair the wound.
After 72 hours following injury, the damaged blood vessels have mended. The resulting increased availability of glucose and oxygen elevates local ATP levels and collagen repair begins by the fibroblasts that accumulated during the acute inflammatory phase.
Soft Tissue Healing Phase #2 Phase Of Regeneration
During the regeneration phase the disruption in the injured muscles and ligaments is bridged. Some references call the regeneration phase the phase of repair, which creates confusion about the timing of healing (Jackson, 1977).
“Repair” connotation is that the process has completed, which, as we well see, is not the case. The fibroblasts manufacture and secrete collagen protein glues that bridge the gap in the torn tissues. This phase will last approximately 6-8 weeks (Jackson, 1977).
At the end of 6-8 weeks, the gap in the torn tissues is more than 90% bridged. Many will erroneously claim this to be the end of healing. However, it clearly is not. There is a third and final phase of healing. This phase is called the phase of remodeling.
Soft Tissue Healing Phase #2 Phase Of Remodeling
The phase of remodeling starts near the end of the phase of regeneration. During the phase of remodeling the collagen protein glues that have been laid down for repair are remodeled in the direction of stress and strain.
This means that the fibers in the tissue will become stronger, and will change their orientation from an irregular pattern to a more regular pattern, a pattern more like the original undamaged tissues.
Proper treatment during this remodeling phase is very necessary if the tissues are to get the best end product of healing. It is during this remodeling phase that the tissues regain strength and alignment. Remodeling takes approximately one year after the date of injury.
It is established that remodeling takes place as a direct byproduct of motion. Chiropractic healthcare puts motion into the tissues in an effort at getting them to line up along the directions of stress and strain, thereby giving a stronger, more elastic end product of healing.
Traditional chiropractic joint manipulation healthcare is directed towards putting motion into the periarticular paraphysiological space.
The concept of paraphysiological joint motion was first described by Sandoz in 1976, and is explained well by Kirkalady-Willis 1983 and 1988, by Kirkalady-Willis/Cassidy 1985, and in the 2004 monograph on Neck Pain (edited by Fischgrund) published by the American Academy of Orthopedic Surgeons (see picture).
These discussions clearly show that there is a component of motion that cannot be properly addressed by exercise, massage, etc, and that this component of motion can be properly addressed by osseous joint manipulation.
Therefore, traditional chiropractic osseous joint manipulation adds a unique aspect to the treatment and the remodeling of periarticular soft tissues that have sustained an injury.
There are some problems associated with the healing of injured soft tissues. Microscopic histological studies show that the repaired tissue is different than the original, adjacent, undamaged tissues.
During the initial acute inflammatory phase there is bleeding from the damaged tissues and consequent local inflammation. This progressive bleeding releases increased numbers of fibroblasts into the surrounding tissues.
Chemicals that are released trigger the inflammation response that is noted in cases of trauma. Subsequent to the inflammatory response and to the number of fibrocytes that are released into the tissues, the healing process is really a process of fibrosis.
In 1975, Stonebrink addresses that the last phase of the pathophysiological response to trauma is tissue fibrosis. Boyd in 1953, Cyriax in 1983, and Majno/Joris in 2004 note that there is tissue fibrosis subsequent to trauma.
This fibrosis of repair subsequent to soft tissue trauma creates problems that can adversely affect the tissues and the patient for years, decades, or even forever.
Fibrosed tissues are functionally different from the adjacent normal tissues. The differences fall into two main categories:
Fibrosis Category 1:
The repaired tissue is weaker and less strong than the undamaged tissues. This is because the diameter of the healing collagen fibers is smaller, and the end product of healing is deficient in the number of crossed linkages within the collagen repair.
Fibrosis Category 2:
The repaired tissue is stiffer or less elastic than the original, undamaged tissues. This is because the healing fibers are not aligned identically to that of the original. Examination range of motion studies will indicate that there are areas of decrease of the normal joint ranges of motion.
In addition, Cyriax notes “fibrous tissue is capable of maintaining an inflammatory response long after the initial cause has ceased to operate.”
Since inflammation alters the thresholds of the nociceptive afferent system, physical examinations in these cases will show these fibrotic areas display increased sensitivity, and digital pressure may show hypertonicity and spasm.
This increased sensitivity can be documented with the use of an algometer, which is a device that uses pressure to determine the initiating threshold of pain.
Because the fibrotic residuals have rendered the tissues weaker, less elastic, and more sensitive, the patient will have a history of flare-ups of pain and/or spasm at times of increased use or stress.
These episodes of pain and/or spasm at times of increased use or stress of the once damaged soft tissues is the rule rather than the exception, and a problem that the patient will have to learn to live with.
It is likely that the patient will continue to have episodes of pain and/or spasm for an indefinite period of time in the future. It is probable that the patient will have a need for continuing care subsequent to these episodes of pain and/or spasm.
Consistent with these concepts, a study by Hodgson in 1989 indicated that…
62% of those injured in automobile accidents still have significant symptoms caused by the accident 12 1/2 years after being injured; and that of the symptomatic 62%, 62.5% had to permanently alter their work activities and 44% had to permanently alter their leisure activities in order to avoid exacerbation of symptoms.
One of the conclusions of the article is that these long-term residuals were most likely the result of post-traumatic alterations in the once damaged tissues.
A study by Gargan in 1990 indicated that…
Only 12% of those sustaining a soft tissue neck injury had achieved a complete recovery more than ten years after the date of the accident.
One of the conclusions of this study is that the patient’s symptoms would not improve after a period of two years following the injury.
It is established neurologically (Wyke 1985, Kirkalady-Willis and Cassidy 1985) that when a chiropractor adjusts (specific directional spinal manipulation) the joints of the region of pain and/or spasm, that there is a depolarization of the mechanoreceptors that are located in the facet joint capsular ligaments, and that the cycle of pain and/or spasm can be neurologically aborted. This is why many patients feel better after they receive specific joint manipulation from a chiropractor following an episode of increased pain and/or spasm.
What Is The Basis For The Chronic Post-Trauma Pain Syndromes So Many Patients Suffer From?
A good explanation is found from Gunn (1978, 1980, 1989). He refers to this type of pain as supersensitivity.
The supersensitivity type pain is a residual of the scarring or the fibrosis that was created by the injuries sustained in this accident.
The treatment that we give to the patient for the injuries sustained in an accident is really not designed to heal the sprain or strain but rather, to change the fibrotic nature of the reparative process that has left the patient with residuals that are weaker, stiffer, and more sore.
The actual diagnosis for this type of problem is initial sprain/strain injuries of the paraspinal soft tissues with fibrotic residuals subsequent to the fibrosis of repair of once damaged soft tissues that have left these tissues weaker, stiffer, and more sensitive as compared to the original tissues.
The majority of our efforts in the treatment of post-traumatic chronic pain syndrome patients is in dealing with the residual fibrosis of repair and its associated mechanical and neurological consequences.
These residuals to some degree are most probably permanent. The patient will have to learn to deal with the long-term residuals and the occasional episodes of pain and/or spasm.
However, as noted above, occasional specific joint manipulation in the involved areas can neurologically inhibit muscle tone, improve ranges of motion, disperse accumulated inflammatory exudates, and the patient will have less pain and improved function.
The concepts briefly discussed above are frequently not understood or appreciated. There is a tendency for healthcare providers to not properly examine the patient in order to document these regions of tissue fibrosis and its consequent mechanical and neurological consequences and, therefore, to quote Stonebrink, the real problem is missed.
Boyd, William, M.D., Pathology, Lea & Febiger, (1952).
Cyriax, James, M.D., Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions, Bailliere Tindall, Vol. 1, (1982).
Fischgrund, Jeffrey S, Neck Pain, monograph 27, American Academy of Orthopaedic Surgeons, 2004.
Gargan, MF, Bannister, GC, Long-Term Prognosis of Soft-Tissue Injuries of the Neck, Journal of Bone and Joint Surgery, September, 1990.
Gunn, C. Chan, Pain, Acupuncture & Related Subjects, C. Chan Gunn,
Gunn, C. Chan, Treating Myofascial Pain: Intramuscular Stimulation (IMS) for Myofascial Pain Syndromes of Neuropathic Origin, University of Washington, 1989.
Hodgson, S.P. and Grundy, M., Whiplash Injuries: Their Long-term Prognosis and Its Relationship to Compensation, Neuro-Orthopedics, (1989), 7.88-91.
Kellett, John, “Acute soft tissue injuries-a review of the literature,” Medicine and Science of Sports and Exercise, American College of Sports Medicine, Vol. 18 No.5, (1986), pp 489-500.
Kirkaldy-Willis, W.H., M.D., Managing Low Back Pain, Churchill Livingston, (1983 & 1988).
Kirkaldy-Willis, W.H., M.D., & Cassidy, J.D.,”Spinal Manipulation in the Treatment of Low-Back Pain,” Can Fam Physician, (1985), 31:535-40.
Majno, Guido and Joris, Isabelle, Cells, Tissues, and Disease: Principles of General Pathology, Oxford University Press, 2004.
Oakes BW. Acute soft tissue injuries. Australian Family Physician. 1982; 10 (7): 3-16.
Oschman, James L, Energy Medicine: The Scientific Basis, Churchill Livingstone, 2000.
Roy, Steven, M.D., and Irvin, Richard, Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation, Prentice-Hall, Inc. (1983).
Stonebrink, R.D., D.C., “Physiotherapy Guidelines for the Chiropractic Profession,” ACA Journal of Chiropractic, (June1975), Vol. IX, p.65-75.
Wyke, B.D., Articular neurology and manipulative therapy, Aspects of Manipulative Therapy, Churchill Livingstone, 1980, pp.72-77.
Woo, Savio L.-Y.,(ed.), Injury and Repair of the Musculoskeletal Soft Tissues, American Academy of Orthopaedic Surgeons,(1988), p.18-21; 106-117; 151-7; 199-200; 245-6; 300-19; 436-7; 451-2; 474-6.
After My Car Accident, Why Do I Hurt So Much?
There are many different reasons why injuries sustained in car crashes result in chronic or long-term pain. First, there are several types of tissues in the neck that can give rise to pain. The most intense pain comes from the tissues with the greatest density of nerve fibers, such as the joint capsules and the ligaments holding the bones of the neck together. There are many ligaments in the neck that are vulnerable to being over-stretched and injured in a motor vehicle collision.
The mechanism of a “whiplash” injury in a rear-end collision is unique. Upon impact, the vehicle rapidly accelerates forward while the head momentarily remains in its original position, resulting in an initial straightening of the neck followed by extension. At the extreme end-range of backward extension motion, the ligaments in the front of the neck are over-stretched and can tear. Within milliseconds, the head is then propelled forwards into flexion which can then injure the ligaments in the back of the neck placing a significant amount of force on the joint capsules and ligaments holding the bones in close proximity. Another reason the neck is injured is the speed at which the head and neck “whip” in the backwards and forwards directions after the impact. This occurs faster than what we can voluntarily contract our neck muscles to resist–within 600 milliseconds! Therefore, even if we brace ourselves in preparation for an impact, we can’t avoid injury to the ligaments and joint capsules. Damage to the ligaments is difficult to “prove” by conventional x-ray, which is why bending views or, flexion/extension x-ray methods are needed. When there is damage to the ligaments, the vertebra will shift forwards or backwards excessively compared to neighboring vertebra. This can be measured to determine the extent of ligament laxity or damage and can help explain why neck pain can be so intense and/or chronic following an automobile collision. Not all car accidents occur from behind. In fact, only about 1/3 occur from this direction. One study investigated which direction created greater degrees of injury and found 57% of chronic pain patients in the study population were involved in rear-end collisions. The study also found that woman are more at-risk than men for whiplash injuries and that frontal and rear-end collisions resulted in significantly higher levels of ligament injury than side impacts
Another well-published reason why neck pain can “hurt so much” after a car crash is that the sensory input from the injured area to the brain can be so extreme that it leaves an “imprint” in the sensory portion of the nervous system and it becomes hypersensitive or sensitized, resulting in a lower pain threshold or being more sensitive to pain. This is similar to the “phantom limb” phenomenon that often occurs after a leg is amputated where the brain still “feels” leg pain after the limb has been removed. This has also been reported to be a reason for the significant constellation of symptoms often accompanying “whiplash” injuries. A partial list of symptoms associated with whiplash injuries includes neck pain, headache, TMJ / jaw pain, dizziness, coordination loss, memory loss, and cognitive difficulty in formulating thought, communicating, and losing your place during conversation.
Understanding whiplash and all of its nuances regarding signs and symptoms, x-ray requirements and measurement techniques, and treatment / management strategies are well understood by doctors of chiropractic. Chiropractors have a unique advantage over other healthcare providers as manual therapies, including spinal manipulation, have been shown to yield higher levels of satisfaction and faster recovery rates compared with other forms of healthcare.