Chronic whiplash syndrome
Chiropractic management of intractable chronic whiplash syndrome
From: Clinical Chiropractic (2004) 7, 16—23
Hyperflexion extension injuries are common and often result in neck and low back pain. As a neuromusculoskeletal complaint, chiropractors, as primary healthcare clinicians, are increasingly providing treatment in such cases. In the case described, a 22-year-old female presented 3 years after a whiplash type injury complaining of chronic neck pain and stiffness and frontal headaches. The neck pain had commenced 24 h after a road traffic accident (RTA) and had remained severe for 2 weeks, during which time a soft collar was worn. The neck pain and stiffness had persisted and had worsened in the 6 months leading up to presentation. In addition, frontal headaches had also developed.
This case demonstrates that chronic whiplash injury patients can respond well to appropriate conservative management, even in the presence of poor prognostic indicators. The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow-up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain. This case demonstrates the use of chiropractic management of chronic whiplash type injuries. However, more high-quality evidence is required to support the use of chiropractic care for chronic and, indeed, acute whiplash cases.
- The Quebec Task Force classification of Whiplash-Associated Disorders Grade Signs and symptoms:
- Grade 0 No complaint of pain or discomfort. No physical sign(s) of injury
- Grade 1 Neck complaint of pain, stiffness or tenderness only. No physical sign(s) of injury
- Grade 2 Neck complaint of pain, stiffness or tenderness and physical, musculoskeletal sign(s) of injury such as point tenderness or decreased range of motion
- Grade 3 Neck complaint of pain, stiffness or tenderness and neurological sign(s) or injury
- Grade 4 Neck complaint of pain, stiffness or tenderness and fracture or dislocation
Whiplash is a common injury with an estimated incidence of approximately 4 cases per 1000 persons. The incidence of whiplash type injuries is steadily increasing, highlighting the need for research in this area. Neck pain and stiffness are the most frequently reported symptoms associated with whiplash type injuries and, as such, patients with whiplash trauma are likely to make up a high percentage of those seeking chiropractic care. This highlights the need for chiropractors and other practitioners of manual therapies to be knowledgeable in the area of whiplash, and reflects both the chiropractic undergraduate degree syllabus and the emphasis of post-graduate continuing professional development.
Whiplash injuries are commonly, but not exclusively, associated with road traffic accidents (RTAs). A rear-end RTA usually involves a sudden acceleration then deceleration with resultant hyperflexion, hyperextension and, possibly, lateral flexion or torsional forces to the cervical spine. Most RTAs are not fatal and result in a sprain/strain type injuries to the muscles, ligaments, soft tissues, intervertebral discs and facet joints of the cervical spine. This leads to local tissue inflammation, oedema, muscle spasm, stiffness11 and nociception as a result of altered cervical facet joint biomechanics12 together with proprioceptive dysfunction. In more severe cases, radicular arm pain, due to nerve root traction or discal lesion, may also be present or, indeed, myelopathy, as a result of spinal cord damage. Whiplash patients may also complain of headaches, dizziness, blurred vision, dysphagia, paraesthesia, shoulder girdle pain, temporomandibular joint dysfunction and cognitive difficulties following a whiplash type injury. These related symptoms are known as Whiplash-Associated Disorders (WAD) and were classified in 1995 by the Quebec Task Force study\.
Regardless of the diagnosis, the prognosis for whiplash patients is dependent upon many factors. For example, the severity of symptoms is dependant on criteria such as the velocity of the motor vehicle at the point of impact, the vehicle type, use of seatbelt and/or headrest and awareness of impending accident. Other aspects affecting severity are the presence of pre-existing risk factors. This includes cervical spine instability or hypermobility due, for example, to inflammatory arthropathy such as rheumatoid arthritis; congenital abnormality with adjacent hypermobile segments; previous traumatic events or pre-existing cervical spondylosis or discal lesion. The variability of pre-existing risk factors and the circumstances surrounding the RTA, together with the individual’s variable reaction to these influences, make each case unique and, therefore, each patient must be considered on an individual basis.
In addition, a general prognostic consideration when treating an acute whiplash patient is that there may be a number of serious delayed reactions that can be fatal. This is due to such pathological events as vertebral artery dissection leading to cerebellar infarction16 and thrombotic embolus. Permanent neurological deficits may also develop due to nerve root or spinal cord damage. In such cases, the prognosis is potentially much worse and an appropriate and immediate surgical referral is obviously required. Post-whiplash patients should, therefore, be evaluated neurologically for cranial nerve abnormalities; sensory, motor and reflex deficits and cerebellar signs and symptoms. Radiographic investigation may also be required depending on the nature and severity of the RTA and the signs and symptoms presenting. For example, a positive ‘Rust’ sign, indicating considerable cervical instability whereby the patient finds relief from holding their head, warrants further investigation. In the presence of normal radiographic findings, MRI imaging is normally only considered in the case of persistent neurological deficit18,19 or when significant soft tissue injury is suspected (such as anterior longitudinal ligament injury or discal lesion) to evaluate the need for surgery
Chronic whiplash syndrome: Neck pain associated with an RTA usually commences within 48 h and, although in most cases this resolves within 6 weeks, it is estimated that between 12 and 50% of patients become chronic sufferers. Chronic whiplash syndrome (CWS) is the term used to describe patients who retain WAD symptoms, 6 months after the RTA2 as in the case described here. The exact risk factors for developing CWS and the mechanisms involved remain controversial and poorly understood. The contributing factors are likely to include unresolved somatic injury, psychological overlay and outstanding medicolegal matters. Studies have highlighted a number of factors that are likely to increase the risk of developing chronicity and, therefore, a poorer prognosis. These include, younger age at the time of the RTA, female gender, neck pain on palpation in the acute phase, pain or numbness radiating into the upper limb and associated headache, as well as neck stiffness and muscle spasm and pre-existing cervical degenerative spondylosis. In addition, a positive correlation has been established between severity of injury and delayed recovery.
Historically, during the acute phase of a whiplash type injury, the preferred medical approach has been rest, analgesia and a soft cervical collar to avoid the risk of further injury, reflected in this case. However, recent studies suggest that soft collars do not influence the duration or severity of pain following an RTA and that rest and immobility actually slow the healing process. The current thinking is that mobility and maintaining good posture in the acute phase, together with active rehabilitative exercises in the subacute/chronic phase are more beneficial.
The most commonly used chiropractic intervention in the acute phase of a whiplash injury typically focuses on pain relief and anti-inflammatory strategies. Mobility is maintained with cervical spine mobilisation and manual traction, often used in the case of a radiculopathy, together with soft tissue work and electrotherapy, to reduce muscle spasm. Specific chiropractic manipulation may also be considered in the acute phase. In chronic whiplash cases, specific chiropractic spinal manipulation techniques are commonly used by chiropractors often incorporating rehabilitative exercises. With an emphasis on active care, exercise and an early return to normal activities, chiropractic management appears to fit nicely with current evidence regarding whiplash injury.
Although there is increasing evidence to support conservative care, such as chiropractic, in the treatment of post-whiplash injuries, the most effective conservative approach remains controversial. A recent systematic review concluded that, due to the small number of randomised controlled clinical trials available, there is inconclusive evidence for the efficacy of conservative treatment for whiplash patients. Other studies identify the need for further research into specific treatments, such as cervical traction. This emphasizes the need for more high-quality research to support the efficacy and best practice of conservative care for both acute and chronic whiplash injuries.
One of the reasons chiropractic manipulation may be likely to have a favourable affect on whiplash patients is its focus on the posterior cervical facet joints, which are a common source of pain following a whiplash injury. Facet joints may be the source of pain due to altered joint mechanics or as a result of pinching of the facet joint capsule or synovium.12 Correcting the joint mechanics and reducing the pinching effect with an appropriate specific chiropractic manipulation may help to restore the normal function, reducing nociceptive input and secondary muscle spasm. Specificity is required to avoid hypermobile segments that may exist at the apex of the whiplash forces, typically C4 to C6. If specificity cannot be accommodated, then the chiropractor must question the appropriateness of the use of spinal manipulative therapy. If hypermobile segments can be avoided, then specific chiropractic manipulative therapy to hypomobile segments may be considered to be appropriate, even in the acute whiplash phase.
One of the reasons for the controversy regarding chiropractic care for whiplash patients may be due to the timing of the treatment. As a result of a whiplash type injury, there is increased stress applied to the cervical spine soft tissue structures, such as the musculature, ligaments and joint capsule, in a similar way to the stress applied to the soft tissues in, say, an ankle inversion sprain. A question therefore arises as to the appropriate timing of specific chiropractic manipulation following a whiplash type injury, which may take the affected facet joint and soft tissue structures further into the paraphysiological zone. In the case of an ankle sprain, early adjustive treatment is not recommended until resolution of the acute inflammatory phase. However, in the sub-acute phase, when adhesions and scar tissue are forming, chiropractic manipulation of the ankle joints may promote flexibility, decrease pain and promote soft tissue healing. However, a further clinical dilemma, in the case of an acute whiplash injury, is that there is typically reduced cervical ROM due to muscle spasm18 and guarding. It is therefore possible that the facet joints may be palpated as dysfunctional, tender and hypomobile in the presence of segmental hypermobility. As a result, it is incumbent upon the practitioner to carefully evaluate the patient for the appropriateness of spinal manipulation therapy immediately following a whiplash injury to avoid further insult. Indeed, the question of specificity also arises as spinal manipulation designed to affect the hypomobile segments may also allow adjustive forces to affect hypermobile segments. As a result, the use of spinal manipulation in the acute phase of a whiplash type injury remains controversial indicating the need for more research in the area.
For chronic whiplash patients, specific chiropractic manipulation has been established as an appropriate conservative option, with one study finding 93% of CWS patients improving with chiropractic manipulation, supporting chiropractic care in the chronic case. In addition, another study of chronic whiplash patients concluded that a combination of spinal manipulation with rehabilitative exercises was more beneficial than manipulation alone.54 As a multimodal treatment plan has the potential to be effective for patients with chronic whiplash-related symptoms, this was the approach used in this case. The patient was given active rehabilitative exercises that were incorporated into the treatment regime from the outset. As pain levels subsided, the patient felt able to return to a more active, gym-based exercise programme, incorporating the rehabilitative exercises. The combined active and passive approach in this case is believed to have impacted beneficially on both somatic dysfunction and psychological overlay due to chronicity, even in the presence of poor prognostic indicators.
Whiplash injuries are common and patients often present to chiropractors due to the presence of neck or low back pain. Chiropractic management of CWS typically involves a combination of specific spinal manipulative therapy (SMT), cervical mobilisation and manual traction, soft tissue work, electrotherapy, cryotherapy and active rehabilitation care. This multimodal approach is in line with current research that promotes an early return to normal activities, believed to promote a more rapid recovery. SMT focuses on correcting neuromusculoskeletal dysfunction and active care addresses postural and muscle imbalance together with psychological overlay, often associated with chronic pain sufferers.
This case confirms the presence of CWS, induced by somatic, biomechanical dysfunction. There were no medicolegal matters outstanding and minimal psychological overlay supporting the development of CWS as one involving somatic injury and dysfunction. The most likely contributing factor to the development of chronicity in this case was the presence of posterior cervical facet joint dysfunction together with postural and muscular imbalance. The rapid and complete resolution of symptoms following a 3-year history of pain, even in the presence of poor prognostic indicators, provides additional support for the use of chiropractic management of CWS.
The appropriate timing of chiropractic SMT, following a whiplash type injury, however, remains controversial, especially in the case of an acute whiplash case due to the possibility of hypermobility. In this case, an acute, mild exacerbation of the chronic condition was treated successfully with SMT and soft tissue work with rapid resolution of symptoms supporting the use of SMT in an acute phase of a whiplash injury. However, more highquality evidence to support the use of chiropractic spinal manipulation for chronic and, indeed, acute whiplash injuries is required.
