Neck Pain and WhiplashNeck pain and whiplash-associated disorders (WAD) affect alarge number of individuals (approx. 12-70% in a givenyear).Recently the Bone and Joint Decade 2000-2010 Task Force on Neck Pain (Spine2008;33[4s]suppl.15:S5-S7) released their findings on treatments for neck pain. Among thehighlights were: Most neck pain becomes chronic and symptoms do not completely resolve; between 50 and 85% of patients will experience neck pain one to five years later; For most patients without radicular symptoms, getting back to work and returning to normal activities appears to improve outcomes; Nonsurgical treatments appear to be more beneficial than usual care, sham, or alternative interventions, but none of the active treatments were clearly superior to any other in the short or long term. Manual therapy, mobilization, manual therapy, exercises, low-level laser therapy, educational videos, and perhaps acupuncture appeared to be helpful; When choosing treatments to relieve WAD grades I and II neck pain, patients and their clinicians should consider the potential side effects and personal preferences regarding treatment options; There was a correlation between chiropractic care and subsequent vertebrobasilar artery (VBAI) stroke in persons <45 years, but a similar association was seen in patients receiving general medical practitioner treatment. This may be explained by patients with VBAI dissection-related headache or neck pain seeking care before having their stroke.We will take great care when adjusting your patient. There are a variety of technical proceduresfor adjusting the neck.If any neck pain patients do not respond to the first few treatments, I will let you know. Caseseries of chronic whiplash patients have shown they can improve their symptoms withchiropractic care (Injury, 1996). A marked increase in symptoms would contraindicate furthertreatment with that type of manipulation.Ask how I examine patients, and whether I feel are x-rays are needed to screen for instability oranomalies. If your patient responds positively to treatment, this would justify continued care,provided there is gradually less weekly frequency. Six to eight adjustments in the first two weekswould not be unusual. This frequency would be rare for a patient in the second month of care.The Healing ofInjured Soft Tissues
In this months issue we’re going to touch on area of patient treatment that has undergoneenormous 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 becauseof these RECENT breakthroughs) there is a considerable amount of misunderstanding regardingsoft tissue injury and its repair.The most common (almost knee-jerk) misconception is that injured soft tissue will heal in aperiod of time between four and eight weeks.Frequently it is claimed that injured soft tissues will heal spontaneously, leaving no long-termresidual damage, and that treatment is not required. This type of information is extremelymisleading and confusing to both doctor and patient alike.Published articles and books concerning the healing of injured soft tissues (Oakes 1982; Roy andIrving 1983; Kellett 1986; Buckwalter/Woo 1988, Majno 2004) indicate that the time frame forsuch healing is approximately one year.Needless to say the difference between a recovery time of 4-8 weeks and 12 months dramaticallyimpacts both clinical practice and expected outcomes.Healing Takes Place In Three Specific Phases.Soft Tissue Healing Phase #1Acute Inflammatory Phase.This phase will last approximately 72 hours. During this phase, after the initial injury, anelectrical 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 theinjured tissues. Because of the increasing inflammatory cascade during this period of time, it isnot 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 ofsubstrate (glucose, oxygen, etc.) to produce large enough quantities of ATP energy to initiatecollagen protein synthesis to repair the wound.After 72 hours following injury, the damaged blood vessels have mended. The resultingincreased availability of glucose and oxygen elevates local ATP levels and collagen repair beginsby the fibroblasts that accumulated during the acute inflammatory phase.Soft Tissue Healing Phase #2Phase 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 aboutthe 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 torntissues. 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 willerroneously claim this to be the end of healing. However, it clearly is not. There is a third andfinal phase of healing. This phase is called the phase of remodelingSoft Tissue Healing Phase #3Phase Of RemodelingThe phase of remodeling starts near the end of the phase of regeneration. During the phase ofremodeling the collagen protein glues that have been laid down for repair are remodeled in thedirection of stress and strain.This means that the fibers in the tissue will become stronger, and will change their orientationfrom an irregular pattern to a more regular pattern, a pattern more like the original undamagedtissues.Proper treatment during this remodeling phase is very necessary if the tissues are to get the bestend product of healing. It is during this remodeling phase that the tissues regain strength andalignment. Remodeling takes approximately one year after the date of injury.It is established that remodeling takes place as a direct byproduct of motion. Chiropractichealthcare puts motion into the tissues in an effort at getting them to line up along the directionsof stress and strain, thereby giving a stronger, more elastic end product of healing.Traditional chiropractic joint manipulation healthcare is directed towards putting motion intothe periarticular paraphysiological space.The concept of paraphysiological joint motion was first described by Sandoz in 1976, and isexplained well by Kirkalady-Willis 1983 and 1988, by Kirkalady-Willis/Cassidy 1985, and in the2004 monograph on Neck Pain (edited by Fischgrund) published by the American Academy ofOrthopedic Surgeons (see picture).These discussions clearly show that there is a component of motion that cannot be properlyaddressed by exercise, massage, etc, and that this component of motion can be properlyaddressed by osseous joint manipulation.Therefore, traditional chiropractic osseous joint manipulation adds a unique aspect to thetreatment and the remodeling of periarticular soft tissues that have sustained an injury.
There are some problems associated with the healing of injured soft tissues. Microscopichistological 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 andconsequent local inflammation. This progressive bleeding releases increased numbers offibroblasts 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 intothe tissues, the healing process is really a process of fibrosis.FibrosisIn 1975, Stonebrink addresses that the last phase of the pathophysiological response to trauma istissue fibrosis. Boyd in 1953, Cyriax in 1983, and Majno/Joris in 2004 note that there is tissuefibrosis subsequent to trauma.This fibrosis of repair subsequent to soft tissue trauma creates problems that can adversely affectthe tissues and the patient for years, decades, or even forever.Fibrosed tissues are functionally different from the adjacent normal tissues. The differences fallinto two main categories:Fibrosis Category 1The repaired tissue is weaker and less strong than the undamaged tissues. This is because thediameter of the healing collagen fibers is smaller, and the end product of healing is deficient inthe 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 becausethe healing fibers are not aligned identically to that of the original. Examination range of motionstudies 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 longafter the initial cause has ceased to operate.”Since inflammation alters the thresholds of the nociceptive afferent system, physicalexaminations in these cases will show these fibrotic areas display increased sensitivity, anddigital pressure may show hypertonicity and spasm.This increased sensitivity can be documented with the use of an algometer, which is a device thatuses 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 orstress.These episodes of pain and/or spasm at times of increased use or stress of the once damaged softtissues is the rule rather than the exception, and a problem that the patient will have to learn tolive with.It is likely that the patient will continue to have episodes of pain and/or spasm for an indefiniteperiod of time in the future. It is probable that the patient will have a need for continuing caresubsequent 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 theaccident 12 1/2 years after being injured; and that of the symptomatic 62%, 62.5% had topermanently alter their work activities and 44% had to permanently alter their leisureactivities in order to avoid exacerbation of symptoms.One of the conclusions of the article is that these long-term residuals were most likely the resultof 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 recoverymore than ten years after the date of the accident.One of the conclusions of this study is that the patients symptoms would not improve after aperiod of two years following the injury.It is established neurologically (Wyke 1985, Kirkalady-Willis and Cassidy 1985) that when achiropractor adjusts (specific directional spinal manipulation) the joints of the region of painand/or spasm, that there is a depolarization of the mechanoreceptors that are located in the facetjoint 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 achiropractor following an episode of increased pain and/or spasm.What Is The Basis For TheChronic Post-Trauma Pain SyndromesSo Many Patients Suffer From?A good explanation is found from Gunn (1978, 1980, 1989). He refers to this type of pain assupersensitivity.The supersensitivity type pain is a residual of the scarring or the fibrosis that was created by theinjuries sustained in this accident.
The treatment that we give to the patient for the injuries sustained in an accident is really notdesigned to heal the sprain or strain but rather, to change the fibrotic nature of the reparativeprocess 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 softtissues with fibrotic residuals subsequent to the fibrosis of repair of once damaged soft tissuesthat 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 isin dealing with the residual fibrosis of repair and its associated mechanical and neurologicalconsequences.These residuals to some degree are most probably permanent. The patient will have to learn todeal 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 canneurologically inhibit muscle tone, improve ranges of motion, disperse accumulatedinflammatory exudates, and the patient will have less pain and improved function.The concepts briefly discussed above are frequently not understood or appreciated. There is atendency for healthcare providers to not properly examine the patient in order to document theseregions of tissue fibrosis and its consequent mechanical and neurological consequences and,therefore, to quote Stonebrink, the real problem is missed.ReferencesBoyd, 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 ofOrthopaedic Surgeons, 2004.Gargan, MF, Bannister, GC, Long-Term Prognosis of Soft-Tissue Injuries of theNeck, Journal of Bone and Joint Surgery, September, 1990.Gunn, C. Chan, Pain, Acupuncture & Related Subjects, C. Chan Gunn, (1985).Gunn, C. Chan, Treating Myofascial Pain: Intramuscular Stimulation (IMS) forMyofascial Pain Syndromes of Neuropathic Origin, University of Washington,1989.Hodgson, S.P. and Grundy, M., Whiplash Injuries: Their Long-term Prognosisand Its Relationship to Compensation, Neuro-Orthopedics, (1989), 7.88-91.Kellett, John, "Acute soft tissue injuries-a review of the literature," Medicine andScience 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 theTreatment of Low-Back Pain," Can Fam Physician, (1985), 31:535-40.Majno, Guido and Joris, Isabelle, Cells, Tissues, and Disease: Principles ofGeneral 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, ChurchillLivingstone, 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 ChiropracticProfession," ACA Journal of Chiropractic, (June1975), Vol. IX, p.65-75.Wyke, B.D., Articular neurology and manipulative therapy, Aspects ofManipulative 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.http://www.chiropractorpeoriail.com/articles/neck-pain-and-whiplash/http://www.chiropractorpeoriail.com/articles/http://www.chiropractorpeoriail.com/bloghttp://www.chiropractorpeoriail.com/