Back Clinic Whiplash Chiropractic Physical Therapy Team. Whiplash is a collective term used to describe injuries to the cervical spine (neck). This condition often results from an automobile crash, which suddenly forces the neck and head to whip back and forth (hyperflexion/hyperextension). Almost 3 million Americans are hurt and suffer from whiplash annually. Most of those injuries come from auto accidents, but there are other ways to endure a whiplash injury.
The symptoms of whiplash may include neck pain, tenderness and stiffness, headache, dizziness, nausea, shoulder or arm pain, paresthesias (numbness/tingling), blurred vision, and in rare instances difficulty swallowing. Soon after it happens at the acute phase the chiropractor will focus on reducing neck inflammation utilizing various therapy modalities (eg, ultrasound).
They might also use gentle stretching and manual therapy techniques (eg, muscle energy therapy, a type of stretching). A chiropractor may also recommend you apply an ice pack in your neck and/or light neck support to use for a short time period. As your neck gets less inflamed and the pain diminishes, your chiropractor will execute spinal manipulation or other techniques to restore normal movement to your neck’s spinal joints.
While bruising, soreness, and scrapes are common, whiplash and chronic whiplash injuries may not show for several days or weeks. While today’s vehicles are safer than ever, they can still only do so much when it comes to the body and musculoskeletal health. Being involved in an automobile accident, even a light tap can give a sudden jolt to the spine that although the individual might not have felt anything like discomfort or pain, it was enough to shift the disc/s out of place or set them up to shift out of place. No one wants to be involved in a car or motorcycle accident, but regardless of good driving habits, or how advanced the safety features on the vehicle might be, the average driver will be involved in three to four automobile accidents in their life.
Whiplash and chronic whiplash injuries are common in motor vehicle accidents. More than 3 million Americans will see a doctor and a chiropractor for automobile accidents and whiplash effects. It only takes a 2.5 mph hit to cause an injury. And whiplash doesn’t only happen when hit from behind, there are several ways an individual can be subjected to whiplash, including being T-boned, amusement park rides, and falling off a bicycle or a horse.
Most whiplash symptoms develop in the first twenty-four hours, but this is not always the case. Common symptoms include:
Most individuals realize they have whiplash a day or two after, but for others, it can take a few weeks or even months to present. Whiplash is classified by degree or grade:
The individual has no complaints and there are no symptoms/signs of physical injury.
There is neck pain but there are no physical signs of injury.
There are signs/symptoms of musculoskeletal damage and neck pain is presenting.
There are signs/symptoms of neurological damage and neck pain is presenting.
The average amount of time most individuals stay home from work is around 40 days. However, when whiplash pain lasts longer than a few weeks, it is deemed to be chronic whiplash.
Some individuals with whiplash experience painful symptoms for years. This is true of those that avoid or refuse medical attention and learn to live with it.
There are very effective methods for treating whiplash and chronic whiplash injuries. Depending on the extent of the injury/s, developing the right treatment/rehabilitation plan requires individual consultation with a chiropractor to discuss options that can include:
The pain can be excruciating. Over-the-counter pain relievers like ibuprofen for temporary relief. However, the individual will need extended treatment to ensure it does not become chronic pain.
Neck braces help limit the pain, but should not be worn for more than three or four days. If worn for too long the neck muscles are prevented from gaining the strength needed to support the head.
Don’t Sit For Too Long
Avoid keeping the head in any one position for too long. This includes sitting in bed, watching TV, or working at a desk. This places a large amount of pressure and stress on the neck, making the pain even more severe and longer-lasting.
Sleeping Properly and Comfortably
For many, it can be difficult to get into a comfortable position when sleeping. Sleeping on the back with the head turned to one side can worsen the pain. Try a high-quality ergonomic pillow that allows the individual to sleep on their side and takes the pressure off of the neck.
Whiplash can cause the spine to shift out of alignment. This can lead to additional problems in the back or shoulders. It�s always a good idea to see a chiropractor that specializes in motor vehicle accident injuries to realign the spine and neck, as well as for rehabilitation to strengthen the muscles and prevent further injuries. See a chiropractor for an evaluation of the injuries and develop a customized treatment plan that works for the individual’s condition.
Everyone is different
Some individuals can be stiff and sore for a few days and then are okay with not much pain. Some individuals experience severe pain immediately after the wreck, while others have no pain for days or even weeks. Both scenarios are pretty common. Soft tissue injuries can be very deceiving. Some don�t experience any pain for months after the accident. Many don�t think they need to see a doctor or chiropractor because there is no pain or symptoms. However, underneath serious problems could be getting ready to present including:
Numbness or pins and needles in the hands or arms
Pain between the shoulder blades
Chronic muscle tension
Degeneration of the discs
Painful inflamed arthritis
The quick development of arthritis
Sore, tight, or inflexible muscles
A decrease in physical activity
Physical inactivity is a primary factor in the progression of sarcopenia. Resistance exercise can help maintain muscle mass and help build muscular strength. Individuals that are more sedentary can exacerbate the effects of sarcopenia.
A decrease in motor neurons
Aging is accompanied by motor neuron loss resulting from cell death. This leads to a decrease in muscle fiber. This decrease in muscle fibers leads to:
A reduction in functional capacity
A decreased ability to perform everyday tasks
Dr. Alex Jimenez�s Blog Post Disclaimer
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*
Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
Axial neck pain is also known as uncomplicated neck pain, whiplash, and cervical/neck strain. They refer to pain and discomfort running along the back or posterior of the neck. Axial is defined as forming or around an axis. This type of pain stays around the neck and immediate surrounding structures. It does not spread/radiate out to the arms, hands, fingers, and other areas of the body. Axial neck pain differs from two other neck conditions. They are:
Cervical radiculopathy describes irritation or compression/pinching of the nerve as it exits the spinal cord. The nerves of the cervical spine are known as the peripheral nerves. They are responsible for relaying signals to and from the brain to specific areas of the arms and hands. The signals sent from the brain are for muscle movement, while signals going to the brain are for sensation.
When one of these nerve/s gets irritated, inflamed, or injured, it can result in:
Other types of abnormal sensations in the arms, hands, or fingers.
Cervical myelopathy describes compression of the spinal cord itself. The spinal cord is the information highway/pipeline to all parts of the body. There is a range of symptoms that can include:
Same symptoms as cervical radiculopathy
Loss of fine motor skills
Bowel and bladder incontinence
Axial neck pain
Axial neck pain is a quite common type of neck pain. It affects around 10% of the population. However, the majority of these cases do not involve severe symptoms that limit daily activity.
Pain in the back of the neck is the primary and most common symptom. Sometimes the pain travels to the base of the skull, shoulder, or shoulder blade. Other symptoms include:
Localized muscle pain
Developmental Risk factors
Poor posture, lack of ergonomics, and muscle weakness increase the chances of developing axial neck pain. Risk factors for development include:
Trauma – Auto accident, sports, personal, work injury
Chronic neck pain
Based on symptoms and physical exam findings are how a diagnosis is usually achieved. A doctor will typically order an x-ray, CT, or MRI of the cervical spine. This calls for an immediate visit to a hospital/clinic for evaluation. There could be severe symptoms that could indicate something more dangerous, causing pain like infection, cancer, or fracture. These symptoms include:
Prior trauma/injury from a fall, automobile accident, sports, work injury
Constant night pain
Rheumatic conditions/diseases that cause neck pain can include morning stiffness and immobility that gets better as the day progresses. If symptoms continue for more than 6 weeks, imaging of the spine could be recommended, especially for individuals that have had previous neck or spine surgery or if it could be cervical radiculopathy or myelopathy.
There is a wide range of treatment options. Surgery is rarely required except for severe cases. Returning to normal activities almost right away is one of the most important things to prevent the pain from becoming chronic. First-line treatments typically begin with:
Muscle relaxants are sometimes prescribed
If a cervical spine fracture has been diagnosed, a neck brace could be recommended for short-term use. A soft collar could be utilized if the pain is severe, but a doctor usually discontinues use after 3 days. Other non-invasive treatment options include:
Invasive treatments like injections, nerve ablation, and surgery are rarely required. But if necessary, it can be beneficial for those cases.
A variety of the neck’s anatomical structures can contribute to the pain. Common causes include:
Injury to muscles or ligaments
All of these can affect vertebral bodies, discs, and facet joints. Shoulder arthritis or a rotator cuff tear can imitate axial neck pain. Dysfunction of the temporomandibular jaw joint or the blood vessels of the neck can cause axial pain, but it is rare.
Symptoms are usually alleviated within 4-6 weeks from when the pain started. Pain that continues beyond this should encourage a visit to a chiropractic physician.
Physical therapy involves both passive and active treatments and�is an effective treatment for whiplash, especially combined with other treatments, like bracing and chiropractic. Whiplash causes the soft tissues in your neck to get damaged. A physical therapist can work with you to restore proper function and movement of those tissues.
Passive treatments help to relax tension in the muscle tissues brought on during the accident in the neck and body. It is considered a passive treatment because the patient does not actively participate. Fresh from the injury acute pain sets in, therefore passive treatment is usually the first type of therapy used as your body begins to heal and adjusts to the symptoms.
The primary goal of physical therapy is to get the patient actively participating in active treatment until they can do the exercises on their own. The therapeutic exercises that physical therapists teach to a patient are for strengthening your entire body to ensure that your spine is optimally supported.
Deep Tissue Massage
This technique focuses on tight muscle tension that develops from the injury. Direct pressure is applied and massaged to release the tension in the soft tissues like the:
This will help these tissues heal quicker and keep them loose.
Heat therapy is used by physical therapists to circulate more blood to the injured area. Increased blood flow allows more oxygen, and nutrients to the area. Blood also removes the waste products created by muscle spasms.
Cold therapy slows the blood’s circulation, which helps to reduce inflammation, muscle spasms, and pain. Physical therapists alternate between hot and cold therapy depending on the patient’s condition.
Whether in a car accident or other type of trauma hot and cold therapy can be used at home. Ice should be used first to bring down the inflammation. After 24 to 48 hours, switch between ice and heat. The heat helps relax tense muscles and increases blood circulation to the injured area. Never put ice or heat directly on the skin, wrap in a towel then apply.
Ultrasound helps reduce muscle:
Sound waves are sent deep into the muscle tissues and create a gentle heat that circulates the blood that optimizes the healing process.
When the active part of the therapy begins, the therapist will teach/train you a variety of exercises to work on strength and range of motion or how the joints move with ease or not. Each physical therapy program is customized to each patient’s condition, health, and medical history.
Some exercises might not be appropriate for someone else with a whiplash injury as they could worsen their symptoms and exacerbate the injury. Learning how to correct your posture and utilizing ergonomics into your regular daily activities is part of the therapy program. Once recovered this posture work will continue to help because of the training/exercising you can prevent other forms of neck pain that develop from regular life.
Physical therapy for whiplash patients helps reduce muscle spasms, increase blood circulation, and promote healing of the neck tissues.
Spinal Bracing Another Treatment Option
Whiplash is very treatable, another option is using a cervical brace or cervical collar. The brace provides support to the neck while the soft tissues heal. The soft tissue’s job is to support your neck, but when they’re injured, they can’t do their job. That’s where the brace comes in.
Cervical devices limit the neck’s movement and support your head, which takes the weight off the neck.
This allows the muscles to rest while they heal. Your doctor will inform you of how long you need to wear the brace. Generally, it is worn for two to three weeks. The doctor will explain how to wear the collar, which means how long to weary it each day, caring for the collar, handling daily activities like showering, sitting, sleeping, etc. Symptoms usually subside in two to three weeks. However, if there is still pain, soreness, or other symptoms, you may have to try other treatments.
Whiplash Massage Therapy El Paso, TX Chiropractor
After a car accident, you may notice neck pain.�It could be a�slight soreness that you think is nothing but take care more than likely you have whiplash.�And that�little soreness can turn into a lifetime of chronic neck pain�if only treated with pain meds and not�treated at the source.
Neck pain caused by a whiplash injury definitely warrants a visit to a chiropractic whiplash specialist that can provide non-surgical treatment and pain relief.
Whiplash is an injury to the neck muscles from a rapid forward and backward motion of the neck caused by trauma from a car accident, sports injury, slip and fall accident or even just turning one’s head but doing it with a fast whipping motion that causes the neck/spine muscles to become swollen and irritated. It can cause acute short-term neck pain and restricted movement.
How a Whiplash Injury Is Diagnosed
A chiropractor evaluates the spine in its entirety. If you go to a chiropractic clinic with neck pain following trauma. The chiropractor will examine the whole spine because the other areas of the spine could be affected and not just the neck region.
The chiropractor locates the areas where motion is restricted if there are any disc injuries, muscle spasms, and ligament injuries. They will first apply motion and staticpalpation diagnostic techniques where they feel and touch the various areas where the pain is present, as well as where there is no pain. A chiropractor will also feel for:
How well the spinal joints move
They will also analyze the patient’s walk noting their posture and if there is possible spinal misalignment. This will help the chiropractor understand the patient’s body’s mechanics and what their spine is doing to compensate for the injury. This can mean:
Leaning to one side
Getting up in a very careful way so as to avoid pain
Only turning in one direction
In addition to the evaluation, they will also order an x-ray or an MRI to evaluate any deteriorating changes that could have existed before the whiplash injury. The images and physical and neurological evaluation resultsare compared to figure out and develop the best treatment plan.
Whiplash Treatment Stages
After a whiplash injury happens a chiropractor works to reduce neck inflammation with various therapies like:
Soft manual therapy techniques
They may also recommend applying an ice pack on the neck and light neck support for a short time. As the inflammation and pain decrease the chiropractor will begin applying gentle spinal manipulation along with other techniques to restore the normal motion to the neck’s facet joints.
Chiropractic Whiplash Injury Treatment
A treatment plan depends on the severity of the whiplash injury. Some manipulation techniques used are:
This is a gentle non-thrusting type of spinal manipulation that helps treat herniated discs. A whiplash injury can cause an aggravated bulging or herniated disc. If this happens a chiropractor uses a slow palm pump action on the disc rather than direct thrusting force.
This technique also non-thrusting utilizes a hand-held instrument. A chiropractor generates force without thrusting directly into the spine. This therapy is great for older patients who may have degenerative joint syndrome.
Specific spinal manipulation
Spinal joints that are restricted or have abnormal motion are identified. Then the chiropractor restores motion to the joint with a gentle thrust. This stretches the soft tissue and stimulates the nervous system to bring back normal motion.
Along with these spinal therapies/techniques, a chiropractor also uses manual therapy to treat the soft tissues like the ligaments and muscles. Some examples of manual techniques are:
Instrument-assisted soft tissue therapy is where a chiropractor uses an instrument/s like the Graston technique, that gently treats any injured soft tissues. They will gently apply the instrument along the injured area with repeated strokes.
Manual joint stretching and resistance therapy is a form of manual therapy that uses the muscle’s own energy to create isometric contractions that help relax the muscles, and help lengthen the muscles.
Therapeutic massage is where a chiropractor or physical therapist performs massage to ease and relax muscle tension in the neck.
Trigger point therapy identifies specific tight painful points/areas of muscle by applying direct pressure with the hands or fingers on these points to alleviate the muscle tension.
Interferential electrical stimulation This technique uses low-frequency electrical current to stimulate the muscles and reduce inflammation.
Ultrasound increases blood circulation and helps reduce muscle spasms, stiffness, and pain. This happens by sending sound waves deep into the muscle’s tissue which generates low heat and increases circulation.
Therapeutic exercises to restore normal spinal motion and reduce whiplash symptoms.
Chiropractic medicine looks at the whole person and not just the symptoms. Neck pain is different for everyone, so chiropractors don�t just focus on the pain because the whiplash injury could have affected other areas that the patient doesn’t feel pain or anything.
But as the spine is a complex structure that works as a unit, a problem in one area can slowly or quickly start to create problems in other areas of the spine much like falling dominoes.
With these techniques, a chiropractor will help increase a patient’s daily activities back to normal as quickly as they can, depending on the severity of the injury. They will work as hard as they can to address any added spinal or nerve-related causes/injuries stemming from the original whiplash injury and treat them as well until normal movement is restored and there is no longer pain.
Remember that prevention is the key to optimal long-term health!
Our team has taken great pride in bringing our families and injured patients only clinically proved treatment protocols. �By teaching complete holistic wellness as a lifestyle, we also change not only our patient�s lives but their families as well.� We do this so that we may reach as many El Pasoans who need us, no matter the affordability issues.
El Paso, TX Chiropractic Neck Pain Treatment
Often,�people with whiplash don�t experience any effects until a day, or even two, after. The key is to stay ahead of the pain and take measures sooner rather than later to relieve it and keep it at bay. It also provides documentation should other issues arise, and you need the information for legal purposes.
If you are in an accident, especially if you get rear-ended, and experience whiplash, see a doctor that day ��even if you don�t feel much pain. The sooner you visit a chiropractic clinic, the sooner you can begin treatment should a problem develop.
Rheumatoid arthritis, or RA, is a chronic health issue which affects approximately 1 percent of the population in the United States. RA is an autoimmune disorder that causes the inflammation and degeneration of the synovial tissue, specific cells and tissue which form the lining of the joints within the human body. Rheumatoid arthritis may and generally does affect every joint in the body, especially as people get older. RA commonly develops in the joints of the hands and feet, severely restricting an individual’s ability to move, however, those with significant disease in the spine are at risk of damage like paraplegia. Rheumatoid arthritis of the spine is frequent in three areas, causing different clinical problems.
The first is basilar invagination, also referred to as cranial settling or superior migration of the odontoid, a health issue where degeneration from rheumatoid arthritis at the base of the skull causes the it to “settle” into the spinal column, causing the compression or impingement of the spinal cord between the skull and the 1st cervical nerves. The second health issue, and also the most frequent, is atlanto-axial instability. A synovitis and erosion of the ligaments and joints connecting the 1st (atlas) and the 2nd (axis) cervical vertebrae causes instability of the joint, which may ultimately result in dislocation and spinal cord compression. In addition, a pannus, or localized mass/swelling of rheumatoid synovial tissue, can also form in this region, causing further spinal cord compression. The third health issues is a subaxial subluxation which causes the degeneration of the cervical vertebrae (C3-C7) and often results in other problems like spinal stenosis.
Imaging studies are crucial to properly diagnose patients with rheumatoid arthritis of the cervical spine. X-rays will demonstrate the alignment of the spine, and if there is obvious cranial settling or instability. It can also be difficult to demonstrate the anatomy at the bottom of the skull, therefore, computed tomography scanning, or CT scan, with an injection of dye within the thecal sac is arranged. Magnetic resonance imaging, or MRI, is beneficial to assess the severity of nerve compression or spinal cord injury, and allows visualization of structures, including the nerves, muscles, and soft tissues. Flexion/extension x-rays of the cervical spine are usually obtained to evaluate for signs of ligamentous instability. These imaging studies entails a plain lateral x-ray being taken with the patient bending forward and the other lateral x-ray being taken with the individual extending the neck backwards.�The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Neck Pain and Auto Injury
Whiplash is one of the most common causes of neck pain after an automobile accident. A whiplash-associated disorder occurs when a person’s head and neck moves abruptly back-and-forth, in any direction, due to the force of an impact. Although whiplash most commonly occurs following a rear-end car crash, it can also result from sports injuries. During an auto accident, the sudden motion of the human body can cause the muscles, ligaments, and other soft tissues of the neck to extend beyond their natural range of motion, causing damage or injury to the complex structures surrounding the cervical spine. While whiplash-associated disorders are considered to be relatively mild health issues, these can cause long-term pain and discomfort if left untreated. Diagnosis is essential.
You are sitting in your car, stopped at a traffic light. Suddenly, a vehicle traveling at low-speed rear-ends your car. The impact isn�t hard although it is unexpected. You take a look at your car and see that there is minor damage, or no damage at all, to either vehicle. The bumpers absorbed the bulk of the energy from the crash, so they protected the car. You feel a little pain in your neck, and upper back, perhaps a little dizzy or you have a headache, but you shrug it off, reasoning that it is from the unexpected jolt. After all, they didn�t hit you that hard. You exchange information with the other driver and go on your way.
The next morning is a different story. Your neck is painful and stiff. You have pain in your shoulders and back as well. A visit to the doctor reveals a diagnosis of whiplash.
Is Whiplash Real?
Some people will tell you that whiplash is a made-up injury that people use to get more money in a settlement stemming from an accident. They do not believe it is possible in a low-speed rear-end accident and see it as a legitimate injury claim, mainly because there are no visible marks.
Some insurance experts claim that about a third of whiplash cases are fraudulent, but that leaves two-thirds of the cases legitimate. There is also a great deal of research that supports the claim that low-speed accidents can indeed cause whiplash � and it is very, very real. Some patients suffer from the pain and immobility the rest of their lives.
The Mechanics of Whiplash
When a person is sitting in their vehicle, they are usually upright with their head directly over their shoulders, and the neck as the support. The key to whiplash is that it is unexpected. The vehicle gets struck, the torso of the person in the first car gets thrust forward. However, the head does not immediately follow but instead falls backward, behind the body for a split second. In this position, the neck is hyperextended for the first time (to the rear).
As the torso snaps back against the back of the seat, the person�s head falls forward but is quickly yanked back as it follows the movement of the chest � then passes it. The second time the neck is hyperextended (to the front). The effects of this movement that lasts only a few seconds can cause debilitating pain and immobility. It gets compounded when the headrests are set too far back and are too low so that they do not provide adequate support.
What To Do If You Are In A�Low-Speed Rear End Collision
If you are in an accident, especially if you get rear-ended, and experience whiplash, see a doctor that day � even if you don�t feel much pain. The sooner you get into a doctor, the sooner you can begin treatment should a problem develop.
Often, people with whiplash don�t experience any effects until a day, or even two, later. The key is to stay ahead of the pain and take measures sooner rather than later to relieve it and keep it at bay. It also provides documentation should other issues arise, and you need the information for legal purposes.
Seeing your chiropractor soon after your accident can help you heal faster and manage your pain more effectively. With techniques like gentle manipulation and deep tissue massage, your neck can begin to improve almost immediately. Then you can get back to life a lot faster.
I got into a car accident, I was rear-ended on Valentine’s Day and things weren’t quite right in my body, the aches and pains started coming. So after I visited another chiropractor and talked to my client, they told me about this place and when I came I was like, okay, I’m not going back to the other place. And that’s how I head about him (Dr. Alex Jimenez) and I’m so grateful. – Terry Peoples
Based on information referenced by the National Highway Traffic Safety Administration, or NHTSA, approximately more than three million individuals are injured annually in automobile accidents throughout the United States alone. While the unique conditions of every car crash can ultimately result in a wide variety of injuries, some types of automobile accident injuries are more common than others.
Fortunately, a majority of automobile accident injuries may resolve on their own without the need for treatment, however, more significant health issues caused by the auto collision may require some amount of treatment and/or rehabilitation and others may unfortunately become permanent if left untreated. It’s fundamental for the victim of an automobile accident to seek immediate medical attention in order for them to receive a proper diagnosis for their motor vehicle injuries before proceeding with the most appropriate treatment option for them.
Prior to following any necessary medical procedure, understanding some of the most common automobile accident injuries can help you become aware of the steps you can take to ensure that you are getting the proper care for your health issues. Furthermore, the type and severity of motor vehicle accidents suffered by the victims involved in a car crash may largely depend on several variables, including:
Was the individual wearing a seat belt?
Did the person’s car get hit from the back, side or front?
Was the occupant facing straight ahead in the seat? Or was the person’s head or body turned in a particular direction?
Was the incident a low-speed collision or a high-speed crash?
Did the car have airbags?
There are two broad categories of automobile accident injuries: impact injuries and penetrating injuries. Impact injuries are generally characterized as those caused when a portion of the individual’s body hits some part of the interior of the car. Frequently, this can be a knee hitting a dashboard or the head hitting the seat rest or the side window during an auto collision. Penetrating injuries are generally characterized as open wounds, cuts and scrapes. Shattering glass or loose items flying inside the car on impact can often cause these types of automobile accident injuries. Below, we will discuss the most common automobile accident injuries and describe them in detail.
Soft Tissue Injuries
Soft tissue injuries are some of the most common types of automobile accident injuries. A soft tissue injury is typically characterized as trauma, damage or injury to the body’s connective tissue, including tendons, ligaments and muscles. Soft tissue injuries can vary depending on the type of connective tissue it affects as well as on the grade and severity of the harm. Because soft tissue injuries do not involve open wounds, it may be challenging to diagnose these type of automobile accident injuries.
A whiplash-associated disorder, most frequently referred to as a whiplash injury to the neck and upper back, is a type of soft tissue injury. In this form of harm, the muscles, tendons and ligaments are stretched beyond their natural range due to the abrupt movements imposed on the neck and head from the force of the impact at the point of collision. These same mechanisms may additionally cause soft tissue injuries in other regions of the body, such as the back. Automobile accidents can also often cause mid-back and low-back muscle sprains, and at times, these may cause severe back injuries and even aggravate underlying conditions due to the sheer force from the impact on the spine.
Cuts and Scrapes from Automobile Accident Injuries
During an auto collision, any loose objects inside the car can immediately become projectiles which can be thrown about the vehicle’s interior. This includes cell phones, coffee glasses, eyeglasses, purses, books, dash-mounted GPS systems, etc.. If one of these objects strikes your body at the time of the incident, they can easily cause cuts and scrapes as well as cause additional trauma, damage or injuries.
Occasionally, these cuts and scrapes are relatively minor and require no immediate medical attention. More severe cases of these type of automobile accident injuries, however, could create a relatively large open wound and may require stitches to prevent blood loss. Cuts or scrapes can also occur when your airbag deploys from the auto collision.
Head injuries in the form of automobile accident injuries can take a number of forms, where some can be considered comparatively minor and others can virtually be quite severe. The sudden stop or shift in direction by a motor vehicle during an car crash can cause an individual’s head and neck to jolt or jerk abruptly and unnaturally in any direction, overstretching the complex structures of the cervical spine beyond their normal range, leading to muscle strains and whiplash-associated disorders.
The head itself can also be injured during an auto accident. Impact with a side window or with the steering wheel may cause cuts, scrapes and bruises to the head, as well as even deeper lacerations. More severe collision impacts can cause a closed head injury. In that circumstance, the fluid and tissue inside the skull are damaged due to the abrupt movement or impact of the head. Less acute closed head injuries often result in concussions, while the most severe head injuries can cause brain damage.
Chest injuries are also common auto accident injuries. These type of injuries are usually identified as contusions or bruises, however, these can also take the form of much more severe injuries, like fractured ribs or internal injuries. Drivers often experience chest injuries due to their position behind the steering wheel, which offers very little space to move before the torso collides with the steering wheel. If an individual’s body is thrown forward during a motor vehicle collision, even if their chest doesn’t impact the steering wheel or dashboard, the torso will experience tremendously high amounts of force, specifically against the shoulder harness or seat belt, which may cause severe bruising.
Arm and Leg Injuries
The very same sheer forces which unexpectedly throw a person’s head and neck back-and-forth during a car crash can behave similarly on arms and legs. If your vehicle experiences a side impact, your arms and legs may be tossed hard against the door. In addition, if you’re a passenger, your legs typically have very little room to move. As a result, automobile accidents often cause an occupant’s knees to strike the dashboard or even chairs in front of them.
Based on the circumstance of the auto collision, automobile accident injuries to your arms and legs may include bruises, scrapes and cuts, however, sprains and even fractures in both the upper and lower extremities can happen. Keep in mind that some injuries aren’t apparent following a car accident. It may take days, weeks, or even months for symptoms to manifest. Therefore, if you’ve been involved in an automobile accident, it is best to seek immediate medical attention.
Dr. Alex Jimenez’s Insight
After being involved in an auto accident, it may sometimes take days, weeks, even months for symptoms to manifest completely. For your own health and wellness, it’s essential to seek immediate medical attention following the car crash. While many types of injuries can occur, there are several common automobile accident injuries which can develop due to the sheer force of the impact, such as whiplash-associated disorders. Whiplash is a prevalent auto accident injury which is characterized as a type of neck injury which happens when the complex structures surrounding the cervical spine are stretched far beyond their natural range of motion. Chiropractic care is a safe and effective treatment option which can treat a variety of auto accident injuries.
Chiropractic Care After an Automobile Accident
Many healthcare professionals are qualified and experienced�in the treatment of a variety of automobile accident injuries, especially chiropractors. Chiropractic care is a well-known, alternative treatment option which focuses on the diagnosis, treatment and prevention of numerous injuries and/or conditions associated with the musculoskeletal and nervous system. If you’ve been involved in an auto collision, chiropractic care can offer substantial benefits towards your current well-being, supporting your recovery process.
After a car collision, you may experience pain and discomfort, decreased range of motion, stiffness or soreness. Remember that these symptoms may not always manifest immediately after a motor vehicle accident. Through the use of spinal adjustments and manual manipulations, chiropractic care will help you manage painful symptoms, as well as help enhance flexibility, increase strength and improve mobility, promoting a faster recovery. In addition, it can prevent long-term symptoms from developing, such as migraines and chronic pain. The sooner you get chiropractic care after a car wreck, the more likely you are to recover fully.
By carefully restoring the original alignment of the spine, chiropractic care helps reduce pain and other painful symptoms. Furthermore, a chiropractor can recommend a series of exercises and physical activities to help pump oxygen, blood and nutrients to the injury site and enhance recovery. A doctor of chiropractic will develop a personalized treatment program targeted to your specific automobile accident injuries. Chiropractic care also makes it possible to avoid the need for surgical interventions. It strengthens ligaments, tendons and muscles, which shield the body’s structures. It’s also a far more cost-effective solution.
Chiropractic care can also restore function in patients with older vehicle collision injuries. You are still able to benefit from chiropractic care even if you had an accident years back. Employing spinal adjustments and manual manipulations, as well as rehabilitation techniques, it helps relieve old pain and improve function. Additionally, it is a non-invasive treatment option, and you won’t end up needing to rely on pain drugs and/or medications for relief of your symptoms.
Chiropractors can even treat vertigo resulting from a car crash. In as little as one treatment, they could fix a dysfunction in the vestibular system. Other types of chiropractic care treatment techniques include massage, ultrasound, ice and cold treatment, specific exercises and physical activities, and even nutritional advice. Chiropractic care is a safe and effective treatment approach which can help treat automobile accident injuries without the need for drugs and/or medications as well as surgery.
If you suffered a car accident injury, don’t delay any longer. Contact a chiropractor and allow them to help you follow the best treatment path. Chiropractors can provide you a consultation to perform a comprehensive evaluation and make a treatment strategy targeted to your injuries.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Concussions are traumatic brain injuries that affect brain function. Effects from these injuries are often temporary but can include headaches, problems with concentration, memory, balance and coordination. Concussions are usually caused by a blow to the head or violent shaking of the head and upper body. Some concussions cause loss of consciousness, but most do not. And it is possible to have a concussion and not realize it. Concussions are common in contact sports, such as football. However, most people gain a full recovery after a concussion.
Blurred eyesight or other vision problems, such as dilated or uneven pupils
Ringing in the ears
Nausea or vomiting
Delayed response to questions
Continued or persistent memory loss
Irritability and other personality changes
Sensitivity to light and noise
Mood swings, stress, anxiety or depression
Disorders of taste and smell
Rigidity and inflexibility
Lack of empathy
Lack of motivation or initiative
Depression or anxiety
Symptoms In Children
Concussions can present differently in children
Loss of appetite
Loss of interest in favorite toys or activities
Unsteadiness while standing
Memory loss and failure to form new memories
Inability to remember things that happened before the injury
Due to failure in recall
Inability to remember things that happened after the injury
Due to failure to formulate new memories
Even short memory losses can be predictive of outcome
Amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute)
Return To Play Progression
Baseline: No Symptoms
As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 48 hours. Keep in mind, the younger the athlete, the more conservative the treatment.
Step 1: Light Aerobic Activity
The Goal: Only to increase an athlete�s heart rate.
The Time: 5 to 10 minutes.
The Activities: Exercise bike, walking, or light jogging.
Absolutely no weight lifting, jumping or hard running.
Step 2: Moderate activity
The Goal: Limited body and head movement.
The Time: Reduced from typical routine.
The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting
Step 3: Heavy, non-contact activity
The Goal: More intense but non-contact
The Time: Close to typical routine
The Activities: Running, high-intensity stationary biking, the player�s regular weightlifting routine, and non- contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.
Step 4: Practice & full contact
The Goal: Reintegrate in full contact practice.
Step 5: Competition
The Goal: Return to competition.
After head trauma microglial cells are primed and can become over active
To combat this, you must mediate the inflammation cascade
Prevent repeated head trauma
Due to priming of the foam cells, response to follow-up trauma may be far more severe and damaging
What Is Post-Concussion Syndrome (PCS)?
Symptoms following head trauma or mild traumatic brain injury, that can last weeks, months or years after injury
Symptoms persist longer than expected after initial concussion
More common in women and persons of advanced age who suffer head trauma
Severity of PCS often does not correlate to severity of head injury
Loss of concentration and memory
Ringing in the ears
Noise and light sensitivity
Rarely, decreases in taste and smell
Concussion Associated Risk Factors
Early symptoms of headache after injury
Mental changes such as amnesia or fogginess
Prior history of headaches
Evaluation Of PCS
PCS is a diagnosis of exclusion
If patient presents with symptoms after head injury, and other possible causes have been ruled out => PCS
Use appropriate testing and imaging studies to rule out other causes of symptoms
Headaches In PCS
Often �tension� type headache
Treat as you would for tension headache
Improve stress coping skills
MSK treatment of the cervical and thoracic regions
Adrenal supportive/adaptogenic herbs
Can be migraine, especially in people who had pre-existing migraine conditions prior to injury
Reduce inflammatory load
Consider management with supplements and or medications
Reduce light and sound exposure if there is sensitivity
Dizziness In PCS
After head trauma, always assess for BPPV, as this is the most common type of vertigo after trauma
Dix-Hallpike maneuver to diagnose
Epley�s maneuver for treatment
Light & Sound Sensitivity
Hypersensitivity to light and sound is common in PCS and typically exacerbates other symptoms such as headache and anxiety
Management of excess mesencephalon stimulation is crucial in such cases
Other light blocking glasses
Cotton in ears
Treatment Of PCS
Manage each symptom individually as you otherwise would
Manage CNS inflammation
Fish oil/Omega-3s � (***after r/o bleed)
Cognitive behavioral therapy
Mindfulness & relaxation training
Brain balancing physical therapy exercises
Refer for psychological evaluation/treatment
Refer to mTBI specialist
mTBI is difficult to treat and is an entire specialty both in the allopathic and complementary medicine
Primary objective is to recognize and refer for appropriate care
Pursue training in mTBI or plan to refer to TBI specialists
�A Head for the Future.� DVBIC, 4 Apr. 2017, dvbic.dcoe.mil/aheadforthefuture.
Alexander G. Reeves, A. & Swenson, R. Disorders of the Nervous System. Dartmouth, 2004.
�Heads Up to Health Care Providers.� Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Feb. 2015, www.cdc.gov/headsup/providers/.
�Post-Concussion Syndrome.� Mayo Clinic, Mayo Foundation for Medical Education and Research, 28 July 2017, www.mayoclinic.org/diseases-conditions/post- concussion-syndrome/symptoms-causes/syc-20353352.
Whiplash Massage: Sandra Rubio describes how whiplash-associated disorders resulting from an automobile accident can cause symptoms of neck pain. An injury to the cervical spine can damage the complex structures of the neck, including vertebrae, intervertebral discs and soft tissues like tendons, ligaments and muscles. Dr. Alex Jimenez, doctor of chiropractic, is a non surgical choice which provides several treatment methods, such as deep-tissue massage, which can help improve neck pain associated with whiplash from an auto accident.
Massage therapy�is the evaluation and manipulation of cells and joints of the human body to effect a curative response in the�prevention and treatment of physical dysfunction. It may be curative or preventative, helping to rehabilitate, to preserve, strengthen bodily function or relieve pain. Massage therapy has established its function as it achieves outcomes that were undeniable, as a wellness option used to alleviate an assortment of physical discomforts.
Massage helps alleviate the soft tissue discomfort associated with everyday stress, muscular overuse and lots of chronic pain syndromes. Massage treatment can decrease the development of painful muscular patterning if used early enough after accidents involving trauma and injury.
Whiplash Massage Therapy
Neck pain can come from various structures in the neck including: vascular, nerve, airway, digestive, and musculature or it can originate from other areas of the human body. Although the causes are many, most are easily rectified by either assistance or using self help suggestions and techniques. Treatment of neck pain is dependent upon the reason. For the vast majority of individuals, neck pain may be treated conservatively. Recommendations in conservative treatment include applying cold or heat. Other frequent treatments could include chiropractic care, physical therapy, body mechanics training, reform that is ergonomic, and drugs and/or medication.
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Whiplash is one of the most prevalent types of injuries resulting from an automobile accident, most commonly during rear-end auto collisions. However, whiplash-associated disorders can develop due to a variety of other circumstances, including sports injuries, amusement park rides or physical abuse. Whiplash occurs when the soft tissues of the neck, such as the muscles, tendons and ligaments, extend beyond their natural range of motion because of a sudden back-and-forth movement of the head. Furthermore, the sheer force of an impact can stretch and even tear the complex structures surrounding the cervical spine.
The symptoms of whiplash-associated disorders may take days, weeks or even months to manifest, which is why it’s important for individuals who’ve been involved in an automobile accident to seek immediate medical attention. There are many different types of treatment options which can safely and effectively help treat whiplash. The purpose of the following article is to demonstrate the treatment guidelines of neck pain-associated disorders and whiplash-associated disorders.
The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline
Objective: The objective was to develop a clinical practice guideline on the management of neck pain�associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
Methods: Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee.
Results: For recent-onset (0-3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I-II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (N3 months) neck pain, we suggest offering 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); 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).
Conclusions: A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain. (J Manipulative Physiol Ther 2016;39:523-44.e20) Key
Whiplash occurs when the sheer force of an impact causes the head and neck to jolt abruptly back-and-forth in any direction, stretching the complex structures surrounding the cervical spine beyond their normal range. Neck pain, headache and radiating pain resulting from whiplash are common complaints frequently reported by individuals after being involved in an automobile accident. However, whiplash can also result from a variety of other circumstances. Whiplash-associated disorders are a prevalent source of disability and a common reason many auto accident victims seek medical attention from chiropractors, physical therapists and primary care physicians. Fortunately, many treatment guidelines exist to safely and effectively improve as well as manage the symptoms of whiplash. Chiropractic care is a well-known alternative treatment option for whiplash-associated disorders. Spinal adjustments and manual manipulations can safely and effectively restore the original alignment of the spine, reducing symptoms and alleviating whiplash complications.
Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common and result in significant social, psychological, and economic burden.1-4 Neck pain, whether attributed to work, injury, or other activities,5 is a prevalent source of disability and a common reason for consulting primary health care providers, including chiropractors, physical therapists, and primary care physicians.6 The estimated annual incidence of neck pain measured in 4 studies ranged between 10.4% and 21.3%, with a higher incidence noted in office and computer workers.7 Although some studies report that between 33% and 65% of people have recovered from an episode of neck pain at 1 year, most cases follow an episodic course over a person�s lifetime, and thus, relapses are common.7 Neck pain is a leading cause of morbidity and chronic disability worldwide.5,8 In 2008 the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders reported that 50% to 75% of individuals with neck pain also report pain 1 to 5 years later.4 Several modifiable and nonmodifiable environmental and personal factors influence the course of neck pain, including age, previous neck injury, high pain intensity, self-perceived poor general health, and fear avoidance.7
Neck pain related to whiplash-associated disorders (WADs) most commonly results from motor vehicle accidents.9,10�Whiplash-associated disorders disrupt the daily lives of adults around the world and are associated with considerable pain, suffering, disability, and costs.3,11 Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceler- ation of the head and neck relative to other parts of the body, typically occurring during motor vehicle collisions.10,12 The majority of adults with traffic injuries report pain in the neck and upper limb pain. Other common symptoms of WADs include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.9,10 The global yearly incidence rate of emergency department visits as a result of acute whiplash injuries after road traffic crashes is between 235 and 300 per 100,000.3,13,14 In 2010, there were 3.9 million nonfatal traffic injuries in the United States.11 The economic costs of motor vehicle crashes that year totaled USD$242 billion, including $23.4 billion in medical costs and $77.4 billion in lost productivity (both market and household).11 In Ontario, traffic collisions are a leading cause of disability and health care use and�expenditures, resulting in the automobile insurance system paying nearly CND$4.5 billion in accident benefits in 2010.15
More than 85% of patients experience neck pain after a motor vehicle accident, often associated with sprains and strains to the back and extremities, headache, psychological symptomatology, and mild traumatic brain injury.10 Whiplash injuries have an effect on general health, with recovery in the short term reported by 29% to 40% of individuals with WAD in Western countries that have compensation schemes for whiplash injuries. 16,17 The median time to first reported recovery is estimated at 101 days (95% confidence interval: 99-104) and about 23% are still not recovered after 1 year.13
The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs,18 be included under the classification of NAD.19 NAD can be classified into 4 grades, distinguished by the severity of symptoms, signs, and impact on activities of daily life (Table 1).
The clinical management of musculoskeletal disorders, and neck pain in particular, can be complex and often involves combining multiple interventions (multimodal care) to address its symptoms and consequences.19�In this guideline, multimodal care refers to treatment involving at least 2 distinct therapeutic methods, provided by 1 or more health care disciplines.20 Manual therapy (including spinal manipulation), medication, and home exercise with advice are commonly used multimodal treatments for recent- onset and persistent neck pain.21,22 Thus, there is a need to determine which treatments or combinations of treatments are more effective for managing NAD and WAD.
Rationale for Developing This Guideline
The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration20 recently updated the systematic reviews from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force).23 Consequently, it was deemed timely to update the recommendations of 2 chiropractic guidelines on NAD (2014)24 and WAD (2010)25 produced by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (the �Federation�) into a single guideline.
Scope and Purpose
The aim of this clinical practice guideline (CPG) was to synthesize and disseminate the best available evidence on the management of adults and elderly patients with recent onset (0-3 months) and persistent (N3 months) neck pain and its associated disorders, with the goal of improving clinical decision making and the delivery of care for patients with NAD and WAD grades I to III. Guidelines are �Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.�26
The target users of this guideline are chiropractors and other primary care health care providers delivering conservative care to patients with NADs and WADs, as well as policymakers. We define conservative care as treatment designed to avoid invasive medical therapeutic measures or operative procedures.
OPTIMa published a closely related guideline in the European Spine Journal.27 Although we reached similar results, OPTIMa developed recommendations using the modified Ontario Health Technology Advisory Committee (OHTAC) framework.28 In contrast, our guideline used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. GRADE provides a common, sensible, and transparent approach to grading quality (or certainty) of evidence and strength of recom- mendations (www.gradeworkinggroup.org). GRADE was the highest scoring instrument among 60 evidence grading systems29 and has been determined to be reproducible among trained raters.30 GRADE is now considered a standard in guideline development and has been adopted by many international guideline organizations and journals.31 The Canadian Chiropractic Guideline Initiative (CCGI) guideline panel considered available high-quality systematic reviews, updated the search of the peer-reviewed published reports up to December 2015, and then used the GRADE approach to formulate recommen- dations for the management of neck pain and associated disorders.
To inform its work, the CCGI considered recent advances in methods to conduct knowledge synthesis,32 derive evidence-based recommendations, 31,33 adapt high- quality guidelines, 34 and develop 35 and increase the uptake of CPGs.36,37 An overview of CCGI structure and methods is provided in Appendix 1.
Because no novel human participant intervention was required and secondary analyses were considered, the research presented in this guideline is exempt from institutional ethics review board approval.
Selection of Guideline Development Panelists
The CCGI project lead (A.B.) appointed 2 co-chairs (J.O. and G.S.) for the guideline development group and nominated the project executive committee and the remaining guideline panelists. J.O. served as the lead methodologist on the guideline panel. G.S. helped ensure geographic representation of the panel and advised on specific duties of panel members, time commitment, and decision-making process for reaching consensus (develop- ment of key questions and of recommendations). To ensure a broad representation, the guideline panel included clinicians (P.D., J.W.), clinician researchers (F.A., M.D., C.H., S.P., I.P., J.S.) methodologists (J.O., A.B., M.S., J.H.), a professional leader/decision maker (G.S.), and 1 patient advocate (B.H.) to ensure that patient values and preferences were considered. One observer (J.R.) moni- tored the 3 face-to-face meetings of the guideline panel held in Toronto (June and September 2015 and April 2016).
All CCGI members, including guideline panelists and peer reviewers, were required to disclose any potential conflict of interest by topic before participation and during the guideline development process. There was no self- declaration of conflicts of interest among the panel or the reviewers.
Key Question Development
Six topic areas (exercise, multimodal care, education, work disability, manual therapy, passive modalities) on the conservative management of NAD and WAD grades I to III were covered in 5 recent systematic reviews by the OPTIMa Collaboration,38-42 among a total of 40 reviews on the management of musculoskeletal disorders.20 The panel met over 2 days in June 2015 to brainstorm about potential key questions.
Because the last search dates of included systematic reviews were 2012,40,41 2013,38,39,42 and 2014,42 the panel updated the literature searches in Medline and Cochrane Central databases on December 24, 2015 using the published search strategies. We used a 2-phase screening process to select additional eligible studies. In phase 1, 2 independent reviewers screened titles and abstracts to determine the relevance and eligibility of studies. In phase 2, the same pairs of independent reviewers screened full-text articles to make a final determination of eligibility. Reviewers met to resolve disagreements and reach consensus on the eligibility of studies in both phases, with arbitration by a third reviewer if needed. Studies were included if they1 met the PICO (population, intervention, comparator, outcome) criteria and2 were randomized controlled trials (RCTs) with an inception cohort of at least 30 participants per treatment arm with the specified condition, because this sample size is considered the minimum needed for non-normal distributions to approx- imate the normal distribution.44
Data Abstraction and Quality Assessment
Data were extracted from the included studies identified in each systematic review, including study design, participants, intervention, control, outcomes, and funding.
The internal validity of included studies was assessed by the OPTIMa collaboration using the Scottish Intercollegiate Guidelines Network (SIGN) criteria.45
For articles retrieved from the updated search, pairs of independent reviewers critically appraised the internal validity of eligible studies using the SIGN criteria,46 similar to the OPTIMa collaboration reviews. Reviewers reached consensus through discussion. A third reviewer was used to resolve disagreements if consensus could not be reached. A quantitative score or a cutoff point to determine the internal validity of studies was not used. Instead, the SIGN criteria were used to assist reviewers in making an informed overall judgment on the risk of bias of included studies. 47
Synthesis of Results
J.O. extracted data from scientifically admissible studies into evidence tables. A second reviewer (A.B.) indepen- dently checked the extracted data. We performed a qualitative synthesis of findings and stratified results based on the type and duration of the disorder (ie, recent [symptoms lasting b3 months] vs persistent [symptoms lasting N3 months]).
We used the Guideline Development Tool (http:// www.guidelinedevelopment.org), and assessed the quality of the body of evidence for our outcomes of interest by�applying the GRADE approach.48 We used the evidence profiles to summarize the evidence.49 The quality of evidence rating (high, moderate, low, or very low) reflects our confidence in the estimate of the effect to support a recommendation and considers the strengths and limitations of the body of evidence stemming from risk of bias, imprecision, inconsistency, indirectness of results, and publication bias.50 Assessment of quality of evidence was carried out in the context of its relevance to the primary care setting.
Using the Evidence to Decisions (EtD) Framework (www.decide-collaboration.eu/etd-evidence- decision-framework), the panel formally met in September 2015 and April 2016 to consider the balance of desirable and undesirable consequences to determine the strength of each recommendation, using informed judgment on the quality of evidence and effect sizes, resource use, equity, acceptability, and feasibility. To make a recommendation, the panel needed to express an average judgment that was beyond neutral with respect to the balance between desirable and undesirable consequences of an intervention, as outlined in the EtD. We defined the strength rating of a recommendation (strong or weak) as the extent to which the desirable consequences of an intervention outweigh its undesirable consequences. A strong recommendation can be made when the desirable consequences clearly outweigh the undesirable consequences. In contrast, a weak recommendation is made when, on the balance of probabilities, the desirable consequences likely outweigh the undesirable consequences. 49,51
The panel provided recommendations based on the evidence if statistically and clinically significant differ- ences were found. The panel followed a 2-step process in making a recommendation. We first agreed that there should be evidence of clinically meaningful changes occurring over time in the study population and that a single consensus threshold of clinical effectiveness should be applied consistently. We reached a consensus decision that a 20% change in the outcome of interest within any study group was required to make a recommendation. The decision to use a 20% threshold was informed by current published reports and relevant available minimal clinically important differences (MCIDs).52-55
However, MCIDs can vary across populations, settings, and conditions and depending on whether within-group or between-group differences are being assessed. Therefore, the panel considered MCID values for the most relevant outcomes (ie, 10% for visual analog scale [VAS] or Neck Disability Index [NDI; 5/50 on the NDI], 20% for numerical rating scale [NRS]) and chose the more conservative of these values as the threshold when evaluating between group differences.52,54
Second, the results from relevant studies were used to formulate a recommendation where appropriate. A treat- ment determined to be effective (with statistically significant differences between baseline and follow-up scores and�clinical significance based on the MCID applied in the study) was recommended by our panel. If a study found 2 or more treatments to be equally effective based on our threshold, then the panel recommended all equivalently effective treatments.
The EtD Frameworks were completed and recommen- dations were drafted over a series of conference calls with panel members after making judgments about 4 decision domains: quality of evidence (confidence in estimates of effect); balance of desirable (eg, reduced pain and disability) and undesirable outcomes (eg, adverse reactions); confidence about the values and preferences for the target population; and resource implications (costs).56,57 A synthe- sis of our judgments about the domains determined the direction (ie, for or against a management approach) and the strength of recommendations (the extent to which one can be confident that the desirable conse- quences of an intervention outweigh the undesirable consequences). A specific format was followed to formulate recommendations using patient description and the treatment comparator.56 Remarks were added for clarification if needed. If the desirable and undesirable consequences were judged to be evenly balanced and the evidence was not compelling, the panel decided not to write any recommendation.
A modified Delphi technique was used at an in-person meeting to achieve consensus on each recommendation.58 Using an online tool (www.polleverywhere.com), panelists�voted their level of agreement with each recommendation (including quality of evidence and strength of recom- mendation) based on a 3-point scale (yes, no, neutral). Before voting, panelists were encouraged to discuss and provide feedback on each recommendation in terms of suggested wording edits or general remarks. To achieve consensus and be included in the final manuscript, each recommendation had to have at least 80% agreement with a response rate of at least 75% of eligible panel members. All recommendations achieved consensus in the first round.
A 10-member external committee composed of stake- holders, end-users, and researchers from Canada, the United States, and Lebanon (Appendix 2) independently reviewed the draft manuscript, recommendations, and supporting evidence. The AGREE II instrument was used to assess the methodological quality of the guideline.35 Feedback received was collected and considered in a revised draft for a second round of review. Chairs of the guideline panel provided a detailed response to reviewers� comments. For a glossary of terms, please see Appendix 3.
Key Question Development
Thirty-two standardized key questions were developed in line with the PICO (population, intervention, comparator, outcome) format. The panel recognized overlap in content and relevance among some key questions. After combining 3 questions, we ultimately addressed a total of 29 key questions (Table 2).
Study Selection and Quality Assessment: OPTIMa Reviews
OPTIMa searches yield 26 335 articles screened.38-42 After removal of duplicates and screening, 26 273 articles did not meet selection criteria, leaving 109 articles eligible for critical appraisal. Fifty-nine studies (62 articles) published from 2007 to 2013 were deemed scientifically admissible and included in the synthesis (Appendix 4). Each review used was rated as either moderate or high quality (AMSTAR score 8-11).59
Search Update and Study Selection
Our updated search yielded 7784 articles. We removed 1411 duplicates and screened 6373 articles for eligibility (Figs. 1-5). After screening, 6321 articles did not meet our selection criteria (phase 1), leaving 52 articles for full-text review (phase 2) and critical appraisal (studies on the topic of multimodal care (n = 12), structured patient education (n = 3),�exercise (n = 8), work disability interventions (n = 13), manual therapy (n = 4), soft tissues (n = 2), and passive modalities (n = 6). Of the 52 RCTs, 4 scientifically admissible studies were included in our synthesis. The remaining articles failed to address the key question (n = 1); selected population (n = 2), outcomes (n = 13), or intervention (n = 11); had no between estimates (n = 19); or were duplicates (n = 1) or a secondary analysis of an included study (n = 1) (Appendix 5).
Quality Assessment and Synthesis of Results
The GRADE evidence profile and risk of bias within included studies are presented in Tables 3-15 and Appendix 6, respectively.
We present recommendations as follows:
Recent-onset (0-3 months) grades I to III NAD
Recent-onset (0-3 months) grades I to III WAD
Persistent (N3 months) grades I to III NAD
Persistent (N3 months) grades I to III WAD
Recommendations for Recent-Onset (0-3 Months) Grades I to III NAD
Key Question 1:Should neck manipulation vs neck mobilization be used for recent-onset (0-3 months) grades I to II NAD?
Summary of Evidence. One RCT by Leaver et al. 60 evaluated the effectiveness of neck manipulation or neck mobilization delivered by physiotherapists, chiropractors, or osteopaths for recent-onset grades I to II neck pain (?2 NRS). All patients received advice, reassurance, or a continued exercise program as indicated for 4 treatments over 2 weeks unless recovery was achieved or a serious adverse event occurred. There was no statistically significant difference in Kaplan-Meier recovery curves between groups for recovery from neck pain and recovery of normal activity, and no statistically significant differences between groups for pain, disability, or other outcomes (function, global perceived effect, or health-related quality of life) at any follow-up point (Table 3).
One other RCT by Dunning et al.61 evaluated the effectiveness of a single high-velocity, low-amplitude (thrust) manipulation (n = 56) directed to the upper cervical spine (C1-C2) and upper thoracic spine (T1-T2) compared with a (nonthrust) mobilization (n = 51) directed to the same anatomical regions for 30 seconds for patients with neck pain. Findings indicated a greater reduction in pain (NPRS) and disability (NDI) in the thrust manipulation group compared with the mobilization at 48 hours. No serious adverse events were reported. Minor adverse events were not collected. This study did not inform our recommendation because1 patient complaints were not recent onset (mean�duration N337 days in both groups), and2 outcomes were measured at 48 hours only. The Guideline Development Group (GDG) considered this an important study limitation because one cannot assume these benefits would have carried on for a longer period. The panel acknowledged, however, that some patients may value obtaining fast pain relief even if temporary.
The panel determined that the overall certainty in the evidence was low, with large desirable relative to undesirable effects. The relative small cost of providing the option would make it more acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided:
Recommendation: For patients with recent (0-3 months) grades I to II NAD, we suggest manipulation or mobilization based on patient preference. (Weak recommendation, low-quality evidence)
Key Question 2:Should integrated neuromuscular inhibition technique be used for recent-onset (0-3 months) grades I to II NAD?
Summary of Evidence. Nagrale et al.62 reported non� clinically significant differences for neck pain and disability outcomes at 4 weeks. This study suggested that a soft tissue therapy intervention to the upper trapezius, combining ischemic compression, strain-counterstrain, and muscle energy technique, provides similar clinical benefit compared with muscle energy technique alone. Participants were required to have neck pain of less than 3 months� duration.
The panel determined moderate certainty in the evidence, with small desirable and undesirable effects and no serious adverse events. Low costs are required for the intervention and no specific equipment is needed, with the exception of training to provide the technique. Because the intervention is widely practiced and taught, it is acceptable and feasible to implement. However, its effects on health equities cannot be determined. Overall, the panel decided the balance between the desirable and undesirable consequences was uncertain, and more evidence is needed before a recommendation can be made.
Key Question 3:Should multimodal care vs intramuscular ketorolac be used for recent (0-3 months) grades I to III NAD?
Summary of Evidence. McReynolds et al. 63 presented short-term outcomes of pain intensity and concluded that sessions of multimodal care (manipulation, soft tissue techniques) provided equivalent outcomes to an intramuscular injection of ketorolac. However, the follow-up time of 1 hour is generally atypical and the dosing was determined to be incomplete for multimodal care as reported. Furthermore, the study was limited to an emergency setting only.
The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects. There is relatively low risk for multimodal care, considering the reported outcomes were equal. From a clinician standpoint, resources required are small assuming no additional staff are needed. However, one practitioner gave most multimodal therapies. Expenses may vary depending on the definition of multimodal care. This option should not create health inequities, except for those who cannot access clinicians or choose to pay out of pocket, and would be feasible to implement. Professional associ- ations would generally support the option, yet extended multimodal therapies can incur additional costs, which can be unfavorable to both payors and patients. Overall, the balance between the desirable and undesirable conse- quences is uncertain and more research is needed in this area before any recommendation can be made.
Key Question 4:Should multimodal care vs home exercises vs medication be used for recent-onset (0-3 months) grades I to II NAD?
Summary of Evidence. One RCT by Bronfort et al.22 evaluated the efficacy of multimodal care over 12 weeks compared with a 12-week home exercise and advice program or medication on neck pain (11-box NRS) and disability (NDI) in 181 adult patients with acute and subacute neck pain (2-12 weeks� duration and a score of ?3 on a 10-point scale). Multimodal care by a chiropractor (mean of 15.3 visits, range 2-23) included manipulation and mobilization, soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed. Daily home exercise was to be done up to 6 to 8 times per day (individualized program including self- mobilization exercise of the neck and shoulder joints) with advice by a physical therapist (two 1-hour sessions, 1-2 weeks apart on posture and activity of daily living). Medication prescribed by a physician included nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioid analgesic, or muscle relaxants (dosage was not reported). The results displayed in Table 4 indicated that multimodal care and home exercises and advice were as effective as medication in reducing pain and disability at short term (26 weeks). However, medication was associated with a higher risk for adverse events (mostly gastrointestinal symptoms and drowsiness in 60% of participants) than home exercises. The choice of medications was based on the participant�s history and response to treatment. Clinicians and patients should be aware that current evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Importantly, evidence supports a dose-dependent risk for serious harms, including increased risk for overdose, dependence, and myocardial infarction.64
Recommendation: For patients with recent (0-3 months) neck pain grades I to II, we suggest either range-of-motion home exercises, medication, or multimodal manual therapy for reduction in pain and disability. (Weak recommendation, moderate- quality evidence)
Remark: Home exercises included education self-care advice, exercises, and instruction on activities of daily living. Medication included NSAIDs, acetaminophen, muscle relaxant, or a combination of these. Multimodal manual therapy included manipulation and mobilization with limited light soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed.
Key Question 5:Should supervised graded strengthening exercises vs advice be used for recent-onset (0-3 months) grade III NAD?
Summary of Evidence. One RCT by Kuijper et al.65 evaluated the effectiveness of supervised strengthening exercises compared with advice to stay active for recent-onset grade III neck pain. This RCT reported that strengthening exercises (n = 70) were more effective than advice to stay active (n = 66).65 Trial participants were followed at 3 weeks, 6 weeks, and 6 months. Based on panel consensus, outcomes determined to be important in the assessment of effectiveness in this RCT included neck and arm pain (VAS) and disability (NDI). These outcomes were both statistically and clinically significant (Table 5).
In this RCT, the strengthening exercise program was delivered by physiotherapists 2 times per week for 6 weeks.65 It included supervised graded strengthening exercises for the shoulder and daily home exercises to strengthen the superficial and deep neck muscles (mobility, stability, and muscle strengthening). Participants in the comparison group were advised to continue daily activities. Both groups were allowed to use painkillers. See Key Question 6 for a recommendation on cervical collar.
Recommendation: For patients with recent (0-3 months) grade III neck and arm pain, we suggest supervised graded strengthening exercises* rather than advice alone.� (Weak recommendation, moderate-quality evidence)
Remark: *Supervised graded strengthening exercises con- sisted of strengthening and stability exercises twice a week for 6 weeks with daily home exercises (which included mobility, stability, and muscle strengthening). �Advice alone consisted of maintaining activity of daily living without specific treatment.
Passive Physical Modalities
Key Question 6:Should cervical collar vs graded strengthening exercise program be used for recent-onset (0-3 months) grade III NAD?
Summary of Evidence. One RCT by Kuijper et al.65 randomly assigned 205 patients with recent-onset neck�cervical radiculopathy (NAD grade III) to 1 of 3 groups 1 : Rest and semi-hard cervical collar for 3 weeks, then weaned off during weeks 3-6 2 ; physiotherapy (mobilizing and stabilizing the cervical spine, standardized graded neck strengthening exercises twice per week for 6 weeks, and education to do daily home exercises); or3 a control group (wait and see with advice to continue daily activities). All patients received written and oral reassurance about the usually benign course of the symptoms and were allowed painkillers.
Wearing a semi-hard cervical collar or receiving standardized graded strengthening exercise program and home exercises for 6 weeks provided similar improvements in arm pain (VAS), neck pain (VAS), or disability (NDI) compared with a wait-and-see policy at 6 weeks. There were no between-group differences at 6 months.
Because of uncertainty about potential for iatrogenic disability associated with the prolonged use of cervical collar,27,42 one recommendation made in the current guideline favoring strengthening exercise programs over advice, and the lack of consensus among the guideline panel, the GDG decided not to make a recommendation against the use of cervical collar (first vote on the proposed recommendation with direct results from the study [11% agree, 11% neutral, 78% disagree, 1 abstained]). A second vote favored also removing the remark from the recommendation (27% agree, 9% neutral, 64% disagree, 1 did not vote). Choice should be based on patient�s preference and management changed if recovery is slow.66
Key Question 7:Should low-level laser therapy be used for recent-onset (0-3 months) grade III NAD?
Summary of Evidence. One RCT by Konstantinovic et al.67 evaluated the effectiveness of low-level laser therapy (LLLT) delivered 5 times per week for 3 weeks compared with placebo (inactive laser treatment) for recent-onset grade III neck pain. LLLT leads to statistically but not clinically significant improvements in neck pain and disability at 3 weeks compared with placebo. Transitional worsening in pain (20%) and persistent nausea (3.33%) were observed in the LLLT group, whereas no adverse events were reported in the placebo group.
The panel determined the overall certainty of the evidence was moderate, with small desirable effects and minor adverse events. LLLT can be expensive. If practitioners choose not to purchase, it may negatively affect health equities. However, the option is acceptable to stakeholders and is relatively easy to implement. The panel was uncertain about the balance between desirable and undesirable consequences and voted against making a recommendation because of a lack of clear evidence (LLLT was no better than placebo but both groups demonstrated within-group change over time).
Work Disability Prevention Interventions
Key Questions 8 and 9:Should work disability prevention interventions vs fitness and strengthening exercise program be used for recent-onset nonspecific work-related upper limb disorders?�Should work disability prevention interventions be used for recent-onset work-related neck and upper limb complaints?
In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain.� As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.
Although some benefits were reported favoring computer-prompted and instructed exercise interventions,68 the incremental self-reported improvement was insufficient to formulate a recommendation considering1 a follow-up period of 8 weeks in reviewed studies is too short to estimate long-term sustained benefits; and2 the potential costs related to programming and worker instruction may be significant.
Overall, it appears that adding computer-prompted exercises (with workplace breaks), or workplace breaks alone, to a program of ergonomic modification and education improves self-perceived recovery and symptomatic benefits in computer workers with neck and upper back complaints.41 However, it is unclear whether the addition of computer- prompted exercises to the various established workplace interventions alters perceived or objective health outcomes. Future research may identify added benefits in order for stakeholders to consider the extra cost as being surmountable.
Recommendations for Recent-Onset (0-3 Months) Grades I to III WAD
Key Question 10:Should multimodal care vs education be used for recent (0-3 months) grades I to III WAD?
Summary of Evidence. A 2-part RCT by Lamb et al.69 evaluated the effectiveness of oral advice compared with written material for improving pain (self-rated neck pain) and disability (NDI) in patients with recent-onset grades I to III WAD. Lamb et al.69 included a total of 3851 participants with a history of WAD grades I to III of less than 6 weeks� duration who sought treatment at an emergency department. A total of 2253 participants received active management advice in the emergency department incorporating oral advice and the Whiplash Book, which included reassurance, exercises, encouragement to return to normal activities, and advice against using a collar;�1598 participants received usual care advice, including verbal and written advice along with anti-inflammatory medication, physiotherapy, and analgesics. No between-group difference was observed in self-rated neck pain and disability at 12-month follow-up and no difference in workdays lost was observed at 4-month follow-up (Table 6).
Lamb et al.69 included 599 participants with WAD grades I to III that persisted for 3 weeks after attending emergency departments. Three hundred participants were treated by a physiotherapist (maximum 6 sessions over 8 weeks) including psychological strategies (goal setting or pacing, coping, reassurance, relaxation, pain and recov- ery), self-management advice (posture and positioning), exercises (shoulder complex mobilization and range of motion [ROM]; cervical and scapular stability and proprioception), and cervical and thoracic spine Maitland mobilization and manipulation; a total of 299 received single-session reinforcement advice from a physiothera- pist during their previous visit to emergency department. No difference in self-rated disability was identified at 4-month follow-up; however, greater reductions in workdays lost after 8-month follow-up were determined with self-management advice over single-session rein- forcement. Similar findings were found in an earlier study.70
Recommendation: For adult patients with recent (0-3 months) WAD grades I to III, we suggest multimodal care over education alone. (Weak recommendation, moderate-quality evidence)
Remark: Multimodal care may consist of manual therapy (joint mobilization, other soft tissue techniques), education, and exercises.
Key Question 11:Should structured patient education vs education reinforcement be used for recent-onset (0-3 months) WAD?
Summary of Evidence. Lamb et al.69 reported outcomes at 4 months for self-rated disability, identifying no clinically significant differences between groups. The study sug- gested that oral advice and an educational pamphlet provide similar benefits.
The panel determined moderate quality in the clinical evidence, yet uncertain desirable effects with small, minor, and transient adverse events. Relatively few resources would be required for the intervention, and wide dissemination of educational materials through electronic tools can help reduce inequities. The option is acceptable to stakeholders and feasible to implement. Overall, the desirable consequences probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 10. Therefore, one recommendation was made, addressing both topics.
Recommendations for Persistent (N3 Months) Grades I to III NAD
Key Question 12:Should supervised exercise (ie, qigong exercise) vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. Two RCTs (Table 7) evaluated the effectiveness of supervised qigong compared with super- vised exercise therapy and no treatment on neck pain (101-point VAS), disability (NDI), and Neck Pain and Disability Scale in a total of 240 patients with chronic neck pain (N6 months). 71,72 Rendant et al. 72 reported that, in adults with chronic neck pain, supervised qigong is more effective than no treatment and as effective as exercise therapy in reducing neck pain and disability at 3 and 6 months. Conclusions regarding the effectiveness of these 2 interventions compared with no treatment in patients aged older than 55 years cannot be drawn from the included studies.
In their study of these interventions for neck pain in elderly patients, von Trott et al.71 observed a reduction in pain and disability in both intervention groups at 3 and 6 months (although not statistically significant). The quality of the evidence was downgraded to low based on the SIGN criteria (concealment method not reported). In the von Trott et al. study, the interventions consisted of two 45-minute sessions per week for 3 months (a total of 24 sessions),71 whereas in the Rendant et al. study, interventions consisted of 12 treatments in the first 3 months and 6 treatments in the following 3 months (total of 18 sessions).72 Exercise therapy in both studies included repeated active cervical rotations and strengthening and flexibility exercises in the form of Dantian qigong71 or Neiyanggong qigong.72 Similar minor transient side effects were reported in both the intervention and comparison groups.
Recommendation: For adult patients with persistent (N6 months) neck pain grades I to II, we suggest supervised group exercises* to reduce neck pain and disability. (Weak recommendation, moderate-quality evidence)
Remark: Patients received 18 to 24 group sessions during a period of 4 to 6 months. Patients considered had a rating of 40/100 on a pain scale (VAS). The intervention group reached suggested MCID level of 10% difference for pain and functional outcomes. *Exercises included qigong or ROM, flexibility, and strengthening exercises. No evidence of significant effect in the elderly population.
Key Question 13:Should supervised yoga vs education be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. Yoga is an ancient Indian practice involving postural exercises, breathing control, and med-
itation. 20 One RCT by Michalsen et al. 73 evaluated the effectiveness of Iyengar yoga compared with a self-care/exercise program on neck pain (VAS) and disability (NDI) in 76 patients with chronic neck pain (pain for at least 3 months and a score of more than 40 mm on a 100-mm VAS). Yoga consisted of a weekly 90-minute session for 9 weeks of a wide range of postures aimed to enhance flexibility, alignment, stability, and mobility. The self-care/ exercise group had to practice for 10 to 15 minutes at least 3 times a week a series of 12 exercises focusing on muscle stretching and strengthening and joint mobility. The results indicated that yoga is more effective for reducing neck pain and disability at short term (4 and 10 weeks) than self-care/ exercise (Table 8). No serious adverse events were reported in either group. In this study, the quality of evidence was downgraded to low because blinding was �poorly ad- dressed.�45
One RCT by Jeitler et al.74 evaluated the effectiveness of Jyoti meditation compared with exercise on neck pain (VAS). The results showed that Jyoti meditation (sitting motionless, repeating a mantra, and visual concentration while keeping the eyes closed) is more effective than exercise (established and previously used self-care manual for specific exercise and education for chronic neck pain).74 Because Jyoti meditation only includes 1 of the 3 components of yoga (ie, meditation), Jeitler et al.74 was not considered in developing the following recommendation.
Recommendation: For patients with persistent (N3 months) grades I to II neck pain and disability, we suggest supervised yoga over education and home exercises for short- term improvement in neck pain and disability. (Weak recommendation, low-quality evidence)
Remark: Baseline intensity of pain was more than 40/100 and duration was at least 3 months. Yoga was specific to the Iyengar type, with a maximum of 9 sessions over 9 weeks.
Key Question 14:Should supervised strengthening exercises vs home ROM or stretching exercises be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. Three RCTs evaluated the effectiveness of supervised strengthening exercises compared with home exercises for grades I to II neck pain and disability.38 Two RCTs (Hakkinen et al.75 and Salo et al.76) reported no significant between group differences at 1 year for primary or secondary outcomes. One RCT (N = 170) reported that supervised strengthening exercises were more effective than home ROM exercises.77 Two smaller RCTs (N = 107) found that both treatments are equally effective.75,76 All 3 trials had a follow-up of 1 year. Based on our panel�s consensus, outcomes determined to be important in the assessment of effectiveness for these RCTs included pain (NRS) and disability (NDI).
In the RCT by Evans et al.77 the strengthening exercise program (delivered by exercise therapists) was determined to be more effective than home exercises. The program�included 20 supervised sessions over a period of 12 weeks and consisted of neck and upper body dynamic resistance strengthening program with and without spinal manipula- tive therapy.77 Conversely, the home exercises included an individualized program of neck and shoulder self- mobilization with initial advice regarding posture and daily activities (Table 9). In the 2 RCTs demonstrating equivalence, the strengthening program included 10 supervised sessions over 6 weeks of isometric exercises for the neck flexors and extensors, dynamic shoulder and upper extremity exercises, abdominal and back exercises, and squats.43,44
A fourth RCT by Maiers et al.78 assessed the effectiveness of supervised rehabilitative exercises in combination with and compared with home exercises alone for persistent neck pain in individuals aged 65 years or older. All participants in the study received 12 weeks of care. One group received 20 supervised 1-hour exercise sessions in addition to home exercises. Home exercises consisted of four 45- to 60-minute sessions to improve flexibility, balance, and coordination and enhance trunk strength and endurance. Participants also received instruc- tions on pain management, practical demonstrations of body mechanics (lifting, pushing, pulling, and rising from a lying position), and massaging to stay active. Results favored supervised rehabilitative exercises combined with home exercises over home exercise for pain (NRS) and disability (NDI) at 12 weeks. However, between-group differences did not reach statistical significance.
Recommendation: For patients with persistent (N3 months) grades I to II neck pain, we suggest supervised strengthening exercises or home exercises. (Weak recommendation, low-quality evidence)
Remark: For reduction in pain, supervised strength- ening exercises, provided along with ROM exercises and advice, were evaluated at 12 weeks within 20 sessions. Home exercises include stretching or self-mobilization.
Key Question 15:Should strengthening exercises vs general strengthening exercises be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. Griffiths et al.79 presented non� clinically significant outcomes for neck pain and disability among patients with persistent neck pain and concluded there is no added benefit of incorporating specific isometric exercise to a general exercise program. Dosages were up to 4 sessions per 6-week period, with advice for 5 to 10 times at home. The general exercise program consisted of postural exercise, active ROM, 5 to 10 times daily with reinforcement.
The panel determined there is low certainty in the clinical evidence and uncertainty in the desirable effects of the intervention. Isometric exercises have little anticipated adverse effects, require minimal resources, and are generally acceptable to stakeholders and feasible to�implement. Yet uncertainty remains regarding their effects on health equity and the overall balance between desirable and undesirable consequences. More research is needed in this area before a recommendation can be made.
Key Question 16:Should combined supervised strengthening, ROM, and flexibility exercises vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. von Trott et al. 71 and Rendant et al. 72 presented significant outcomes for reduction in neck pain and disability that favor combined strengthening, ROM, and flexibility exercises. Both studies address different popula- tions and lead to similar outcomes (von Trott et al.71 addressed elderly populations).
The panel determined there was moderate certainty in the clinical evidence, with large desirable and small undesirable anticipated effects. Yet there may be differences in adverse events for strengthening vs ROM and flexibility exercises, along with the chal- lenges of such adverse events being self-reported. For example, strengthening exercises likely coincide with short-term pain after the intervention. Further, signifi- cant space may be required for exercises, which may incur large costs that need to be considered up front. As a result, there is uncertainty about the feasibility to implement and whether this could widely affect health inequalities. However, the option would be acceptable to stakeholders. Overall, the desirable consequences would probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 12 (qigong was considered exercise). Therefore, 1 recommendation was made, addressing both topics.
Key Question 17:Should multimodal care vs self-management be used for persistent (N3 months) grades I-II NAD?
Summary of Evidence. One RCT by Gustavsson et al.80 evaluated the effectiveness of self-management of persis- tent musculoskeletal tension type neck pain for grades I to II neck pain. They compared treatment effects of a multicom- ponent pain and stress self-management group intervention (n = 77) to individually administered multimodal physical therapy (n = 79). Measures of pain (NRS) and disability (NDI) were collected at baseline and at 10 and 20 weeks. Both groups had within-group differences for decreased pain intensity and disability. At the 20-week follow-up after an average of 7 sessions, based on the measures used, the multicomponent pain and stress self-management group intervention had a greater treatment effect on coping with pain and patients� self-reported pain control and disability than the multimodal care group. The initial treatment effects were largely maintained over a 2-year follow-up period (Table 10).81
Recommendation: For patients with persistent (N3 months) neck pain and associated disorders grades I to II, we suggest multimodal care* or stress self-management� based on patient preference, prior response to care, and resources available. (Weak recommendation, low-quality evidence)
Remark: *Individualized multimodal care may include manual therapy (manipulation, mobilization, massage, trac- tion), acupuncture, heat, transcutaneous electrical nerve stimulation, exercise, and/or ultrasound. �Stress self-manage- ment may include relaxation, balance and body awareness exercises, pain and stress self-management lectures, and discussion. The multimodal care group received an average of 7 (range 4-8) sessions, compared with 11 (range 1-52) sessions for the stress self-management group over 20 weeks.
Key Question 18:Should structured patient education vs massage therapy be used for persistent (N3 months) NAD?
Summary of Evidence. Sherman et al.82 reported non� clinically significant outcomes at 4 weeks for disability. This study suggests a mailed self-care book and a course in massage therapy provide similar clinical benefits for
patients with persistent neck pain.
The panel determined the overall certainty of the evidence was low, with relatively large anticipated effects and no serious adverse events noted from intervention (some headaches possibly). There is uncertainty in the costs required, including necessary staff, equipment, and mate- rials. Yet this option is feasible to implement in most settings and has strong implications for reducing health inequities. As a preventive strategy, the intervention is acceptable to stakeholders, including the chiropractic practitioners, patients, and policymakers. The panel was uncertain about the balance between the desirable and undesirable consequences. Additional high-quality studies are needed in this area before any recommendation can be made.
Key Question 19:Should manipulation be used for persistent grades I to II NAD?
Summary of Evidence. Evans et al.77 compared spinal manipulation in addition to 20 weeks of supervised exercise therapy (20 sessions) to supervised exercise therapy alone in adults with persistent grades I to II neck pain, whereas Maiers et al.78 compared spinal manipulation in addition to home exercises (20 sessions maximum) to home exercise alone in seniors with persistent grades I to II neck pain. Pain and disability outcomes at 12 and 52 weeks did not reach statistical significance in between-group differences, except for pain level at 12 weeks in the Maiers study.78 A third RCT by Lin et al.83 allocated 63 persistent neck pain patients (NAD I-II) to the experimental group (n = 33) treated with�cervical spine manipulation and traditional Chinese massage (TCM) compared with TCM alone (n = 30) over 3 weeks. Results favored cervical manipulation with TCM over TCM alone for pain (NPS) and disability (Northwick Park Neck Disability Questionnaire) at 3 months (Table 11).
The panel concluded low certainty in the evidence, with small desirable and undesirable effects of the intervention. Few resources are required for the intervention, and it is probably acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided.
Recommendation: For patients with persistent grades I to II NAD, we suggest manipulation in conjunction with soft tissue therapy. (Weak recommendation, low-quality evidence)
Remark: Evaluated after eight 20-minute sessions (over a 3-week period). Does not include manipulation as a standalone treatment.
Key Question 20:Should massage vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. Sherman et al.82 and Lauche et al.84 reported non�clinically significant differences in outcomes for disability at 4 and 12 weeks, respectively. Sherman et al.82 suggested Swedish and/or clinical massage with verbal self- care advice provides similar clinical benefit to a self-care book for disability outcomes. Lauche et al.84 suggested cupping massage and progressive muscle relaxation lead to similar changes in disability. Sherman et al.85 reported outcomes for neck pain and disability at 4 weeks and suggested that higher doses of massage provide superior clinical benefit (Table 12).
The panel determined low certainty in the evidence, with small desirable and undesirable effects. Additional costs may be needed to get clinical benefit. Sherman et al.85 suggested a minimum of 14 hours of staff time needed. Because of the costs associated with high-dose massage, it may not be entirely acceptable to patients or payors. However, this option is feasible and relatively easy to implement in educated and affluent populations similar to subjects primarily studied.85 Overall, the panel decided the desired consequences probably outweigh the undesirable consequences and suggest offering this option.
Recommendation: For patients with persistent (N3 months) grades I to II NAD, we suggest high-dose massage over no treatment (wait listing) based on patient preferences and resources available. (Weak recommendation, low-quality evidence)
Remark: Interventions were given 3 times for 60 minutes a week for 4 weeks. Lower dosages and duration did not have therapeutic benefit, and we cannot suggest offering as an option.
Passive Physical Modalities
Key Question 21:Should LLLT be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.
Key Question 22:Should transcutaneous electrical nerve stimulation vs multimodal soft tissue therapy program be used for persistent (N3 months) grades I to II NAD?
Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high quality studies are needed in this area before certainty in judgments or recommendations can be made.
Key Question 23:Should cervical traction be used for grade III NAD (variable duration)?
Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.
Key Question 24:Should multimodal care vs continued practitioner care be used for persistent grades I to III NAD?
Summary of Evidence. One RCT by Walker et al.86 evaluated the effectiveness of multimodal care for neck pain with or without unilateral upper extremity symptoms (grades I-III). They compared treatment effects of combined multimodal care and home exercises (n = 47) to multimodal minimal intervention (n = 47). Both intervention groups received on average of 2 sessions per week for 3 weeks. No interventions were rendered after 6 weeks. Baseline self- reported questionnaires included neck and arm pain (VAS) and disability (NDI). All measures were repeated at 3, 6, and 52 weeks. Patients in the multimodal care and home exercise group had significantly greater reduction in short-term neck pain and in short-term and long-term disability compared with the multimodal minimal interven- tion group (Table 13). A secondary analysis of the Walker et al. study87 determined that patients receiving both�cervical thrust and nonthrust manipulations did no better than the group receiving cervical nonthrust manipulations only. This underpowered secondary analysis prohibits any definitive statement regarding the presence or absence of a treatment advantage of one approach over the other. The reduction in pain reported by Walker�s multimodal care and exercise group compared favorably to the change scores reported by other studies, including Hoving et al.88,89
In an RCT, Monticone et al.90 evaluated the effective- ness of multimodal care for persistent neck pain. They compared treatment effect of multimodal care alone (n = 40) to multimodal care in conjunction with cognitive behavioral treatment (n = 40). Both groups had a reduction in pain (NRS) and disability (NPDS), but there were no clinically significant differences between the groups at 52 weeks. The addition of a cognitive behavioral treatment did not provide greater outcomes than multimodal care alone.
Recommendation: For patients presenting with persistent neck pain grades I to III, we suggest clinicians offer multimodal care* and/ or practitioner advice based on patient preference. (Weak recommendation, low-quality evidence)
Remark: *Multimodal care and exercises may consist of thrust/nonthrust joint manipulation, muscle energy, stretching, and home exercises (cervical retraction, deep neck flexor strengthening, cervical rotation ROM). �Multimodal minimal intervention may consist of postural advice, encouragement to maintain neck motion and daily activities, cervical rotation ROM exercise, instructions to continue prescribed medication, and therapeutic pulsed (10%) ultrasound at 0.1 W/cm2 for 10 minutes applied to the neck and cervical ROM exercises.
Key Question 25:Should group exercises vs education or advice be used for workers with persistent neck and shoulder pain?
Summary of Evidence. We have combined the key questions for �Should structured patient education vs exercise programs be used for persistent neck pain and associated disorders in workers?� and �Should workplace-based exercises vs advice be used for neck pain in workers?� One large cluster RCT (n = 537) by Zebis et al.91 evaluated the effectiveness of strength training in the workplace compared with receiving advice to stay physically active on nonspecific neck and shoulder pain intensity. The findings indicated a similar reduction in neck and shoulder pain intensity at 20 weeks for the exercise program compared with advice (Table 14). The intervention consisted of 3 sessions per week, each lasting 20 minutes, for up to 20 weeks (total of 60 sessions).
The workplace exercise program consisted of high- intensity strength training relying on principles of progres- sive overload and involved local neck and shoulder muscles strengthening with 4 different dumbbell exercises and 1 exercise for the wrist extensor muscles. More than 15% of�workers assigned to the workplace exercise group reported minor and transient complaints. The comparison group reported no adverse events.
A subgroup analysis92 of the primary Zebis et al. study91 included 131 women with a baseline neck pain rating of at least 30 mm VAS from the 537 male and female participants. Results favored specific resistance training over advice to stay active for pain (VAS) at 4 weeks. This study was not included because findings were already considered in the primary study.
Recommendation: For workers with persistent neck and shoulder pain, we suggest mixed supervised and unsupervised high- intensity strength training or advice alone. (Weak recommendation, moderate-quality evidence)
Remark: For reduction in pain intensity, 3 sessions per week, each lasting 20 minutes, over a 20-week period. Exercise includes strengthening. Extra resources are likely required for complete exercise intervention implementation.
Structured Patient Education
Key Question 26:Should structured patient education vs exercise programs be used for persistent (N3 months) NAD in workers?
Summary of Evidence. Andersen et al.93 reported non� clinically significant outcomes at 10 weeks for neck and shoulder pain, suggesting weekly e-mailed information on general health behaviors and shoulder abduction exercise programs provide similar clinical benefit. Yet implementa- tion of high-intensity strength training exercises in industrial workplaces (implementation of exercise into day-to-day life and to increase active leisure time) is generally supported.94,95 In another RCT, pain reduction was significantly greater than in the group receiving advice alone. 91 Findings from Zebis et al. 91 are also included in the exercise intervention section of this guideline.
The panel determined moderate certainty in the clinical evidence, with small desirable and undesirable effects of the intervention. The resources required are relatively small, assuming the practitioner presents the education to the patient. Health inequities would be positively affected, and the intervention would be acceptable to stakeholders and feasible to implement. The panel decided not to repeat these findings in the current section. The panel felt that the benefits of increasing the frequency and intensity of exercise regimes was not restricted to those working in an industrial environment or to any specific population subgroup with the exception of older adults.
Work Disability Prevention Interventions
Key Questions 27-29:Should work-based hardening vs clinic-based hardening be used for persistent (N3 months) work-related rotator cuff tendinitis? Should work disability prevention interventions be used for persistent neck and shoulder pain?�Should work disability prevention interventions be used for persistent (N3 months) upper extremity symptoms?
Summary of Evidence. In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain� for Key Questions 27-29. As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.
Recommendations for Persistent (N3 Months) Grades I to III WAD Exercise
Key Question 30:Should supervised general exercise and advice vs advice alone be used for persistent (N3 months) grades I to II WAD?
Summary of Evidence. In an RCT, Stewart et al. (2007)96 evaluated the effectiveness of 3 advice sessions alone compared with 3 advice sessions combined with 12 exercise sessions over 6 weeks on neck pain (NRS) and disability�(NDI) among 134 patients with persistent grades I to II WAD. The results, presented in Table 15, indicated that supervised exercises with advice are as effective as advice alone at long term (12 months). Advice included standardized education, reassurance, and encouragement to resume light activity and consisted of 1 consultation and 2 follow-up phone contacts. However, the quality of the evidence was downgraded to low based on SIGN criteria (randomization and outcome measurement were �poorly addressed�) and the low number of participants and events.45
A pragmatic trial assigned 172 patients with persistent WAD grades I to II to receive a comprehensive 12-week exercise program (20 sessions including manual therapy technique the first week [no manipulation] and cognitive behavioral therapy delivered by physiotherapists) or advice (1 session and telephone support).97 The comprehensive exercise program was not more effective than advice alone for pain reduction or disability, although findings favored a comprehensive physiotherapy exercise program over advice.
The panel determined low certainty in the evidence, with small desirable and undesirable effects and no serious adverse events (5 patients who received the comprehensive exercise program and 4 who received advice had minor transient adverse events). Overall, the panel decided the balance between the desirable and undesirable conse- quences such as costs was uncertain, and more evidence is needed before a recommendation can be made.
In a 20-week cluster RCT, Gram et al. (2014)98 randomly assigned 351 office workers to 2 training groups receiving the same total amount of planned exercises 3 times per week, with 1 group supervised throughout the intervention period and the other receiving minimal supervision only initially, and a reference group (without exercise). Although results indicated that supervised training at the workplace reduced neck pain, results were not clinically significant and both training groups improved independently of the extent of supervision. The panel decided not to consider this study in formulating a recommendation because exercise was not directly com- pared with advice and an important loss to follow-up occurred across groups. Although supervised exercise appears to be beneficial, costs can be high. This could possibly be mitigated, however, by offering group treat- ment, which may increase compliance and accountability with a supervised group.
Recommendation: For patients with persistent (N3 months) grades I to II WAD, we suggest supervised exercises with advice or advice alone based on patient preference and resources available. (Weak recommendation, low-quality evidence)
Remark: Extra resources may be required for supervised exercises.
Key Question 31:Should multimodal care vs self- management program be used for persistent (N3 months) grade II WAD?
Summary of Evidence. Jull et al.99 reported no clinically or statistically significant outcomes for pain and disability at 10 weeks. They suggested that multimodal care (exercises, mobilization, education, and ergonomic advice) provided similar outcomes to a self-management program based on an educational booklet (mechanism of whiplash, reassur- ance of recovery, stay active, ergonomic advice, exercise). Care did not include high-velocity manipulation. Although this study is specific to physiotherapists, it is well within the scope of chiropractors (manual therapists).
One other RCT by Jull et al.100 evaluated the effectiveness of multidisciplinary individualized treat- ments for patients with acute whiplash (b4 weeks postinjury). Patients randomly assigned to pragmatic intervention (n = 49) could receive medication including opioid analgesia, multimodal physiotherapy, and psy- chology for post-traumatic stress over 10 weeks. No significant differences in frequency of recovery (NDI ? 8%) between pragmatic and usual care groups was found at 6 or 12 months. There was no improvement in current nonrecovery rates at 6 months (63.6%, pragmatic care; 48.8%, usual care), indicating no advantage of the early multiprofessional intervention.
The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects reported. Yet there were relatively small costs and resources required to implement the intervention. Electronic dissem- ination of the educational component of multimodal care may reduce health inequities. The option may be acceptable to clinicians (assuming collaborative care approaches), policymakers, and patients and is likely feasible to implement in usual care settings. Overall, the balance between the desirable and undesirable consequences is uncertain, and no recommendation is given at this time. Further studies need to be conducted in this area and should involve multimodal care including high-velocity proce- dures or manipulation.
Key Question 32:Should structured patient education vs advice be used for persistent (N3 months) WAD?
Summary of Evidence. Stewart et al. (2007)96 reported non�clinically significant between differences for pain and disability outcomes at 6 weeks. This study suggested that adding a physiotherapy-based graded exercise program to a structured advice intervention provided similar clinical benefit as structured education alone.
The panel determined low certainty of the evidence, with low desirable and undesirable anticipated effects. The main complaints were muscle pain, knee pain, and spinal pain with mild headaches.96 The small resources required for the intervention may reduce health inequities, and the option is acceptable to stakeholders and feasible to implement in most settings.
The panel determined that this key question had substantial overlap with Key Question 5 and decided to make 1 recommendation addressing both topics.
This evidence-based guideline establishes the best practice for the management of NAD and WAD resulting from or aggravated by a motor vehicle collision and updates 2 previous guidelines on similar topics.24,25 This guideline covers recent-onset (0-3 months) and persistent (N3 months) NADs and WADs grades I to III. It does not cover the management of musculoskeletal thoracic spine or chest wall pain.
The primary outcomes reported in the selected studies were neck pain intensity and disability. Although all recommendations included in this guideline are based on low risk of bias RCTs, the overall quality of evidence is generally low considering other factors considered by GRADE such as imprecision, and thus the strength of recommendations is weak at this time. Weak recommen- dations mean that clinicians need to devote more time to the process of shared decision making and ensure that the informed choice reflects patient values and preferences.56 Interventions not described in this guideline cannot be recommended for the management of patients with NAD or WAD because of a lack of evidence about their effective- ness and safety (Table 16).
A recent systematic review and meta-analysis by Wiangkham (2015)101 on the effectiveness of conservative management for acute WAD grade II included 15 RCTs, all assessed as high risk of bias (n = 1676 participants), across 9 countries. Authors concluded that conservative interven- tions (noninvasive treatment), including active mobilization exercises, manual techniques, physical agents, multimodal therapy, behavioral approaches, and education, are gener- ally effective for recent-onset WAD grade II to reduce pain in the medium and long term and to improve cervical ROM in the short term compared with standard or control intervention.101 Although findings from the Wiangkham review are generally in line with those from the systematic reviews we included in this guideline,24,25 the pooling of high risk of bias and of clinically heterogeneous trials seriously challenges the validity of this more recent review.
Similarities and Differences With Recommendations by the OPTIMa Collaboration
First, the recommendations for the management of minor injuries of the neck were recently released by the Ministry�of Finance of Ontario in collaboration with the OPTIMa Collaboration 20 and published as a separate guideline. 27 They considered the risks of bias of included RCTs using the SIGN criteria45 and the guideline recommendations developed using the modified OHTAC framework,28 based on 3 decision determinants1: overall clinical benefit (evidence of effectiveness and safety) 2 ; value for money (evidence of cost-effectiveness where available); and3 consistency with expected societal and ethical values. In the current guideline, we used the GRADE approach, which, in addition to considering risk of bias of included RCTs, takes into account 4 other factors (imprecision, inconsistency, indirectness, publication bias) to rate the confidence in effect estimates (quality of evidence) for each outcome.102 As a result of imprecision of estimates in several RCTs, the overall quality of admissible studies was deemed low. GRADE considers similar decision determi- nants as the modified OHTAC to develop recommendations when subsequently making an overall rating of confidence in effect estimates across all outcomes based on those outcomes considered critical to a particular recommenda- tion.56 Accordingly, the guideline panel was asked to consider this low quality of evidence when judging the �desirable� consequences. When the benefits of important outcomes slightly outweighed undesirable effects of the intervention, a weak recommendation was made (ie, suggestions for care). This is likely to involve ensuring patients understand the implications of the choices they are making, possibly using a formal decision aid.56 However, if the judgment was �closely balanced or uncertain,� no recommendation could be made.
Second, OPTIMa 20 recommended that interventions should only be provided in accordance with published evidence for effectiveness, including parameters of dosage, duration, and frequency, and within the most appropriate phase. The emphasis during the early phase (0-3 months) should be on education, advice, reassurance, activity, and encouragement. Health care professionals should be encouraged to consider watchful waiting and clinical monitoring as evidence-based therapeutic options during the acute phase. For injured persons requiring therapy, time-limited and evidence-based interventions should be implemented on a shared decision-making basis, an approach that equally applies to patients in the persistent phase (4-6 months). Despite using slightly different methods to derive recommendations, the 2 processes generally led to similar guidance.
Third, OPTIMa20 reported that the following interven- tions are not recommended for recent-onset NAD: struc- tured patient education alone (either verbal or written); strain-counterstrain or relaxation massage; cervical collar; electroacupuncture (electrical stimulation of acupuncture points with acupuncture needles or electrotherapy applied to the skin), a topic not covered in our guideline; electric muscle stimulation; heat (clinic based). Similarly for�persistent NAD, programs solely of clinic-based supervised high-dose strengthening exercises, strain-counterstrain or relaxation massage, relaxation therapy for pain or disability outcomes, transcutaneous electrical nerve stimulation (TENS), electric muscle stimulation, pulsed shortwave diathermy, heat (clinic based), electroacupuncture, and botulinum toxin injec- tions are not recommended. In contrast, based on the RCT by Zebis et al.91 the current guideline suggests offering multimodal care and/or patient education for industrial workers presenting with neck pain grades I to III. Although structured patient education used alone cannot be expected to yield large benefits for patients with neck pain, this strategy may be of benefit during the recovery of patients with persistent WAD when used as an adjunct therapy.40 For persistent neck pain (grades I-II), Gustavsson et al.80 reported that multimodal care combining manual therapy (spinal manipulation, mobilization, massage, traction) and passive modalities (heat, TENS, exercise, and/or ultrasound) reduced neck disability. It should be noted, however, that past reviews were unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain 103 or chronic pain 104 in adults, nor about the effectiveness of heat therapy.105,106
A comparison of the recommendations with 2 previous chiropractic guidelines 24,25 reveals that a multimodal approach including manual therapy, advice, and exercise remains the overall recommended strategy of choice for the treatment of neck pain. However, treatment modalities included in recommended multimodal care differed accord- ing to the quality of the evidence available at the time. The 2010 guideline on the management of WAD developed treatment recommendations based on low-quality evidence from 8 available RCTs and 3 cohort studies.25 Overall, recommendations for recent and persistent WAD are similar (multimodal care, and supervised exercise and multidisciplinary care, respectively). The 2014 guideline on neck pain24 developed 11 treatment recommendations from 41 RCTs. The current guideline developed 13 recommenda- tions from 26 low risk of bias RCTs. In line with the 2014 guideline24 for recent-onset neck pain, the current recom- mendations suggest offering multimodal care including mobilization, advice, and exercises. The current guideline recommendations also suggest offering supervised graded strengthening and stability exercises. Similar to the 2014 guideline for persistent neck pain (grades I-II),24 the current recommendations suggest offering multimodal care consisting of manual therapy (spinal manipulation therapy or mobilization) and exercises. Details on specific exercise modalities are now provided, including suggestions for supervised and unsuper- vised exercises, strength training, and supervised group exercises such as workplace exercise programs and supervised yoga.
This guideline did not specifically review the evidence on adverse events from treatments. However, in the review�by Wong et al.42 on manual therapy and passive modalities, 22 of the low risk of bias RCTs addressed the risk of harm from conservative care. Most adverse events were mild to moderate and transient (mostly increased stiffness and pain at the site of treatment, with a mean rate of about 30%). No serious neurovascular adverse events were reported. Another review of published RCTs and prospective cohort studies confirmed that around half of people treated with manual therapy can expect minor to moderate adverse events after treatment, but that the risk of major adverse events is small.107 The pooling of data from RCTs of manual therapy on the incidence of adverse events indicated that the relative risk of minor or moderate adverse events was similar for manual therapy and exercise treatments, and for sham/passive/control interventions.
A patient-centered holistic and collaborative view of the needs of the patient with pain and disability is encouraged. 108,109 Although chiropractors are not responsible for pharmacologic management, they should have sufficient knowledge about pharmacologic agents and their adverse events. One eligible RCT22 found home exercises and advice to be as effective as medication (acetaminophen, NSAIDs, muscle relaxant, and opioid analgesic) in reducing pain and disability at short term for patients with acute or subacute neck pain grades I to II. However, medication was associated with a higher risk for adverse events. Of interest, recent evidence suggests that acetaminophen is not effective for managing low back pain,110,111 and the effectiveness of long-term opioid therapy for improving chronic pain and function is uncertain.64 However, a dose-dependent risk for serious harms is associated with long-term use of opioid (increased risk for overdose, opioid abuse and dependence, fractures, myocardial infarction, and use of medications to treat sexual dysfunction).64 Risk of unintentional opioid overdose injury appears to be particularly important in the first 2 weeks after initiation of long-acting agents.112,113
Choosing a Care Provider. A range of health care providers (chiropractors, general medical practitioners, physiothera- pists, registered massage therapists, and osteopaths) deliver care for NADs and WADs.108,114 Considering the level of skills required to deliver manual therapy, including spinal manipulative therapy and other forms of therapies (eg, prescription of specific exercise) and based on individual patient preference, cervical spine manipulation as part of multimodal care should be delivered by properly trained licensed professionals. 115
Best Practice Recommendations-Initial Assessment and Monitoring.
This guideline specifically addresses the treatment of NAD and WAD grades I to III. Importantly, our panel supports�the following 5 best practice recommendations on patients care outlined in the OPTIMa guideline27: Clinicians should1 rule out major structural or other pathologic conditions as the cause of neck pain�associated disorders before classifying as grade I, II, or III2; assess prognostic factors for delayed recovery3; educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I to III and the importance of maintaining�activity and movement4; refer patients with worsening symptoms and those who develop new physical or psychological symptoms for further evaluation at any time during their care; and5 reassess the patient at every visit to determine whether additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged. Similar recommendations were formulated by the Neck Pain Task Force116 and in prior practitioner guides on the management of WAD and NAD by chiropractors.24,25
Benefits of Physical Activity and Self-management. Educating patients about the benefits of being physically active and participating in their care has become the standard of care internationally. Despite the benefits of therapeutic exercise for managing chronic neck pain and the strong evidence favoring regular physical activity to reduce related comorbidities, care providers fail to routinely prescribe these to patients.117-120 When prescribed, the amount of supervision and types of exercises do not follow practice guidelines and are not linked to the degree of patient impairment.118,121 On the patient side, adherence to prescribed exercise programs is often low. 122
The promotion of physical activity, including exercise, is a first-line treatment considered important in the prevention and treatment of musculoskeletal pain and its related comorbidities (eg, coronary heart disease, type 2 diabetes, and depression).123-126 For a minority of patients with chronic spine pain, clinician-delivered interventions and pharmacologic treatments are appropriate; and in fewer cases, multidisciplinary pain management or surgery may be indicated. 118
People with musculoskeletal pain will often adopt an inactive lifestyle. Unfortunately, physical inactivity is associated with important adverse health effects, including increased risks of coronary heart disease, type 2 diabetes, and breast and colon cancers, and shorter life expectancy in general.127 The World Health Organization128 provided clear guidance on physical activity for health for children, adults, and elders. In addition, recent research suggests that WAD patients with high levels of passive coping�strategies have slower pain and disability recovery.129 Self-management support (SMS) strategies aimed at increasing physical activity and active coping strategies are key to effectively managing spinal pain and related comorbidities. 124,125,130-134 The CCGI developed a theory-based knowledge translation (KT) intervention targeting identified barriers to professional behavior change to increase the uptake of SMS strategies among Canadian chiropractors.135 Interviews of clinicians identified 9 theoretical domains as likely relevant (ie, factors perceived to influence the use of multimodal care to manage nonspecific neck pain).135 The intervention, comprising a webinar and a learning module on Brief Action Planning, is a highly structured SMS strategy that allows patient- centered goals136 and is being pilot-tested among Canadian chiropractors (ongoing pilot trial).137 Care providers are encouraged to perform periodic clinical revaluations and to monitor patient progression of self-management strategies while discouraging dependence on passive treatment.
Overall, the quality of the research on conservative management of NADs and WADs remains low, partly explaining that only weak recommendations could be formulated for clinical practice. Further, the reporting of RCTs remains suboptimal. 138 Past recommendations for improving the quality of the research still apply.24,25 Future research should aim to clarify the role of spinal manipulation therapy alone or as part of multimodal care for the management of recent neck pain and have adequate frequency and length of follow-up. For instance, a large number of patient visits to the emergency departments each year are for acute neck and arm pain resulting from WADs.14,139 A small RCT suggested that cervical spine manipulation is a reasonable alternative to intramuscular NSAID for immediate pain relief in these patients.63 However, the small sample size, comparison of a single session of spinal manipulation to an NSAID injection, and a 1-day follow-up was not representative of clinical practice.
Few recent adequately controlled high-quality research studies of chiropractic care for NADs have been published. In addition, studies included in the reviews did not estimate the maximum therapeutic benefits (ie, best dosage for treatment under evaluation). Well-designed clinical trials with sufficient numbers of participants, longer-term treatments, and follow-up periods are needed to increase the confidence in the recommendations and to advance our understanding of effective and cost-effective conservative care, and spinal manipulation, for the management of patients with NADs and WADs.
Dissemination and Implementation Plan. Evidence-based practice aims to improve clinical decision making and patient care.140,141 When followed, CPGs have the potential to improve health outcomes and the efficiency of the health care system.142-144 However, low adherence to CPGs has been noted across health care sectors145 and in the management of musculoskeletal conditions, including NADs and WADs.77,101,102 Such gaps contribute to wide geographic variations in the use and quality of health care services. 146
Efforts to bridge the �research-practice gap� have led to a growing interest in KT.145,147 Knowledge translation is defined as the exchange, synthesis, and ethically sound application of knowledge to improve health and provide more effective health services. 148 Knowledge translation aims to bridge the research-practice gap and improve patient outcomes by promoting the integration and exchange of research and evidence-based knowledge into clinical practice.
To prepare for guideline implementation, we considered the Guideline Implementation Planning Checklist 149 and�available strategies and supporting evidence141,150 to increase guideline uptake. Although effects of KT inter- ventions tend to be modest, they are likely important at a population health level.37
To raise awareness, chiropractic professional organiza- tions are encouraged to inform their members of new CCGI guidelines and tools easily accessible on our website (www. chiroguidelines.org). The guideline implementation tools framework was used to clarify the objectives of the tools; identify end users and the context and setting where tools will be used; provide instructions for use; and describe methods to develop the tools and related evidence and to evaluate the tools.151 Implementation tools designed to increase guideline uptake include practitioner and patients� handouts (Fig. 8, Appendix 7); algorithms (Figs. 6 and 7), webinars, videos, and learning modules (www.cmcc. ca/CE); point-of-care checklists; and health status reminders.152-154 The CCGI has established a network of opinion leaders across Canada (www.chiroguidelines.org). Based on successful efforts to implement a WAD guideline in Australia using opinion leaders among regulated physiotherapists, chiropractors, and osteopaths, 155 the CCGI is planning a series of implementation studies among Canadian chiropractors.137 We will also pilot within chiropractic practice-based research networks.156 Monitor- ing guideline use in chiropractic is challenging because the use of electronic health records to routinely collect clinical practice information is not common in Canada and those using electronic health records often collect different indicators. 157 Nonetheless, the frequency of downloads (posting of the open access guideline on the CCGI website) and number of registering participants and completion of educational online material (webinar, video, and learning module) will be monitored monthly as proxy measures of guideline uptake.
The methods for updating the guideline will be as follows: 1) Monitoring changes in evidence, available interventions, importance and value of outcomes, resources available or relevance of the recommendations to clinicians (limited systematic literature searches each year for 3-5 years and survey to experts in the field annually): 2) assessing the need to update (relevance of the new evidence or other changes, type and scope of the update); and 3) communi- cating the process, resources, and timeline to the Guideline Advisory Committee of the CCGI, who will submit a recommendation to the Guideline Steering Committee to make a decision to update and schedule the process.158-163
Strengths and Limitations
Shortcomings for this guideline include the low quantity and quality of supporting evidence found during the searches. Most of the downgrading of evidence supporting the outcomes occurred because of imprecision. In addition, our updated search of the published reports included 2 databases (Medline and Cochrane Central Register of Controlled Trials) but was limited to the English published reports, which possibly excluded some relevant studies. This, however, is an unlikely source of bias.164,165 Qualitative studies that explored the lived experience of patients were not included. Thus, this review cannot comment on how patients valued and experi- enced their exposure to manual therapies or passive physical modalities. Although the composition of the guideline panel was diverse, with experienced methodologists, expert clini- cians, and stakeholder and patient representatives, only 1 member was from another health discipline (physiotherapist). The scope of this guideline focused on selected outcomes such as pain and disability, although included studies assessed several additional outcomes.
This CPG supersedes the original (2005) and revised (2014) neck pain guideline as well as the 2010 whiplash-associated guidelines produced by the Canadian Chiropractic Association (CCA); Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB).
People should receive care based on evidence-based therapeutic options. Based on patient preference and resources available, a mixed multimodal approach includ- ing manual therapy and advice about self-management and exercise (supervised/unsupervised or at home) may be an effective treatment strategy for recent-onset and persistent NAD and WAD grades I to III. Progress should be regularly monitored for evidence of benefit, in particular on the basis of pain alleviation and reduction of disability.
Funding Sources and Conflicts of Interest
Funds provided by the Canadian Chiropractic Research Foundation. The views of the funding body have not influenced the content of the guideline. No conflicts of interest were reported for this study.
The evidence-based practice guidelines published by the CCGI include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.21 Guidelines are intended to inform clinical decision making, are not prescriptive in nature, and do not replace professional chiropractic care or advice, which always should be sought for any specific condition. Furthermore, guidelines may not be complete or�accurate because new studies that have been published too late in the process of guideline development or after publication are not incorporated into any particular guideline before it is disseminated. CCGI and its working group members, executive committee, and stakeholders (the �CCGI Parties�) disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, expressed or implied. Guideline users are urged to seek out newer information that might impact the diagnostic and/or treatment recommendations contained within a guideline. The CCGI Parties further disclaim all liability for any damages whatsoever (including, without limitation, direct, indirect, incidental, punitive, or consequential damages) arising out of the use, inability to use, or the results of use of a guideline, any references used in a guideline, or the materials, information, or procedures contained in a guideline, based on any legal theory whatsoever and whether or not there was advice of the possibility of such damages.
Through a comprehensive and systematic literature review, CCGI evidence-based CPGs incorporate data from the existing peer-reviewed literature. This literature meets the prespecified inclusion criteria for the clinical research question, which CCGI considers, at the time of publication, to be the best evidence available for general clinical information purposes. This evidence is of varying quality from original studies of varying methodological rigor. CCGI recommends that performance measures for quality improvement, performance-based reimbursement, and public reporting purposes should be based on rigorously developed guideline recommendations.
A multimodal approach including manual therapy, self-management advice, and exercise can be an effective treatment strategy for recent-onset and persistent neck pain and whiplash-associated disorders.
We thank the following people for their contributions to this paper: Dr. John Riva, DC, observer; Heather Owens, Research Coordinator, proofreading; Cameron McAlpine (Director of Communication & Marketing, Ontario Chiro- practic Association), for assistance in producing the companion document intended for patients with NAD; members of the guideline panel who served on the Delphi consensus panel, who made this project possible by generously donating their expertise and clinical judgment.
In conclusion, whiplash-associated disorders can cause damage to the complex structures of the cervical spine, or neck, because the sheer force of an impact can extend the soft tissues beyond their natural range of motion. Many healthcare professionals can safely and effectively treat whiplash as well as other automobile accident injuries. The results of the article above demonstrate that a multimodal approach, including manual therapy, self-management advice and exercise can be an efficient treatment strategy for both recent-onset and persistent neck pain caused by whiplash-associated disorders.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
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Approximately 15 to 40% of those injured in automobile accidents will struggle with chronic pain for the rest of their life. Journal of the American Academy of Orthopedic Surgeons, 2007
Whiplash injuries not only increase your chances of chronic neck and shoulder pain, they also increase the probability of other seemingly unrelated health problems. Journal of Clinical Epidemiology, 2001
Chronic Pain does bad things to people. According to standardized assessment tests, 100% of those struggling with chronic pain caused by whiplash injuries have abnormal psychological profiles. The only way to resolve these abnormal psychological profiles is to relieve / remove the chronic back pain, neck pain and headaches. Counseling / Psychiatry has not been shown to improve the pain nor the psychological profiles of people suffering from the effects of their automobile accident. Pain, 1997
The longest-running study ever done on whiplash patients looked at the overall health of whiplash patients almost twenty years after their automobile accident. Nearly two decades after their accident, 55% of those patients still deal with chronic pain. Accident Analysis and Prevention, 2002
Unless you have a fracture or specific ligament tear, Cervical Collars are no longer recommended for treating patients with whiplash injuries. When cervical collars are used as a whiplash injury treatment, there is a 90% probability that you will still have chronic neck pain in six months. Spine, 2000
One in one hundred people around the world (1% of the population, or just over 70 million people) suffer from ongoing chronic neck pain due to an automobile-induced whiplash injury. Injury, 2005
One in fifty people injured in Whiplash-like accident deal with chronic pain severe enough to need diagnostic testing, medications, and doctor visits, on an ongoing basis —– nearly eight years after the accident occured. Pain, 1994
“Statistically, every American can expect to be in a motor vehicle collision once every ten years. Motor vehicle collisions have been the number one cause of death of our children for decades. Since 9/11 (September 11, 2001), about 3,000 Americans have died as a consequence of terrorism; about 360,000 Americans have died in motor vehicle crashes. Since the start of the American Revolution in 1775, about a million Americans have died in our wars. Since Henry Ford introduced the mass-produced motorcar in 1913, more than 2.5 million Americans have met their deaths on the road. And millions of Americans who did not die from motor vehicle collisions were injured.” Orthopedist and one of the world’s foremost experts on whiplash, Dr. Dan Murphy. There are 3,000,000 new cases of whiplash in the US every year.
Whiplash Injuries Explained
The word �whiplash� is a layperson�s term —- and although it is typically associated with Car Crashes, crashes are certainly not the only way to get a whiplash injury. Whiplash Associated Disorders (WAD) are typically referred to in the medico-legal literature as �Acceleration / Deceleration� injuries, or “Hyperflexion / Hyperextension” injuries. And, as many of you have come to understand the hard way, they can be incredibly violent � even in seemingly minor accidents that had surprisingly little vehicular damage. With over three million new cases of Acceleration / Deceleration injuries occurring each year, and over 50% of those progressing to at least some degree of unresolved or �chronic� symptoms, it is clear that Whiplash Associated Disorders are taking a massive toll on our country financially, physically, and emotionally.
When people think of �whiplash� they tend to think of motor vehicle accidents (MVA�s). Although MVA is probably the single most common cause of the symptoms most frequently associated with and experienced by those suffering with Whiplash Associated Disorders (neck pain, upper back pain, shoulder pain, fuzzy thinking, numbness, tingling and / or weakness of the hands, dizziness, etc), whiplash can occur in about a thousand and one different ways. And while there are certain symptoms that we see over and over and over in our clinic (neck pain and headaches, for instance), whiplash can seemingly cause about a thousand and one different symptoms as well. Some of the most common causes of WAD that I see in my office include sports injuries, work injuries (think logging here), spousal abuse, fights, horse accidents (falls), and almost anything else that has the capacity to �snap� your head suddenly and violently.
Although the most common problems associated with Whiplash Associated Disorders are related to the neck (neck pain, numb hands, headaches), scientific research shows that Acceleration / Deceleration injuries routinely cause all sorts of other injuries as well. For instance, I commonly see people whose low back pain started with an MVA. I even see people whose FIBROMYALGIA was brought on by the emotional and physical stress of an MVA! One of the most shocking conclusions concerning Whiplash Associated Disorders, was written by a pair of the most well known whiplash researchers on the planet � medical researchers, not chiropractic researchers. Drs. Gargan & Bannister stated in a study that was done in the 1990?s, that whiplash-like injuries frequently result in a whole host of, �bizarre and seemingly unrelated symptoms�. Although there are plenty of malingerers, fakers, scam artists, money-grubbers, and drug seekers out there; far too many people are lumped into these categories simply because their problems do not show up on traditional medical tests such as MRI / CT.
Even though there are literally scores of scientific studies concluding that Whiplash Associated Disorders are difficult (often to the point of being impossible) to image on x-rays, CT’s, or MRI�s, these are still the chief method the medical community is using to determine whether or not you were injured, and just how serious this injury might be. The problem is, if the vast majority of soft-tissue injuries (injuries to LIGAMENTS, TENDONS, MUSCLES, FASCIA, etc) do not image well with advanced imaging techniques, and imaging is the medical community�s chief method of diagnosis; unless you have a herniated disc, you will invariably be treated like nothing is really wrong with you � like you are a scam artist trying to extort a huge settlement from an insurance company. Stop and think for a moment about how problematic that fascia, arguably the single most pain-sensitive tissue in your entire body, will not show up on any tests —- including MRI.
When you are taken the the ER, you will have some tests run and the doctor will look at you and say, �Thank God Mrs. Smith. Nothing is broken! Now, go home and rest, and call your family doctor tomorrow. In the mean time, wear this collar, and take these Anti-Inflammatory Medications, pain pills, and muscle relaxers. Oh, and don�t forget to use a heat pack as well.� Is this good advice? Sure it is � if you own a medical clinic! Follow this advice and you are certain to become a lifetime ARTHRITIC! The truth is, when it comes to the evaluation and treatment of injuries to fascia and other elastic, collagen-based connective tissues, all of our hi-tech equipment with its bells and whistles is simply not helping diagnose or help most injured people. You are reading a page on whiplash —- my guess is that you completely understand this concept because you have been there, and done that! The Old Model of tissue injury evaluation and treatment went out the door about 25 years ago. It just seems like no one has remembered to tell treating physicians about the NEW MODEL.
Brain Based Injury
Your short drive to work was no different than any other day —- until you began slowing down for the school bus stopping in front of you. Just as you’re coming to a complete stop, BAM; your world explodes as someone plows into your car from behind, knocking you into the bus. Turns out the kid driving the full-sized crew cab pickup truck that hit you was texting, and never even hit his brakes. You’re having a hard time remembering exactly what happened. You remember a flash of light and your head being slammed backwards over the top of your headrest. You vaguely recall that your head rocketed forward as you hit the bus — almost hitting the windshield. You step out of your 1997 Toyota Camry to take stock of the situation. There is no blood or guts. In fact, you don’t even have a bruise to show for your trouble. But by the time the State Troopers arrive to work the accident, you not only have a neck pain unlike anything you have ever felt before, you have a banging headache as well. You’re having trouble putting the pieces in order for them. They ask if you need an ambulance, but you do not want to go to the Emergency Room. But a few weeks later, you’re still having trouble with your memory. Work is not going well because on top of the pain and exhaustion (yeah, since the accident you can’t sleep either), everything seems fuzzy, foggy, and hazy. Who would have thought that whiplash could cause these sorts of symptoms —– particularly without any overt / obvious injuries?
Whiplash Injuries are particularly dangerous because they are a common cause of MTBI (Mild Traumatic Brain Injury). MTBI results from the brain bouncing off the inside of the skull during the hyperextension / hyperflexion of the neck. As you can imagine, this damages / destroys nerve cells. Depending on which part of the brain is injured, a person might have problems in some of the following areas…
Walking / Moving
Strength / Endurance
Ability to Communicate
Ability to Understand
Ability to Think
Strange or Unexplainable Pain Patterns or Symptoms (these are some of the “bizarre and seemingly unrelated symptoms” talked about by whiplash researchers Gargan and Bannister.)
Altered Psychological Profiles
Because these symptoms are often subtle, not very specific, and do not show up on standard medical tests such as x-rays or MRI’s, it�s common for patients with MTBI not to complain about them — at least initially. For many people it can be embarrassing “complaining” to the chiropractor or doctor about these vague and difficult-to-describe symptoms that have no external findings to relate them to (bruising, abrasions, broken bones, etc). Believe it or not, many patients are relieved to find out that there is a physiological reason that they feel the way they do, and that it is not “all in their head”. The good news is that with the correct kind of care, most of the patients who are struggling with these injuries will recover within a year’s time. But unfortunately, not all do. It is for this group of people that the term MTBI or “Post Concussive Syndrome” is used.
Factors That Worsen Whiplash Injury
The �old� model of whiplash said that WAD was simply caused by stretched or torn tissue, which was solely the result of the head flying around upon impact. That model simply did not explain the injuries being reported in low-speed collisions (15 mph and under). The most current whiplash models shows that a wave is �shot� through the spine upon impact —- quite similar to the wave you create to move the garden hose a couple of feet to the left. This wave, which occurs in a fraction of a second, can tear both connective tissue and nerve tissue microscopically. It also momentarily induces a tremendous amount of pressure in the smallest blood vessels (capillaries) which is known as �blood hammer�. Blood Hammer, FASCIAL TEARING, and subsequent Neurological Damage, helps to explain some of these “bizarre and seemingly unrelated symptoms” that are almost epidemic in those who have suffered whiplash injuries due to MVA’s.
What Can Make Whiplash Injury Worse?
FACTORS THAT POTENTIALLY INCREASE WHIPLASH SEVERITY
Unaware of approaching impact
Being Female (less muscle mass)
Incorrectly positioned headrest (too low)
Wet, Icy, or Slick roads (or gravel)
Your vehicle is small and light or struck by a larger vehicle
Elderly or arthritic spine (or history of previous whiplash injury)
Head turned at impact
Angled or side-impact accidents (rear-enders are particularly bad)
FACTORS THAT POTENTIALLY DECREASE WHIPLASH SEVERITY
Aware of approaching impact
Being Male (more muscle mass)
Headrest positioned at mid-ear
Your vehicle is large, heavy, or struck by a much smaller vehicle
Younger or more flexible and healthy spine (no previous injury)
Head facing forward at impact
Relationship: Severity Of Injury & Amount Of Vehicle Damage
“Different parts of the human body have different inertial masses. The mechanism of injury from a rear-end motor vehicle collision, is, as a rule, an inertial injury. This means the injury does not occur as a consequence of direct contact of vehicle parts to the patient�s body; rather, injury occurs as a consequence of different inertial masses moving independently from one another.” Dr. Daniel Murphy, Board Certified Orthopedist and Leading Expert in Whiplash Diagnosis and Treatment
In 1687, famed astronomer / mathematician / physicist / philosopher / and theologian, Sir Issac Newton, wrote his still-renowned Philosophiae Naturalis Principia Mathmatica (now referred to as Principia or simply “Principles”), that is still considered to be the greatest scientific textbook in human history.
In Principia, Newton laid out his three Laws of Motion. These laws are able to explain whiplash and the subsequent injury that follows better than anything else I have seen thus far. For understanding whiplash injuries and their relationship to vehicle damage, Newton’s first law is the most important —- The Law of Inertia. Channel your 8th grade science class and stay with me here as we take a brief science / physics review. Newton’s First Law: Objects at rest remain at rest unless they are acted on by an outside force. Likewise, objects in motion stay in motion unless they are acted on by an outside force. And remember this; Like Dr. Murphy described above, whiplash injuries occur because different parts of your body can and will have different inertias — sometimes very different inertias.
Let’s say that you are sitting at a stoplight and minding your own business. You’re humming along to Manfred Mann’s Blinded by the Light, when all of a sudden —- BAM! You are slammed from behind and launched across the intersection like you were shot from a cannon! You are not sure what happened, but you feel like you just got knocked into next week. PHYSICS LESSON: When your vehicle was struck from behind, it shot forward. Much of this had to do with the fact that you were driving a 1992 Toyota Corolla, and the kid that hit you (he was texting of course) was headed to the sale barn for his dad, driving a F-350 Supercab, and pulling a stock trailer loaded with eight steers. When he hit you, there was a huge instantaneous change in momentum. In a fraction of a second, your Corolla was accelerated from zero to over 50 mph. Let’s look at this event in frame-by-frame fashion.
As the Corolla shot forward, so did your torso that was sitting in the seat. Follow me, because here is the precise point where whiplash occurs. As your body was accelerated forward, your head (at least in the initial milliseconds) did not move. The head is much smaller (and lighter) than your torso, and attached by a thin column of muscles, tissues, and tiny vertebrate we call the neck or Cervical Spine. Because of the weight difference between the head and the body, as well as the fact that the connector between them (the neck) is stretchy and relatively thin; the head has a completely different inertia than the body. This was magnified by the fact that the seat back kept your torso from moving very far backwards, but did nothing to stop your neck — and unfortunately, your head restraint was not adjusted to the proper height. In other words, your body was essentially driven out from under your head; then a fraction of a second later, your head not only caught up with your body, it actually accelerated to a greater velocity than your body, and overshot it as your head slammed forward.
Let’s review: As the vehicle, the seat, and your body rocketed forward with the explosive energy and momentum shift from the impact, your head remained stationary for a split second. Your body was essentially driven out from under your head, making it appear that your head slammed backwards. As your head’s momentum began catch up to that of your body, the tissues in your neck began to stretch and deform. Unfortunately, when the force of the accident is greater than the forces holding your tissues together, these tissues begin to tear —- at least on a microscopic basis (remember, most of the time this tearing and SCAR TISSUE will not show up on an MRI). The result was a whiplash injury —- an inertial injury to the SPINAL LIGAMENTS, SPINAL DISCS, FASCIA, TENDONS, and other soft tissues of the neck and upper back. In fact, there are studies showing that even though they are too small to be effectively imaged with current MRI technology, there are often (usually) microscopic fractures of the FACET JOINTS present with intense whiplash injuries. Frequently, there is also sub-clinical brain injury as well.
Interestingly enough, one of the things that make muscles contract with greater intensity is to maximally stretch them (think of the windup and cocked arm of a baseball pitcher here). When the neck is stretched to such a great degree, it’s muscles contract to an equally intense degree. When coupled with the acceleration and subsequent deceleration of the vehicle, this causes the neck to slam forward causing still more tissue tearing in the neck and upper back. And the most important thing to grasp is that your neck and head never hit anything throughout the entire process. The injury to the neck itself (which happened in a matter of milliseconds) occurred because of a huge momentary shift in momentum, energy, and inertia between your body and your head —- just like what you see in Shaken Baby Syndrome.
Although you are slightly dazed, you get out of your Corolla and begin to appraise the situation. You look at your limbs. They look intact. You can move. You are breathing. There’s no blood. Nothing looks bruised or feels broken. In fact, you do not have as much as a scratch on you. You do not want to go to the Emergency Room, but the State Trooper working the accident talks you in to it. You have several spinal x-rays and a CT of your neck. Everything is negative. The ER doctor comes in, pokes you, prods you a couple times, and has you move a bit. He then delivers a short monologue — one he has delivered hundreds of times previously, “Wow Mr. Jones. Sounds like you were born under a lucky star. Thank God nothing is broken. Neurologically you check out fine. You’ll be sore, but just go see your family doctor tomorrow. You’ll get some PAIN PILLS, NSAIDS, CORTICOSTEROIDS, and MUSCLE RELAXERS. Don’t worry. You’ll be just fine.”
But that’s just it. You saw your doctor, and as the weeks go by, you’re not fine. Far from it. You are in pain, and it’s getting worse. But you have nothing to show for it. Like I said, there were no broken bones and no bruises. Heck, there was not even a cut or scratch. There is nothing that would alert anyone (let alone a doctor who is not up on the most current research) that you are in pain —- and that it’s getting worse. And on top of that, the damage to the rear end of your Corolla looked surprisingly light compared to how hard you were hit and the way that you feel (for Pete’s sake, the car is actually drivable). The other fellow’s insurance company paid you $2,000 for your Toyota, which was over double the Kelly Blue Book value. They took care of the ambulance ride and Emergency Room visit, and even offered you $1,500 for pain and suffering. You hired an attorney, but he acts like he does not really believe how much you hurt either. What’s going on here?
Almost half a century ago (1964), the prestigious medical journal, American Journal of Orthopedics revealed a still well-concealed fact — that there is no relationship (none, nada, zilch, zero) between the damage done to the vehicle and the amount of injury to the vehicle’s occupants. Since that time, the medical and scientific communities have proved this fact over and over and over again via research. It is a fact that I have heard verified over and over and over again by the Law Enforcement Officers and Paramedics that I adjust on a regular basis. Although most of the time, Insurance Companies and the Attorneys that represent them would have you believe just the opposite (there was not enough vehicle damage to have an injury), it’s just not true. Decades worth of scientific studies tell us that the severity of the vehicle damage cannot predict….
If patients will suffer whiplash injuries.
How severe those injuries might be.
How long it will take to effectively treat / heal the injury — or whether they will ever really heal at all.
Whether or not the injured party will end up with Chronic Pain and / or Arthritis as a direct result of the accident.
Dozens upon dozens of studies on Motor Vehicle Accidents have shown that vehicles that do not crumple upon impact will be accelerated with a far greater force and momentum. The faster that your vehicle is accelerated upon impact, the greater the inertial stresses to the neck and upper back. This is why today’s vehicles are made with “crumple zones”. You are much better off if the force of impact is absorbed by vehicular deformation, than by deformation of your body, particularly the soft tissues and discs of your neck. The larger the inertial stresses to the neck and upper back, the greater the damage to the soft tissues of the cervical spine / neck.
So, it stands to reason that harder impacts and greater amounts of vehicle damage lead to greater amounts of bodily injury. Not only is this not true, but most of the medical research on whiplash injuries today is being done on the effects of low speed impacts (those under 15 mph). Here are a few of the Scientific / Medical / Legal profession’s journals saying that there is no relationship between the amount of vehicular damage and the amount of injury to the vehicle’s occupants.
The Spine, 1982
Orthopedic Clinics of North America, 1988
Society of Automotive Engineers, 1990
Trial Talk, 1993
American Journal of Pain Management, 1994
Society of Automotive Engineers, 1995
Society of Automotive Engineers, 1997
Archives of Physical Medicine and Rehabilitation, 1998
Journal Of Whiplash & Related Disorders, 2002
Journal of Neurology, Neurosurgery, and Psychiatry, 2005
Whiplash Injuries, 2006
One of the problems, however, with whiplash injuries is that they frequently end up causing DEGENERATIVE ARTHRITIS. This has to do with the fact that these inertial injuries damage tissues in ways that cannot be imaged using even the most advanced technologies. Because most doctors are not up on current whiplash research, and feel you are looking for a big settlement, they frequently treat you like a malingerer (faker). However, these injuries cause the microscopic fibrosis that causes abnormal joint motion over time. This leads to arthritis so frequently, that I can often predict with a great deal of accuracy when a person’s injury occurred — just by looking at a current x-ray of their neck.
Arthritis After An Automobile Accident
X-rays taken an average of seven years after a whiplash injury revealed that arthritis in the neck’s spinal discs in almost 40% of the patients. The study’s uninjured group showed only a 6% rate of arthritis. What did the authors conclude? �Thus, it appeared that the injury had started the slow process of disc degeneration.� The Cervical Spine Research Society, 1989
Whiplash patients who already had degenerative arthritis of their cervical spine (neck), showed evidence of degenerative arthritis at previously non-arthritic discs and vertebrates in 55% of cases. The Cervical Spine Research Society, 1989
Compared to the necks of uninjured patients, a single incidence of whiplash increases the occurance of neck arthritis by 10 years. The Journal of Orthopedic Medicine, 1997
Pre-exisiting arthritis of the neck / Cervical Spine, greatly worsens the effects of a whiplash injury. Numerous studies show how this slows recovery times and increases the probability of ending up with Chronic Pain and even more arthritis than you started with. British Journal of Bone and Joint Surgery, 1983; The American Academy of Orthopedic Surgeons, 1987; Orthopedic Clinics of North America, 1988; Spine, 1994; British Journal of Bone and Joint Surgery, 1996
A great example of Inertia Injuries involves the sport of soccer. Soccer players who regularly “head” soccer balls, speed up degenerative arthritis of the neck by as much as twenty years. European Spine Journal, 2004 This is not new information, however. I wrote a newspaper column on the subject clear back in 1993. We saw that professional soccer players had double the amount of neck arthritis as their non-soccer playing peer group.
Whiplash Disorders: Difficult To Diagnose Despite Advanced Imaging
WAD is difficult to properly diagnose or evaluate using standard medical tests. X-rays do not ever show soft connective tissues, and dozens of studies show that MRIs, contrary to popular belief, do a poor job of imaging injured soft tissues — ESPECIALLY FASCIA. This is why you might feel like you are �dying�, but all of the tests are negative. People go through this experience over and over. They are then sent home from the E.R. or doctor�s office with pain killers, muscle-relaxers, and anti-inflammation drugs which can actually cause injured tissue to heal approximately 1/3 weaker and less elastic than it otherwise would, and told that in time it will heal. Just like a broken arm that is cocked off at a funny angle but never set or put in a cast; it will heal�.. It just won�t heal the right way or with the proper amount of joint function / motion.
So just how should a problem like this be addressed? The key to a functional recovery is controlled motion. CHIROPRACTIC ADJUSTMENTS, specific stretches, and strengthening exercises are the number one way to accomplish this! Because FASCIAL ADHESIONS are usually part of the whiplash equation, you will probably need to undergo some form of Tissue Remodeling as well. Restoring movement, function, and strength (both to individual joints or vertebrate, and to the spine or limb as a whole) is the only proven method that is effective in truly reducing the symptoms of whiplash. Contrary to popular belief, using drugs to simply cover symptoms, is never a good option.
If the only treatment you receive for your whiplash injury is palliative (meaning covering symptoms with drugs, without addressing the underlying cause of those symptoms), then any relief achieved is temporary, and the end product of this process will likely be dysfunction, degeneration, and chronic pain!
Doctor/s Cannot Find Anything Wrong: What To Do
I would seriously consider getting a new doctor. As you have already read, whiplash is frequently a “clinical” diagnosis. This simply means that it is not going to show up well on standard imaging tests such as x-rays, CT, and even MRI. If your doctor is not up on the most current whiplash research, you lose — in more ways than one. Let me show you the results of one study that wanted to determine if the effects of whiplash were real (“organic”) or in the patient’s head (“psychometric”). By the way, this study comes from a 1997 issue of one of the planet’s most prestigious medical journals, The Journal of Orthopedic Medicine. They compared a large control group to a large whiplash group, ten years after the accident. Not only does this give us a long-term look at the effects of whiplash, it also removes the potential effects of litigation on the research as any legal issues would have been long settled.
NON-WHIPLASH INJURED GROUP
Numbness, Tingling, Pain, Paresthesia in Arms / Hands
Combined Back and Neck Pain
Neck Degeneration as Seen on X-rays
WHIPLASH INJURED GROUP
Eight Times more Neck Pain
Eleven Times more Headaches
Sixteen Times more Numbness, Tingling, Pain, Paresthesia in Arms / Hands
Thirty Two Times more Combined Back and Neck Pain
Neck Degeneration was Ten Years Advanced when Compared to the Control Group
Hyperflexion/Hyperextension Of The Cervical Spine
With Hyperflexion, the spine goes forward, which drives the Nucleus of the disc to the back. This is why Herniated Discs are a frequent result of Whiplash Injuries. In Hyperextension, the spine is slammed backward. Although this rarely if ever results in frontal Disc Herniations, it jams the facets (the two little joints to the rear and on either side of the disc). This can lead to a degenerative condition called Facet Syndrome.
Notice in this Flexion / Extension X-ray that there is Spinal Degeneration occurring at the level of the C5-C6 Spinal Disc. This means that either this X-ray is being taken years (maybe decades) after an injury, or that this person had pre-existing degeneration (bone spurs, thin discs, and calcium deposits) prior to this latest injury. Either way, the individual being X-rayed had a Flexion / Extension injury of some sort probably 20 years ago or so. How can we predict this. Although there is a certain degree of “guesswork” that goes into knowing this, we know that DEGENERATIVE ARTHRITIS occurs due to loss of joint motion over time, and that whiplash tends to strike worst at C5-C6.
Soft Tissue Injuries?: How Long Do They Take To Heal?
That the spine and its supporting Connective Tissues can take up to two years to heal is not really new information. It can be found at least as far back as a 1986 issue of the Canadian Family Physician. More recent studies showing these longer healing times include a 1994 issue of the journal Pain, a 1994 issue of the journal Spine, and a 2005 issue of the medical journal Injury. In fact, the 1994 issue of Spine said that appropriately treated whiplash patients took an average time of over seven months to heal. This means that for every person who took 4-6 weeks to heal from their injuries, someone else is taking well over a year.
For people injured in Automobile Accidents, falls, Horse Accidents, Motorcycle Crashes, or any number of other ways that people end up with “Whiplash Injuries”, this is a commonly-asked question.� But it’s also a commonly asked question for those whose soft tissue injury was not traumatic, but was due to chronic, repeated, sub-maximal loading.� It’s more than understandable.� No matter how the injury occurred or what it is, everyone wants to know how long it is going to take to get better.� Just bear in mind that healing takes time.� And although you will often hear “6-8 weeks” bantered around, this is only partially true.� If you will notice the chart below, you can see that after about 3-4 weeks, the only thing going on is “Maturation and Remodeling”.� Do not be fooled!� This phase is not only critical, but far too often ignored by those who have a financial interest in your injury.
Tissue Repair & Healing Phases
STAGE I (Inflammatory Phase): This phase lasts from 12-72 hours, and is characterized by a release of inflammatory chemicals by injured cells. When cells are injured and die, they rupture and release their contents into the extracellular fluid (WHAT IS INFLAMMATION). These �Inflammatory Chemicals� that are released from ruptured cells are a necessary and vital component of the healing process. However, in excessive amounts, they can cause a great deal of pain. They also promote excessive microscopic scarring. Be aware that if you visit your doctor for a soft tissue injury, you will be given anti-inflammatory medications. These have serious side-effects (heart, liver, kidneys, etc). However, the real kick in the teeth is the fact that this class of drug has been scientifically proven to cause injured connective tissues to heal significantly weaker and with less elasticity than they otherwise would. Nowhere is this more true tha with Corticosteroids. Do a quick search of the Medico-Scientific Literature on Corticosteroids and soft tissue injuries. You will see over and over again that they are detrimental to the healing process and should play no part in the treatment of these injuries (HERE is an example from the field of Sports Injuries).
STAGE II (Passive Congestion): In this phase that begins by the 2nd to 4th day, we begin to see swelling (sometimes we do not see it, because it is not on the body�s surface). Remember; �inflammation� is not synonymous with swelling. Inflammatory Chemicals released by dying cells attract the fluid that causes swelling. This is why using cold therapy (ice) to control both inflammation and swelling is such an important part of the healing process � particularly in its earliest stages. However, the best method for moving out this “Congestive Swelling” is via controlled motion if possible. Oh, and your doctor may tell you to use heat during these initial two phases of soft tissue healing; don’t do it. Use ICE to control the inflammation!
STAGE III (Regeneration & Repair Phase): The Repair Phase is where new collagen fibers are made by fibroblasts. The body then uses these collagen fibers as a sort of soft tissue �patch�. Just like with your old blue jeans, a patch is not ideal. But once those old Levis tear or rip, what else are you going to do? In the body, this collagen patch (scar tissue) tends to be different than the tissue around it in a number of ways. Scar Tissue is weaker, less elastic, MUCH MORE PAIN SENSITIVE, has SEVERELY DIMINISHED PROPRIOCEPTIVE ABILITIES, etc). Be aware that the Repair Phase of tissue healing only lasts about 6 weeks, with the majority being completed in half that time. WARNING: This 3rd stage of healing is where many of the so-called �experts� want you to believe the process of Tissue Healing & Repair ends because this phase ends within a month of injury. But that’s not where the story ends. Dr. Dan Murphy uses dozens of studies to, “document that the best management of soft tissue injuries during this phase of healing is early, persistent, controlled mobilization. In contrast, immobilization is harmful, leading to increased risk of slowed healing and chronicity”.
STAGE IV (Maturation / Remodeling Phase): Not only is it the longest, but the Remodeling Phase is by far the most critical of the four stages of Connective Tissue healing. Yet it is the phase that most often gets overlooked. It is also where people most often get duped (sometimes inadvertently, but more often than not, purposefully) by doctors, insurance companies, and attorneys. Many of you reading this know exactly what I am talking about. The most current research shows that in case of serious Connective Tissue Injury, the Remodeling Phase can last up to two years; making the old �6-8 weeks� sound ridiculous (gulp)! The Remodeling Phase is characterized by a �realignment� (REMODELING) of the individual fibers that make up the injured tissue (the collagen �patch� that we call Scar Tissue). What is interesting is that each study that comes out on this topic, seems to be saying that this phase of healing lasts longer than what the study that came out before it said. This is a good thing. However, bear in mind that if you have not improved within 90 days after injury, standard forms of treatment become much less likely to help you. Phase IV can also be risky because although a person’s pain may have dissipated, the injury itself has not completely healed and is vulnerable to re-injury.
As Controlled Loading / Tensile Loading is applied to the healing tissues via CHIROPRACTIC ADJUSTMENTS, Scar Tissue Remodeling, STRETCHING and strengthening exercises, Proprioceptive Re-education, Massage Therapy, TRIGGER POINT THERAPY, PNF, etc; the individual tissue fibers move from a more random, tangled, and twisted wad of unorganized collagen fibrils; to a tissue that is much more organized, parallel, and orderly as far as its microscopic configuration is concerned. Again, this takes time! Although our Scar Tissue Remodeling Therapy can frequently bring immediate relief (just look at our VIDEO TESTIMONIALS), it is obvious from the medical literature that there is a healing processes that cannot be bypassed. Because numerous Scientific Studies have proved Cold Laser Therapy to be effective in regenerating Collagen (SEE HERE), we highly recommend it for our more seriously injured patients as well.
Everyone has heard the old cliche that is still used by doctors, “You�d have been better off to break the bone than to tear the ligaments”. Knowing what we know about the healing of the Collagen-Based, Elastic Connective Tissues; this statement makes a lot of sense! Soft tissues heal much slower than other tissues (including bones). Do not let anyone try and convince you otherwise! This is why following the complete stretching and strengthening protocol that goes hand-in-hand with our �Tissue Remodeling� treatment, is the one and only way that it will work properly over the long haul. By the way, we have dealt extensively with the fact that whiplash injuries heal best with forms of therapy that employ controlled motion such as does chiropractic. Now I want to explore what the scientific literature says about using medications for whiplash injuries explained.
Whiplash Injuries Explained: Relationship Of Inflammation To Pain & Scar Tissue
In 2007, the renowned pain researcher Dr. Sota Omoigui, published an article in the medical journal Medical Hypothesis called, “The Biochemical Origin of Pain: The Origin of All Pain is Inflammation and the Inflammatory Response”. In it, he showed the relationship between pain, inflammation, and fibrosis (Scar Tissue). Most people tend to think of Inflammation as a “local” phenomenon. You know; sprain an ankle, and it swells — sometimes a whole bunch. But it is critical to remember that the terms “swelling” and “inflammation” are in no ways synonymous. When cells of soft tissues are seriously injured (like in Whiplash Injuries), they die. These dead then rupture their contents into the surrounding extra-cellular fluid. In response to this, the Immune System makes a group of chemicals that we collectively refer to as “Inflammation”, which in small amounts, are normal and good. Their local presence is indicated by five well known signs and symptoms. The classical names for the various signs of Local Inflammation come from Latin and include:
Tumor (Swelling) Chemicals we collectively call “Inflammation” are not synonymous with swelling, but they attract swelling.
Functio Laesa (Loss of Function)
Although these chemicals can remain in a local area (I stub my toe, the toe gets red and inflamed), they can invade the blood stream and have a systemic (whole body) effect as well. But inflammation does not end there. These immune system chemicals that we refer to collectively as “inflammation” (prostaglandins, leukotrienes, thromboxanes, cytokines, chemokines, certain enzymes, kinnins, histamines, eicosanoids, substance P, and dozens of others) are being touted by the medical community as the primary cause of a whole host of physical ailments, when there are too many of them in the body. Some of the other problems that Inflammation is known to cause includes;
Disc Injuries, Slipped Disc, Disc Herniation, and Disc Rupture
Heart Disease and virtually all forms of Cardiovascular Problems
Skin conditions including Eczema and Psoriasis
Arthritis & Fibromyalgia
ADD, ADHD, Depression, and various forms of Dementia
Inflammatory Bowel Disease / Leaky Gut Syndrome
Diabetes, Insulin Resistance, Hypoglycemia, and other Blood Sugar Regulation Problems
Inflammation causes pain, ill health, and eventually, death. But this list is not the thrust of this section. To understand is the way that inflammation is related to Scar Tissue, Adhesion, and Fibrosis.
Born in 1904, Dr. James Cyriax, a Cambridge-educated M.D. widely known as the “The Einstein of Physical Medicine” wrote his Magnum Opus, Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions, in 1982 shortly before he passed away. Cyriax is still considered one of the brilliant pioneers of soft tissue research. One of Dr. Cyriax’ groundbreaking discoveries is that Scar Tissue / Fibrosis can and will generate an Inflammatory Response long after the Fourth Stage of Healing (Maturation & Remodeling) is over. Pay attention to what Cyriax wrote over three decades ago.
�Fibrous tissue appears capable of maintaining an inflammation, originally traumatic, as the result of a habit continuing long after the cause has ceased to operate…… It seems that the inflammatory reaction at the injured fibers continues, not merely during the period of healing, but for an indefinite period of time afterwards, maintained by the normal stresses to which such tissues are subject.�
Why would what Cyriax refers to as “normal mechanical stresses” cause an “indefinite period” of inflammation? This one is easy. Scar Tissue and Fibrosis are so dramatically different from normal tissue. One of the most obvious ways that this can be seen is by looking at any good Pathology Textbook. Scar Tissue and Fibrosis is far weaker and much less elastic than normal Connective Tissue. What does this mean? Only that it is easily re-injured. This starts the whole vicious cycle over again. Injury —-> Inflammation —> Pain —> Fibrosis & Scar Tissue Formation —> Re-injury —> Repeat indefinitely. Just remember that the end result of this cycle is degeneration of the affected bones and spinal discs!
HEALTHY CONNECTIVE TISSUE
SCAR TISSUE & FIBROSIS
Notice how the Connective Tissue on the left is uniformly wavy. This is due to the collagen fibrils that provide stretchiness and elasticity. Now notice how the cells of the Scar Tissue and Fibrosis run and swirl in many different ways. This decreases both elasticity and strength of the Scar Tissue.
Scar Tissue & Fibrosis: Different From Normal Tissue, 3 Ways
SCAR TISSUE IS WEAKER
Repaired soft tissues are weaker than the body’s undamaged soft tissues. The diameter of the collagen fibers of scar tissue are smaller than those of normal tissue. Also, as you can see from the pictures above, the structure has been physically changed. This weakness leads to a viscous cycle of instability, re-injury, and degeneration.
SCAR TISSUE IS LESS ELASTIC
Repaired soft tissues are always less elastic and “stiffer” than the body’s undamaged soft tissues. This has to do with the fact that the individual collagen fibers will never identically align themselves quite like the original uninjured soft tissue. This is all easy to see because range of motion testing on injured individuals will always show areas of decreased ranges of motion.
SCAR TISSUE IS MORE PAIN-SENSITIVE
Repaired soft tissues have a strong tendency to be more pain-sensitive than their uninjured counterparts. In fact, for reasons that are not completely understood, Scar Tissue has the neurological capability of going into something called “super-sensitivity”, and can end up 1,000 times more sensitive to pain than normal tissue.
Dr. Soto Omoigui had this to say about the relationship between pain, inflammation, and fibrosis, “The origin of all pain is inflammation and the inflammatory response…. Irrespective of the type of pain, whether it is acute or chronic pain, peripheral or central pain, nociceptive or neuropathic pain, sharp, dull, aching, burning, stabbing, numbing or tingling, the underlying origin is inflammation and the inflammatory response.” Fellow pain researcher Doctor Manjo stated in the “Chronic Inflammation” chapter of his 2004 pathology textbook that (slightly paraphrased for patients), “After a day or two of acute inflammation, the connective tissue�in which the inflammatory reaction is unfolding�begins to react, producing more fibroblasts, more capillaries, more cells�more tissue, but it cannot be mistaken for normal connective tissue. Fibrosis means an excess of fibrous connective tissue. It implies an excess of collagen fibers. When fibrosis develops in the course of inflammation it may contribute to the healing process. By contrast, an excessive or inappropriate stimulus can produce severe fibrosis and impair function. Why does fibrosis develop? In most cases the beginning clearly involves chronic inflammation. Fibrosis is largely secondary to inflammation.”
It is not difficult to connect the dots! Chronic Inflammation of a whiplash injury leads to Scar Tissue Formation, and Scar Tissue Formation leads to even more pain. And like I mentioned earlier, the whole mess leads to Spinal Degeneration. How can you break free? Dr. Cyriax goes on to say in his book that immobilization of injured soft tissues is a bad thing, and mobilization of injured soft tissues is not only good, but necessary for proper healing to take place. But under the umbrella of America’s PHARMACEUTICAL DRUG CULTURE, functional restoration frequently takes a back seat to different kinds of medicines. Don’t get me wrong; if you need something for the pain after a whiplash injury, there is no dishonor in doing something on a short-term basis. However, this is never the solution. It is masking symptoms to get you through a rough place. As long as you understand this, OK. However, there is one class of drugs that should play no part in the healing of your Whiplash Injury…
Inflammation Medications For Whiplash & Soft Tissue Injuries
The most prestigious medical school on the planet, John’s Hopkins proved that 1,000 200 mg capsules of Tylenol consumed over the course of a person’s lifetime doubles that person’s chances of dialysis. Furthermore, 5,000 pills increase kidney failure by nearly nine times. New England Journal of Medicine, 1994
Regular use of Tylenol and other similar medications is a top cause of liver disease / liver failure. New England Journal of Medicine, 1997
NSAID’s (Non-Steroidal Anti-Inflammatory Drugs) used by arthritis sufferers causes 16,500 Americans to die of bleeding ulcers each year. Fatal GI bleeds are the 15th most common cause of death in America. New England Journal of Medicine, 1999
Gastrointestinal (GI) toxicity caused by NSAID use is one of the most commonly seen and serious drug side effects in modern cultures. Spine, 2003 & Surgical Neurology, 2006
Regular use of Tylenol doubles one’s chances of developing high blood pressure. Hypertension, 2005
All NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) increase chances of Myocardial Infarction (heart attack) by about 40%. This risk starts the first day the drug is consumed. European Heart Journal, 2006
Celebrex increases your chances of intestinal bleeding by four times (nearly 400%). Vioxx increases your chances of bleeding ulcers and other GI Bleeds by over three times (nearly 330%). Medications taken for pain increase your chances of GI Bleeds by nearly 140%. Drug Safety, 2009
Vioxx was removed from the market in 2004 because it increased one’s chances of a heart attack by 230% (exponentially more if you already had a congestive heart). Celebrex increased the risk of heart attack by 44%. Pain Medications, on average, increase your chances of a heart attack by nearly half 50%. While Vioxx was pulled from the market, the others are considered to be “acceptably safe” and they were allowed to stay on the market. Drug Safety, 2009
Those who took the greatest amounts of NSAID pain medications increased their chances of all types of dementia —– Alzheimer�s included. The increase was a whopping 2/3 (66%). Neurology, 2009
So, what is a person supposed to do? Despite decades of research saying that NSAID’s are not “therapeutic” (actually helps you get better), but are instead, “palliative” (makes you feel better without any therapeutic benefits), the medical community continues to hand these and other dangerous drugs out almost like candy. Just remember that any pain relief achieved without addressing the underlying components of the Whiplash Injury, are temporary. And that’s not all. When joints and tissues heal in RESTRICTED FASHION, they always end up with copious amounts of decay, degeneration, and deterioration. And the final kick in the teeth for those of you who have been on this MEDICAL MERRY-GO-ROUND is that much of this research is at least two decades old. As I have said for a very long time, much of the medical community is caught in a time warp. They are treating whiplash injuries using outdated models, often times very outdated models.
Chiropractic Benefits: Whiplash, Neck/Back Pain
Over 70 years ago, the best available research said that soft tissue injuries require early and regular joint motion in order to heal properly. American Journal of Anatomy, 1940
Over 50 years ago, research pointed out that the most effective treatment for whiplash injury does not involve medication, but instead needs mobilization, manipulation and traction to heal. The best results for patients with whiplash injuries require early and regular joint mobilization. Furthermore, it must be done by someone expertly trained in rehabilitation of injured joints. Journal of the American Medical Association, 1958
For injured soft tissues to heal properly requires joint movement / motion. Joint immobilization should be avoided. Textbook of Orthopedic Medicine, 1982 & Continuous Passive Motion, 1993
Chiropractic spinal adjustments fix over 4/5 of disabled patients suffering from chronic low back and sciatica. This is true despite the failure of other approaches. Canadian Family Physician, 1985
Chiropractic spinal adjustments have been proven superior in the treatment of chronic and acute low back pain, when compared to hospital outpatient treatment. These benefits of chiropractic adjustments were still seen 3 years post-treatment. British Medical Journal, 1991
Chiropractic spinal adjustments have been shown to be more effective than physical therapy mobilizations and manipulations. Lancet, 1991
93% of those struggling with chronic pain due to whiplash injury —- who have already failed medical care and physical therapy —- improve significantly under chiropractic care. Injury, 1996
When it comes to chronic neck pain, manual manipulation of the neck has been shown to be significantly better than pain meds and exercise. Annals of Internal Medicine, 2002
Chiropractic spinal adjustments have been clinically proven to be over five times more effective than NSAID’s (Non-steroidal Anti-Inflammatory Drugs) for chronic neck and low back pain. In this study, the chiropractic group suffered from no adverse reactions, but the the NSAID group had more patients reporting adverse drug reactions than were actually helped. Half the NSAIDS used in the study are now off the market. Spine, 2003
For chronic neck and back pain, chiropractic spinal adjustments proved significantly better than both acupuncture and pain medicines. Furthermore, chiropractic adjustments were the only treatment studied that showed therapeutic benefit one year post-treatment. Journal of Manipulative and Physiological Therapeutics, 2005
In patients with chronic pain from DEGENERATIVE ARTHRITIS, 59% can eliminate their pain meds by taking omega-3 fatty acids found in fish oil (EPA & DHA). Surgical Neurology, 2006
In the recent medical publication called, �A Review of the Evidence for the American Pain Society and the American College of Physicians Clinical Practice Guideline�, only spinal manipulation was touted as effective for the treatment of both acute and chronic low back pain. Annals of Internal Medicine, 2007
A joint research effort from the University of California, San Francisco, and Harvard Medical School, showed that �Chiropractic care is more effective than other modalities for treating low back and neck pain�. Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending, 2009
Long Term Prognosis: Whiplash
Despite the fact that you can see from the current scientific literature how successful chiropractic care is at helping people with severe, debilitating, whiplash injuries; not everyone injured in an MVA will recover. Unfortunately, many will never recover —- even after several decades. It seems that whiplash caused by Motor Vehicle Accidents is the portal whereby numerous people enter into the realm of Chronic Pain and dysfunction. The truth is that there is a great deal of scientific research done of this particular topic. And furthermore, as you can see from the small comments in red made by the authors of each individual study, litigation seems to have little or no effect on clinical outcomes.
The Journal of Bone and Joint Surgery published research in 1964 showing that of 145 patients involved in a study of whiplash injuries; as many as 83% of the injured patients continued to suffer from pain two years after the accident. The study’s authors said this, “If the symptoms resulting from an extension-acceleration injury of the neck are purely the result of litigation neurosis, it is difficult to explain why [at least] 45%of the patients should still have symptoms two years or more after settlement of their court action.”
A 1989 issue of Neuro-Orthopedics published a study was carried out on patients suffering with whiplash for well over a decade. Despite the length of time involved, nearly two thirds still struggled with moderate to severe pain symptoms due to their accident. The study’s authors said this, “If symptoms were largely due to impending litigation it might be expected that symptoms would improve after settlement of the claim. Our results would seem to discount this theory, with the long-term outcome seeming to be determined before the settlement of compensation.”
A 7-year study on whiplash-injured patients published in a 2000 issue of the Journal of Clinical Epidemiology showed that 40% of those suffering an accident-induced whiplash injury continued to suffer from neck and shoulder pain seven years post-accident.
A 2005 research project published in the medical journal Injury, showed that over 20% of those injured in a whiplash injury struggled with Chronic Pain nearly 8 years post-injury. Furthermore, almost half of those in the study suffered from “Nuisance Pain” during the same time frame.
An 11 year study published in a 1990 issue of the British Journal of Bone and Joint Surgery showed 40% of the whiplash patients struggling with Chronic Pain over a decade after the fact. 40% of the remainder of the study’s people dealt with “Nuisance Pain” during the same period. The study’s authors said this, “The fact that symptoms do not resolve even after a mean 10 years supports the conclusion that litigation does not prolong symptoms.”
A fifteen and a half year study published in a 1996 issue of the British Journal of Bone and Joint Surgery reported that well over 40% of whiplash-injured patients struggled with Chronic Pain from the accident over a decade and a half after the fact. Almost 30% of the rest dealt with “Nuisance Pain” over the course of the study. The study’s authors said this, “Symptoms did not improve after settlement of litigation, which is consistent with previous published studies”.
The European Spine Journal published a nearly two decade long study on whiplash-injured patients in 2002. Well over half (55%) of those studied had pain seventeen years post-accident. One quarter of these dealt with daily neck pain, and almost one quarter had radiating arm pain on a daily basis. The study’s authors said this, “It is not likely that the patients exposed to motor vehicle accidents would over-report or simulate their neck complaint at follow-up 17 years after the accident, as all compensation claims will have been settled.”
In one of the longest studies done to date on whiplash injured patients, a 2006 issue of the British Journal of Bone and Joint Surgery looked at whiplash-injured patients three decades after their initial injury. 15% of these patients struggled with daily pain severe enough to require treatment. Four out of ten of the remainder dealt with “Nuisance Pain” over the same time frame.
Attorney’s, Insurance, Fees & Medical Pay
After 20 years of practice, I can almost say that I have seen it all. Almost. One thing that I have not seen is an improvement in the way that the financial responsibility for Motor Vehicle Accidents (MVA) is handled by insurance companies. This is a big part of the reason that I do not accept automobile insurance (yours or the other party�s) for the treatment of injuries sustained in MVA�s. Attorneys tend to get involved, and I have found that in most cases, attorneys don’t really work for you, they work for themselves.
WHERE DOES THIS ALL LEAD?
Although, I do not treat huge numbers of MVA cases acutely (they tend to go wherever their attorney sends them usually whoever can run up the highest bills), I treat scores of MVA victims once they have reached the chronic stage. After their attorney reaches a settlement for their injured client, any treatment they were receiving typically ends. As you can tell from both our Patient Testimonial Page, as well as our Blog Post called the WEEKLY TREATMENT DIARY, the treatment frequently ends without ever effectively dealing with the underlying scar tissue and Fibrotic Adhesions that leave so many people in Chronic Pain, long after they have settled their injury claim.
These folks enter the miserable world of CHRONIC NECK / BACK PAIN and HEADACHES, and then wonder what the heck they are going to do because their $3,000 settlement check is long gone. The patient is then left with a choice. They can climb back on the Medical Merry-Go-Round and continue to spin in circles. Tests, blood work, MRI�s, CT scans, drugs, drugs, and more drugs; and therapy � more of the same (expensive) stuff you went through before you settled your case, with more of the same crappy results. Or they can do something different.
Prevent Whiplash Injuries & Lessen The Effects
There are several ways to go about preventing or at the very least, lessening the potential effects of a whiplash-like accident / injury. one of the most effective would be driving a vehicle that is highly rated in crash tests. What is the safest vehicle on the road today? Without a doubt, the Volvo and Saab brands have out-performed every other auto maker in the market today as far as safety is concerned. However, there are a number of things you can do to protect yourself besides trading your Chevy in for a Volvo.
DRIVE A SAFE VEHICLE: Make sure that the vehicle you drive is highly rated by the organizations that rank automobile safety. This information can be found HERE.
DRIVE SAFELY AND DEFENSIVELY: This is common sense. Because I rode a motorcycle for many years, I learned how to drive defensively. I always thought that by paying attention and trying to think one step ahead of everything going on around me, crashes with other vehicles could be avoided. That was until I hit a drunk who ran a stop sign (I was in a full-sized Chevy Silverado). Things happen quickly, that you have no control over. However, driving your automobile in an unsafe manner definitely puts you at a higher risk for suffering a Whiplash Injury.
WEAR YOUR SEAT BELTS: The simple truth of the matter is that seat belts will probably not lessen the “Whiplash” component of an Automobile Accident. In fact, by holding your body in place while your head flies around, they can potentially worsen a neck injury to the soft tissues. However, seat belts will help to keep you alive.
MAKE SURE YOUR HEAD RESTRAINT IS ADJUSTED PROPERLY: This is by far the most important thing you can do diminish your chances of Whiplash Injury should you end up in an MVA. The truth is, most of us refer to these things that stick out of the top of our seats as “Head Rests” instead of “Head Restraints”, and actually have them adjusted improperly (all the way down). The purpose of these devices is not to “rest” your head because you are tired, it is to “restrain” your head from flying backwards during a rear-ender accident. The top of the Head Restraint should be level with the top of your head, and the gap between the two should not be more than about two inches. For the record; if you recline your seat more than 20 degrees, all bets are off. A serious rear-ender will cause you to ramp up in your seat rendering the Head Restraint useless.
Chiropractic Care: Our neck is a busy body part. It holds up and turns our head, allowing us to see, hear, and speak in the direction we choose.
Although the neck is a real “team player” it’s a bit of a diva, meaning it’s fairly delicate. There are many ways everyday motion injures the neck, ending up causing pain, decreased mobility, and varying degrees of short and long-term misery.
Whiplash is a common neck injury caused by a sudden movement that jerks the neck forth and then back in a whipping motion. Automobile accidents frequently result in whiplash, as the vehicle is moving and then stopping rapidly.
This affects the neck’s ligaments and joints in various degrees, depending on the speed of the vehicle and the site of the impact. In severe cases, the discs and the nerves may also be damaged.
Symptoms of whiplash include varying degrees of pain, stiffness in the neck, headaches, and sometimes dizziness, blurred vision, and nausea. Some people only suffer with whiplash a few days, while others experience ongoing issues.
If you have been injured in an automobile crash, it’s in your best interest to immediately schedule an appointment with a chiropractor. There are a myriad of ways chiropractic care assists in managing the pain and minimizing the symptoms of whiplash.
Here Are The 5 Best Reasons For Chiropractic Care:
#1: Reduces Inflammation To Promote Healing
The first order of business for whiplash sufferers is to get the neck’s inflammation reduced, as this hinders proper healing. Your chiropractor will utilize chiropractic adjustments, along with other forms of treatment based on your specific injury. It�s essential to undergo this type of treatment as soon after the injury occurs as possible in order to reach optimum results.
#2: Minimizes Pain For Greater Comfort
Whiplash can be extremely painful, as so many of the neck’s components may be involved, and the neck is such a mobile body part. Every neck movement hurting is no way to live! Chiropractic care soothes the pain of whiplash through therapeutic techniques that promote healing of the damaged area.
#3: Returns Proper Body Alignment
When the inflammation and the pain of whiplash are reduced, the next step is to promote healing and alignment within the body. A chiropractor will perform a series of chiropractic adjustments that includes the neck and spine, but may also incorporate other parts of the body. Whiplash does a number on the body’s natural alignment, and it’s the chiropractor’s job to put it all back together in workable order.
#4: Offers Exercises To Increase Mobility
Contrary to old movies where the whiplash sufferer wears a cumbersome neck brace, it’s vital to the rehabilitation process to keep moving. During chiropractic visits, patients receive a regimen of exercises to perform regularly at home. These, combined with chiropractic care, lessen the time it takes to recover.
#5: Provides An Alternative To Surgery
The good news is that a whiplash injury rarely requires surgery. However, it’s best to not tempt fate and visit a chiropractor to make certain your injuries are treated and begin healing. A chiropractor monitors improvements and keeps you apprised of your progress, empowering you to get better and back to normal activity faster than simply suffering through the symptoms, hoping they go away.
If you are involved in a motor vehicle crash and end up with whiplash, don’t despair. A chiropractor will map out a treatment regimen that will decrease inflammation and pain, increase mobility, and promote healing. Remember, the sooner you see your chiropractor, the faster the treatment begins, and the sooner you see results. Don’t suffer needlessly!
Chiropractic Care & Headaches
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Question: My car was rear-ended. Since then, my neck hurts, feels rigid, and I have upper back pain. My wife says it’s whiplash and that I should see a physician. Is there anything that I can do to accelerate my recovery? Should I see my physician and/or chiropractor? How long will my pain last?
El Paso, TX
Answer: Your symptoms are typical of a whiplash injury caused by a vehicle accident. Whiplash is cervical spine strain caused when the head and neck are thrust quickly forward and backward. To fully grasp how whiplash can lead to neck pain, you want to recognize the head, which weighs 8-13 pounds and is supported and moved by the neck. Because of this, it’s easy to understand how soft neck muscles and ligaments are stretched during a whiplash accident!
The seriousness of whiplash is dependent on the force of the impact, the way you were seated in your vehicle, and if you were properly restrained with a shoulder and seat belt. By way of instance, if your head was turned, your neck injury may be more painful.
Whiplash Home Treatment Tips
1. Even though your neck injury occurred last week, you may try ice and heat. Ice will help to reduce swollen overstretched muscles and ligaments. Heat increases circulation and eases tight stiff muscles.
Ice: Apply an ice pack for 15 minutes as often as once each hour.
Heat: Apply warmth (moist is greatest!) For 15 minutes every 2 or 3 hours.
Never sleep with a ice or heat pack!
Wrap heat or ice in a towel to protect your skin.
Discard punctured store-bought ice or heat products.
2. If your doctor agrees, try an over-the-counter anti-inflammatory medication.
3. Move your neck softly to assist in preventing additional stiffness.
4. Should you work in a computer or desk, take regular breaks to relax your neck muscles.
5. Avoid cradling the phone between your shoulder and head.
6. Avoid carrying heavy packages, especially things such as a pocket book or backpack slung over only one shoulder.
Check With Your Doctor & Chiropractor
Neck pain is common either immediately after or several days following a whiplash injury. Other symptoms can develop too. Fortunately, most symptoms go away in two to four weeks. If your symptoms worsen, or you develop headache, dizziness, blurred vision, difficulty swallowing, arm or hand numbness, check-in with your physician or chiropractor. If necessary, you’ll be referred to a spine specialist.
Your physician or chiropractor will carry out a physical and neurological examination, and acquire a neck X-ray. After they produce a diagnosis, treatment is coordinated for your recovery! Treatment may include prescription pain medication, anti inflammatory drugs, muscle relaxants, a cervical collar, massage and physical therapy.
Other�Symptoms Associated With Whiplash Or Neck Strain:
Ringing in your ears
Difficulty chewing or swallowing
Upper back, shoulder, and/ or arm pain
Abnormal sensations such as numbness, burning or prickling
Fatigue and sleep problems
Keep in Mind
Most individuals with whiplash improve quickly within a matter of weeks. When you have concerns, we recommend you to speak to a doctor or chiropractor.
Various injuries can be caused by automobile crashes. One of the most frequent car accidents is the collision in which a vehicle is hit from behind. If you have been in these events you may be receiving neck pain therapy for a accident called whiplash that occurs when an occupant of this vehicle is thrust forth and back.
This injury may cause a herniated disc in the cervical (neck) area, in addition to a variety of other symptoms. A whiplash injury can include neurological impairment in mobility, joint aches, problems with concentration and chronic pain. Besides damaging the delicate tissues (muscles, tendons, and ligaments) that maintain the neck, it may also harm the cervical spine (the neck region of the backbone), inducing a herniated disc in the neck. The herniation can compress the nearby nerves, causing pain. Symptoms of a herniated disc in the neck may include tingling, numbness, and muscle weakness.
Pain from Previously Existing Conditions
In a study published in the journal Spine, doctors found that disabling pain in the back following whiplash may be due to a previously disc in the spine. These conditions may present no symptoms that are apparent before the accident. The researchers further concluded that pain was successfully treated following microdiscectomies for these discs.
Symptoms from whiplash injuries cannot be necessarily resolved with neck pain treatment, and can be tricky to diagnose since the pain lower back and even in the shoulder region can radiate to other regions of the body. It can be especially challenging for the physician when symptoms are vague and non-localized.
When the natural reactions of the body don’t operate properly, injuries occur. In the normal state, a C-shape is maintained by the cervical spine. On an S-shape as the portion extends and the upper portion of this area flexes, the individual’s cervical spine takes upon impact from behind. This phenomenon risks herniating a disc or tearing a ligament. If the human body’s protective response is working correctly, it will recognize the impact and signal the cervical muscles and make a supportive scaffold for the cervical spine and ligaments.
Although pain can heal on its own it may often require therapy. A treatment program for a herniated disc in the neck may consist of anti-inflammatory pain medication, rest, and physical therapy. With these conservative treatments, the symptoms generally improve over time. But if imaging tests find out that the damaged disc is compressing nearby nerves and/or the spinal cord, or if symptoms persist despite the treatment, neck surgery may be considered.
There are a few things you can do in order to stop whiplash injuries requiring neck pain treatment and increased risk for pain . These include maintaining fitness and good posture. You can start focusing on those goals.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Automobile Accident Injuries
Whiplash, among other automobile accident injuries, are frequently reported by victims of an auto collision, regardless of the severity and grade of the accident. The sheer force of an impact can cause damage or injury to the cervical spine, as well as to the rest of the spine. Whiplash is generally the result of an abrupt, back-and-forth jolt of the head and neck in any direction. Fortunately, a variety of treatments are available to treat automobile accident injuries.
If given the opportunity, a herniated disc can occur as a consequence of trauma and can create a plethora of problematic symptoms which might become chronic pain conditions. Whiplash is most frequently associated with car collisions, but can actually happen from any injurious procedure that snaps the neck forward or back beyond its normal selection of movement.
This informative article will detail the prevalence of herniated discs related to whiplash events. We’ll investigate how whiplash occurs and how the process can enact disc injury in the cervical or upper thoracic spinal regions.
Whiplash Herniated Disc Incidents
Whiplash happens because of abrupt acceleration, or more commonly, sudden deceleration. Inertia is the force which can create harm to the spinal structures and the throat muscles at the neck and back.
The head is a really heavy weight that is supported by the slightly thinner and weaker vertebrae and intervertebral discs in the cervical spine. When inertia is applied to the entire body, the head will snap backwards or forward, causing both and typically hyperflexion or hyperextension. As it whips about causing an assortment of injurious events that are possible, including a herniated disc, this heavy weight places stress on the cervical spine.
Herniated Disc Pain and Discomfort
Whiplash typically occurs from severe trauma, such as an automobile accident, slip and fall, sports injury or act of violence. Any situation which causes the head to jolt abruptly back-and-forth, can cause whiplash.
Whiplash is a condition which sometimes occurs after an accident, but could also take some time to become apparent. The reasons for this time delay response vary, but are commonly linked to three possible causations:
First, it’s the pain relieving quality of adrenaline, which often fills the bodily systems during a crash. This can diminish the severity symptoms which might otherwise be debilitating when they occur. Second, is the psychological nocebo effect of the trauma, which could take some time to infiltrate and to come up within the subconscious mind. Finally, the secondary gain principle enacted by legal action having to do with the accident might causes time delay. It’s no coincidence that people begin to experience pain right around the time they seek professional help.
Whiplash & Herniated Disc Consequences
The vast majority of whiplash complaints are due to muscular injury, not damage to the spinal column. Neck muscle pain can be extremely severe, but is not a significant worry and should resolve with symptomatic treatment.
Extreme trauma or highly focused trauma can cause a bulging disc or even a ruptured disc in the neck or upper back. Symptoms are very likely to be painful for a number of weeks, but should resolve within 2 months, as is typical for practically any disc injury condition with the proper treatment and care.
Other less common effects of severe whiplash might incorporate a change in the natural curvature of the spine, a fractured or shattered vertebra or a torn ligament or tendon.
Whiplash Herniated Disc Guidance
A lot of men and women suffer whiplash traumas on a daily basis. These types of injuries are an inherent part of the fear we have towards spinal damage and are an integral component of litigation. Both of these factors make judging the actual degree of any whiplash neck injury complicated.
Pain is often worsened or perpetuated through psychosomatic or secondary gain factors, instead of structural anatomical problems. It is crucial, as a patient, to look past the psychological and legal implications of your injury and concentrate on your recovery.
The neck, like every other area of the human body, was made to heal, but will only do so in the event that you give it the mental and emotional support and trust it requires.
There isn’t anything more important than your health. Unfortunately, this is a lesson for those who endure a plethora of herniated disc treatments and eventual disc surgery simply to bolster a case that is legal. When the case is over, you might have some money, but is it really worth it to lose your freedom and functionality for the remainder of your life?
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Automobile Accident Injuries
Whiplash, among other automobile accident injuries, are frequently reported by victims of an auto collision, regardless of the severity and grade of the accident. The sheer force of an impact can cause damage or injury to the cervical spine, as well as to the rest of the spine. Whiplash is generally the result of an abrupt, back-and-forth jolt of the head and neck in any direction. Fortunately, a variety of treatments are available to treat automobile accident injuries.
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