The impact of rehabilitation on chronic whiplash

Clinical Chiropractic (2003) 6, 129—136
CASE REPORT
<strong>The</strong> <strong>impact</strong> <strong>of</strong> <strong>rehabilitation</strong> on chronic whiplash
Julie-Maria Gosnold
Broomhill Chiropractic Clinic, 172 Whitham Road, Broomhill, Sheffield S10 2SR, UK
Received 25 June 2003; accepted 12 September 2003
KEYWORDS
Chiropractic;
Cervical spine injury;
Human adult female;
Spinal <strong>rehabilitation</strong>;
Whiplash
Introduction
<strong>The</strong> vast majority <strong>of</strong> research performed on the
effectiveness <strong>of</strong> Spinal Manipulative <strong>The</strong>rapy
(SMT) has been for low-back pain. 1 This is despite
the fact that the most frequent site <strong>of</strong> injury in the
spinal column is the cervical region. 2 In 1996 3 and
2000 4 , extensive reviews <strong>of</strong> the literature on the
efficacy <strong>of</strong> manipulation and/or mobilisation <strong>of</strong> the
cervical spine were produced, highlighting the
increasing trend to research in this area. Neck pain
constitutes one <strong>of</strong> the most prevalent and costly
health problems facing the workplace and healthcare
community. 5 Within the chiropractic pr<strong>of</strong>ession,
neck pain is the second leading chief complaint
reported by patients seeking care, with approximately
one third <strong>of</strong> the population being affected
each year. 6
E-mail address: juliemarie@btopenworld.com
(J.-M. Gosnold).
Abstract One <strong>of</strong> the most prevalent causes <strong>of</strong> neck pain is related to automobile
accidents in the form <strong>of</strong> ‘‘Whiplash’’, or acceleration/deceleration injuries. <strong>The</strong>
debate on causes <strong>of</strong> chronicity <strong>of</strong> symptoms, pain mediation, the most effective
treatment regime and the socio-economic <strong>impact</strong> <strong>of</strong> the problem has produced a
marked increase in the number <strong>of</strong> research studies and funding available for such in
recent years. Whilst the majority <strong>of</strong> chiropractors include basic ergonomic advice in
their treatment <strong>of</strong> cervical dysfunction, Spinal Manipulative <strong>The</strong>rapy (SMT) alone is still
the treatment <strong>of</strong> choice. This is despite the lack <strong>of</strong> conclusive statistical evidence to
support this approach. Recent interest and preliminary research in the effectiveness <strong>of</strong>
a combined approach, incorporating <strong>rehabilitation</strong> <strong>of</strong> the cervical spine via sensorimotor
and cervical stabilisation techniques, has created much interest. <strong>The</strong> following
case demonstrates how the initial SMT approach failed to gain a satisfactory improvement
in the clinical symptoms. Emphasis is placed on the ability to perform rehab at
home without the need for specific <strong>rehabilitation</strong> equipment, which is still not widely
available in many chiropractic clinics. <strong>The</strong> Biopsychosocial model and the effect that
an active patient approach has on this <strong>of</strong>ten-chronic problem is discussed.
ß 2003 <strong>The</strong> College <strong>of</strong> Chiropractors. Published by Elsevier Ltd. All rights reserved.
One <strong>of</strong> the most prevalent causes <strong>of</strong> neck pain is
related to automobile accidents in the form <strong>of</strong> ‘‘Whiplash’’,
or acceleration/deceleration injuries. <strong>The</strong>
National Safety Council (Chicago) 7 reported in 1996
that there are approximately 2.3 million disabling
injuries from motor vehicle crashes per annum. Of
these, about 730,000 non-fatal injuries occur in rearend
collisions, 640,000 in side <strong>impact</strong>, and 60,000 in
frontal collisions. Rear end collisions therefore produce
the largest number <strong>of</strong> non-fatal injuries.
<strong>The</strong> reported incidence <strong>of</strong> whiplash from such
accidents varies dramatically depending on the
research study involved. In 1994, Barnsley et al. 8
estimated the overall incidence to be about 1 per
1000 in western societies, with a mean age in the
thirties and no gender preponderance. Variations in
figures depend on each studies criteria <strong>of</strong> inclusion,
i.e. definition <strong>of</strong> whiplash, insurance involvement,
reporting <strong>of</strong> injury, etc.
Similarly, the risk and prognostic factors associated
with whiplash injuries is equally varied.
1479-2354/$30.00 ß 2003 <strong>The</strong> College <strong>of</strong> Chiropractors. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clch.2003.09.006

130 J.-M. Gosnold
Table 1 Risk and prognostic factors for whiplash injury. 9
Risk/prognostic Type <strong>of</strong> factor Factor
Risk factor Demographic Female
Age
Physical History <strong>of</strong> neck pain
Collision with heavier vehicle
Rear-end <strong>impact</strong>
Seatbelt use
Prognostic factor Demographic Female
Increasing age
Married/cohabiting
Greater number <strong>of</strong> dependents
Family history <strong>of</strong> neck pain
Physical Fatality/severe injury involved
Stationary vehicle
Lack <strong>of</strong> seatbelt use
Unpreparedness at <strong>impact</strong>
Rotated or inclined head position
Multiple injuries involved
Initial head/neck pain intensity
Cervical spine degeneration
Psychosocial Expectation <strong>of</strong> disability
Table 1 shows those factors known to influence risk
and prognosis according to Hurwitz. 9
To fully understand the mechanism <strong>of</strong> injury,
knowledge <strong>of</strong> how both vehicles and occupants
behave in a crash is necessary, 10 the main determining
factor being related to the type <strong>of</strong> <strong>impact</strong>
involved (i.e. frontal, side, or rear-end collisions).
Numerous research studies in recent years have
provided valuable information on both the mechanism
<strong>of</strong> injury and the factors leading to the likelihood
<strong>of</strong> chronic symptoms and risk <strong>of</strong> long-term
disability.
<strong>The</strong> following case demonstrates how SMT alone
may not provide the full functional and symptomatic
recovery achievable by an individual with a
chronic neck problem, especially when post-traumatic
in nature.
Case presentation
Mrs. G, a slim, fit, 31-year-old part-time music
teacher and mother <strong>of</strong> two young children, presented
with pain between the shoulder blades
and lower neck <strong>of</strong> 6 months duration, following a
road traffic accident. She explained that she had
been driving a Ford Mondeo at approximately
50 mph when a vehicle <strong>of</strong> similar size pulled out
in front <strong>of</strong> her at a crossroads. Despite braking, she
hit the side <strong>of</strong> this car, resulting in her vehicle being
written <strong>of</strong>f. At <strong>impact</strong>, she felt a severe jarring
sensation to her upper back and neck as she was
restrained by her seatbelt. <strong>The</strong>re was no loss <strong>of</strong>
consciousness. Although a headrest was present,
Mrs. G was unable to recall if her head made contact
with it and explained that, as she and her husband
shared the car, she had never bothered to position
the headrest to provide specific support. Initial
onset <strong>of</strong> pain was felt in the anterior chest and right
shoulder, with an increasing awareness <strong>of</strong> upper
back and posterior neck pain developing within half
an hour. Hospital examination, including X-ray
examination <strong>of</strong> her cervical spine, was unremarkable
and she was discharged without treatment.
<strong>The</strong> pain was described as a ‘‘constant deep
ache’’, coupled with some ‘‘burning’’ pain felt
between the shoulder blades towards the end <strong>of</strong>
the day. On a visual analogue pain scale, the intensity
ranged from 3/10 (tending to be in the mornings),
to 8/10 at worst (tending to be in the late
afternoon/evenings). Further questioning revealed
that her symptoms were exacerbated by most
housework and when performing her duties as a
music teacher, especially when seated at a desk.
Temporary relief had been provided by sleep,
Transcutaneous Electric Nerve Stimulation (TENS)
and by osteopathic manipulation and s<strong>of</strong>t tissue
work. <strong>The</strong>re was no prior history <strong>of</strong> previous neck
or upper back problems.
On examination, postural evaluation revealed
marked anterior head carriage and a prominent
kyphotic curve at the cervico-thoracic junction.
<strong>The</strong> regional examination revealed marked restrictions
in cervical rotation to the left, coupled with

<strong>The</strong> <strong>impact</strong> <strong>of</strong> <strong>rehabilitation</strong> on chronic whiplash 131
discomfort on both active and passive ranges <strong>of</strong>
motion. Left lateral flexion was likewise affected.
Orthopaedic assessment reproduced discomfort on
the left side <strong>of</strong> the cervico-thoracic junction with
maximal foraminal compression testing. Vertebrobasilar
insufficiency tests detected no abnormalities.
Segmental restrictions into the end range <strong>of</strong>
motion were detected from the fourth cervical
vertebra to the second thoracic vertebra (C4—T2)
on the left, producing marked discomfort. <strong>The</strong>
thoracic spine showed marked restriction in all
segmental ranges <strong>of</strong> motion from T4 to T7 and at
T12 on the left. Some mild dysfunction at ribs 4 and
5 was present on the left. Examination <strong>of</strong> the
temporomandibular joint revealed left sided dysfunction
with clicking, deviation and protrusion
noted. A comprehensive medical and neurological
examination elicited no further findings <strong>of</strong> note.
Multiple my<strong>of</strong>ascial trigger points were detected
bilaterally over the trapezius, scalenes, sternocleidomastoid
(SCM), suboccipital and pectoralis major
and minor muscles. Teres major trigger points were
present on the left, with all the lower shoulder
stabilisers being notably less toned bilaterally.
<strong>The</strong> history and examination findings led to the
diagnosis <strong>of</strong> chronic, moderate, whiplash with associated
postural and muscular imbalances. Prognosis
was regarded as only moderate due to the already
chronic nature <strong>of</strong> the complaint and failure to
improve with the four osteopathy treatments
received 3 months earlier.
<strong>The</strong> accident was currently in the hands <strong>of</strong> her
solicitors and a legal case was pending. Copies <strong>of</strong>
the orthopaedic evaluation, which had taken place
2 months after the accident, were obtained. <strong>The</strong>
consultant involved reported that ‘‘this lady has
sustained a more moderate musculo-ligamentous
neck strain injury extending into the intrascapular
area <strong>of</strong> the upper back .... It is probable there has
been no underlying intervertebral disc disruption
and it must remain more probable that her ongoing
symptoms will continue to gradually diminish over
the ensuing months and that beyond some 12
months from injury not give rise to longer term
disability’’.
<strong>The</strong> X-ray results were also obtained. <strong>The</strong>se stated
that there were no bony abnormalities present.
A request for copies was declined unless the patient
was prepared to pay for them. As the accident had
occurred in Ireland, it was not possible view the films
in situ, so the decision was made only to send for the
film copies if deemed necessary at a later date.
Mrs. G was given SMT to the involved segments
using diversified techniques combined with s<strong>of</strong>t
tissue massage, trigger point work and post-isometric
relaxation (PIR) techniques. <strong>The</strong> massetter
and lateral pterygoid muscles were treated, with
strengthening exercises prescribed for the digastric
muscle to control protrusion. Treatment frequency
started at twice a week for the first 3 weeks. Despite
finding a marked improvement in her range <strong>of</strong>
motion and pain levels within five treatments, these
results only lasted, at best, for 4 days. Mrs. G never
returned to full function and still felt some discomfort
at the end <strong>of</strong> every day.
<strong>The</strong>se results appeared to be consistent with her
previous osteopathic treatment. Patient re-assessment
highlighted weak deep neck flexor ratio, poor
head repositioning and balance control as a probable
reason for the lack <strong>of</strong> sustained recovery and
the concept <strong>of</strong> re-educating the muscles via <strong>rehabilitation</strong>
was discussed with Mrs. G.
<strong>The</strong> <strong>rehabilitation</strong> programme involved sensorimotor
and cervical stabilisation training. An intensive
home-stretching programme was instigated
immediately, incorporating the Brugger-relief position,
with good patient compliance evident. Initial
stretches were prescribed for the trapezius, rhomboids,
suboccipital and scalene muscles. <strong>The</strong>n a restrengthening
regime was incorporated. As gym
equipment was not available, the patient was taught
to place small, repetitive, isometric pressures
against her hand in all ranges <strong>of</strong> cervical motion.
<strong>The</strong> short foot and co-contraction techniques were
mastered and utilised whilst training on a balance
board. <strong>The</strong> Wall Angel technique for strengthening
the lower shoulder stabilisers was also emphasised.
With some imagination, a cycling helmet and small
pen torch were adapted to improvise head repositioning
techniques using a wall chart and the assistance
<strong>of</strong> the patient’s husband.
Over the subsequent 3-week period, with treatment
occurring once a week, a marked decrease in
the frequency and intensity <strong>of</strong> pain occurred, leaving
only mild muscle ache at the end <strong>of</strong> particularly
busy days. Mrs. G found that she was able to return
to all <strong>of</strong> her normal activities <strong>of</strong> daily living and has
remained diligent with her <strong>rehabilitation</strong> at home.
She currently attends 6-weekly for care.
Discussion
<strong>The</strong> vast majority <strong>of</strong> research performed on the
effectiveness <strong>of</strong> SMT has been for low-back pain. 1
In 1996, Hurwitz et al. 3 produced an extensive review
<strong>of</strong> the literature on manipulation and/or mobilisation
<strong>of</strong> the cervical spine. <strong>The</strong> evidence was updated in
2000 by Humphreys 4 to include several recent studies,
highlighting the increasing trend in research
on the effectiveness <strong>of</strong> manipulation for the cervical
spine. In 1997, Bronfort 11 stated that there was

132 J.-M. Gosnold
inconclusive evidence for the short-term efficacy <strong>of</strong>
SMT for acute neck pain patients and limited evidence
for chronic neck pain patients. Conflicting
studies in 1997 12 and 1998 13 both suggest benefits
from manipulation and/or mobilisation for neck
pain, but neither gave conclusive statistical evidence.
Humphreys 4 concluded that, despite the lack
<strong>of</strong> high quality studies in this area, the current body
<strong>of</strong> evidence suggests that cervical spine manipulation
is a valid form <strong>of</strong> treatment for headaches and neck
pain, providing clinical benefit to the patient.
A major influence on the recent interest in the
treatment <strong>of</strong> neck pain is the economic <strong>impact</strong> <strong>of</strong>
the problem, the scale <strong>of</strong> which has steadily
increased in the past 25 years. 5 In non-traumatic
cases, it has been suggested that this is in relation to
the changing structure <strong>of</strong> the workforce. By 1992, it
was estimated that 45% <strong>of</strong> American workers were
now <strong>of</strong>fice-based. 14
In the case <strong>of</strong> whiplash, the debate on causes <strong>of</strong>
symptomatic chronicity, the most effective treatment
regime and the socio-economic <strong>impact</strong> <strong>of</strong> the
problem has, in recent years, produced a marked
increase in the number <strong>of</strong> research studies and
funding available for such. <strong>The</strong> ever-increasing
trend towards litigation in Western societies has
only served to further complicate the problem. This
surge <strong>of</strong> interest has been present in both mainstream
medicine and ‘‘alternative’’ treatment studies,
including chiropractic research, as well as car
safety design groups.
A particularly interesting study, aimed at establishing
information on pain after whiplash was produced
in 1999. 15 To assess the situation without the
psychosocial aspect <strong>of</strong> whiplash being a major factor,
they examined the results <strong>of</strong> questionnaires
sent to 210 Lithuanian accident victims at 2 months
and again at 12 months following the incident. <strong>The</strong>
study used 210 age and sex matched controls taken
from the population register in the same geographical
area. <strong>The</strong> basis for the study was that, in
Lithuania, there is little awareness that chronic
symptoms can occur after a whiplash accident
and, in most cases, no health care is sought and
no litigation is involved. <strong>The</strong> results showed that,
despite 73% <strong>of</strong> the victims reporting initial pain, the
median duration for neck pain was between 3 and 17
days. Follow-up at 1 year showed no significant
differences between the whiplash and control
groups concerning frequency and intensity <strong>of</strong> neck
symptoms. <strong>The</strong>se results strongly suggested that
chronicity <strong>of</strong> symptoms was related to other factors,
such as psychological expectation <strong>of</strong> ongoing
injuries and financial compensation. Yet, on examination
in western societies, there are <strong>of</strong>ten genuine
problems detectable after whiplash injuries.
Despite the extensive studies done, the
mechanisms involved in maintaining the pain in
chronic whiplash patients are poorly understood.
<strong>The</strong> results <strong>of</strong> a study looking at the muscular
sensibility in areas within and outside the region
involved in a whiplash trauma were published in
1999. 16 Although the study only examined 11
chronic whiplash patients and controls, the results
showed that pressure-provoked pain in these
patients had a significantly lower threshold than
that <strong>of</strong> the control group. <strong>The</strong> skin sensibility to pin
prick and cotton swab testing was not found to be
different between the two groups. Infusion <strong>of</strong>
saline into the infraspinatus and anterior tibial
muscles showed that the area <strong>of</strong> local and referred
pain was significantly larger and more intense in
the whiplash patients. <strong>The</strong> authors concluded that
a generalised hyper-excitability in patients with
chronic whiplash was suggested, indicating a type
<strong>of</strong> neurogenic pain. This was similar to the symptoms
found in Fibromyalgia patients. In 1994,
Magnusson 17 found that 10.4% <strong>of</strong> whiplash patients
had symptoms corresponding to the diagnosis <strong>of</strong>
Fibromyalgia.
It is now widely accepted that when Fibromyalgia
patients take regular exercise to maximise the
bodies ability to function effectively without over
activation <strong>of</strong> the involved postural muscles, the
symptoms are better controlled and the patients
feel more able to deal with their pain. This paradigm
reflects that now being established in the
treatment <strong>of</strong> chronic whiplash patients.
How central hyperexcitability is maintained to
cause chronic symptoms is unclear. <strong>The</strong> hypothesis
raised is that the injury causes tissue damage and
mild nerve injuries not always readily detectable,
even with advanced imaging techniques such as Magnetic
Resonance Imaging (MRI) or Computer Tomography
(CT). This causes an ongoing nociceptive
afferent barrage, releasing excitatory amino acids
and neuropeptides, which can cause hyper-excitation
<strong>of</strong> the dorsal horn cells. In 1993, excessive
depolarisation <strong>of</strong> the dorsal horn neurones was established
as causing excitotoxicity, subsequent cell dysfunction
and loss <strong>of</strong> inhibition. 16 As yet, this
explanation for the findings in chronic whiplash cases
is still hypothetical.
In the past 6 years, two studies have strongly
suggested that manipulation has provided a successful
long-term decrease in the symptoms <strong>of</strong> chronic
whiplash. 18,19 <strong>The</strong> earlier study (1996) called for a
prospective randomised controlled trial (RCT) to be
instigated to allow comparison <strong>of</strong> the effectiveness
<strong>of</strong> conventional, compared to chiropractic, treatment
<strong>of</strong> chronic whiplash injuries. Such a study was
published in 1998, 20 in the form <strong>of</strong> a pilot physician

<strong>The</strong> <strong>impact</strong> <strong>of</strong> <strong>rehabilitation</strong> on chronic whiplash 133
survey <strong>of</strong> the treatment and assessment <strong>of</strong> acceleration/deceleration
injuries. <strong>The</strong> anonymous
questionnaire was sent to 1,591 members <strong>of</strong> the
American Back Society, with only 14.7% being
returned. <strong>The</strong> results showed that medical practitioners
(neurologists, neurosurgeons, orthopaedic
surgeons and physiatrists) were more likely to utilize
pharmacological therapies than manipulation
and objective assessment than the non-medical
practitioners (chiropractors and physical therapists).
<strong>The</strong> non-medical respondents reported a
small but significant improvement in patient recovery
relative to the medical respondents.
A comparison <strong>of</strong> intensive training, physiotherapy,
using active and passive care regimes including cervical
mobilization and chiropractic, using manipulation
and trigger point therapy was undertaken in
1998. 21 <strong>The</strong> study found that patients from all three
groups demonstrated significant improvement in
self-reported pain and disability on completion.
<strong>The</strong> main difference detectable amongst the treatment
regimes was that those patients who underwent
the intensive training demonstrated a
significantly greater endurance level at the completion
<strong>of</strong> treatment. Although this study failed to
produce statistical evidence that chiropractic was
more effective than physiotherapy, the results
served to indicate that combining endurance training
in the form <strong>of</strong> <strong>rehabilitation</strong> as well as manipulative/
mobilization therapy, enhances the patients’ chance
<strong>of</strong> preventing chronicity <strong>of</strong> symptoms brought on by
activities <strong>of</strong> daily living.
In the many factors surrounding this particular
case, it is interesting to note that all the subjective
and objective elements directly fit the front-end
collision mechanism that she sustained. <strong>The</strong> driver’s
body moves forward in a front-end collision until the
seat belt system loads the person’s body along the
belt path. <strong>The</strong> driver will have loading from the
shoulder harness in the left side <strong>of</strong> the neck and
anterior chest wall. 10 Despite the patient’s lack <strong>of</strong>
prior knowledge <strong>of</strong> where the mechanism <strong>of</strong> injury
was likely to actually result in symptoms, she clearly
demonstrated left-sided symptomatology in line
with that found in drivers sustaining front end collisions.
<strong>The</strong> psychological aspect <strong>of</strong> these cases should
not be overlooked. When 40 whiplash patients were
compared through a comprehensive <strong>rehabilitation</strong>
programme to 97 consecutive patients under the
care <strong>of</strong> a neurosurgeon for cervical pain, cervical
disc herniation or spondylosis, the results were very
interesting. 22 <strong>The</strong> Coping Resources Inventory (CRI)
used measured cognitive, social, emotional, spiritual/philosophical
and physical aspects. <strong>The</strong> whiplash
patients showed decreased coping resources
and poorer life satisfaction at the beginning <strong>of</strong> the
<strong>rehabilitation</strong> programme. Follow-up at the end
showed that 49% had improved their coping
resources, rising to 63% after 2 years. Life satisfaction
had increased by 46%. Despite this, sick leave in
the whiplash group had increased, whereas the
other patients showed a definite decrease in absenteeism.
<strong>The</strong> authors concluded that social environment
and coping resources made useful predictors
for treatment and <strong>rehabilitation</strong> outcome.
One method <strong>of</strong> dealing with the psychosocial
aspect <strong>of</strong> whiplash cases is to follow the biopsychosocial
paradigm. When emphasis is placed on the
patients’s responsibility for their own care, in the
form <strong>of</strong> participating in <strong>rehabilitation</strong>, the provision
<strong>of</strong> care becomes a shared experience. This leaves
most patients feeling that they are actively involved
in their progress and gives them a method <strong>of</strong> assessing
their improvement in functional, and not just
symptomatic, terms. Attention is thus drawn away
from their pain and what they cannot do, to notice
the steady improvement in what they can achieve in
their exercise regime, decreasing the likelihood <strong>of</strong>
chronicity.
Early return to work is well established as an
important aspect <strong>of</strong> decreasing the risk <strong>of</strong> chronicity
or developing abnormal illness behaviour. Initially,
the patient may find that activities previously
perceived as easy now cause some difficulty and
increase discomfort due to their postural changes
post-whiplash. <strong>The</strong> most common cause <strong>of</strong> workrelated
neck problems is the static muscle loading
that results from faulty working posture, perhaps
exacerbated by psychological stress. 23 Donald Murphy
24 states that:
‘‘All static postures should be viewed not only
in terms <strong>of</strong> the positions <strong>of</strong> the body and the
activity <strong>of</strong> the muscles at any given moment in
time, but as a ‘Postural Set’, from which is
derived any movement in which the person
engages, following the maintenance <strong>of</strong> that
posture’’.
Jones 25 established the concept <strong>of</strong> postural sets
in 1963, explaining that if a person had a poor
postural alignment initially, any movement that
followed would have to be adapted to compensate
for the initial flaws. Janda 26 believes that to repeat
any incorrect pattern <strong>of</strong> movement will establish a
‘pathological engram’ that will lead to faulty movement
patterns and subsequent functional compromise.
Whilst the body can deal with pathoanatomy
quite adequately, disturbances <strong>of</strong> function can
cause a chain reaction to occur. 24 <strong>The</strong>se present
the body with a far more complex challenge and
interact to produce clinical symptoms.

134 J.-M. Gosnold
Joint dysfunction, such as cervical facet syndrome,
is a common manifestation <strong>of</strong> faulty movement
patterns. In 1964, Mennel 27 defined joint
dysfunction as ‘‘loss <strong>of</strong> joint-play movement that
cannot be produced by voluntary muscles’’. It has
been theorised that a loss in joint play can lead to
pain, producing reflex effects on the surrounding
muscles. 24 <strong>The</strong> result is that certain muscles
become hypertonic, whilst others become neurologically
inhibited. This imbalance leads to local dysfunction
in muscle and joint interaction, causing
faulty movement patterns. <strong>The</strong>refore, it can be
hypothesised that, to address only the joint dysfunction
through manipulation, will only create a
temporary increase in motion. If the muscle imbalance
and faulty movement patterns are not
addressed, this continued dysfunction would prevent
the joint from maintaining normal function.
This cycle <strong>of</strong> perturbing factors is commonly seen in
chronic neck pain patients both <strong>of</strong> non-traumatic
and traumatic origin. To break this cycle requires a
‘three-pronged’ approach. Firstly, to reduce joint
dysfunction via manipulation; secondly, to restore
normal muscle balance and function and, thirdly, to
re-educate the body’s movement patterns via <strong>rehabilitation</strong>.
Joint manipulation is performed to restore jointplay
and is thought to work by releasing entrapped
synovial folds or plica, relaxing hypertonic muscles
and disrupting articular or periarticular adhesions.
28 Muscle dysfunction, particularly in the case
<strong>of</strong> trigger points, can become a significant cause <strong>of</strong>
pain. This pain is <strong>of</strong>ten responsible for antalgic
posture or compensatory muscular facilitation. 29
Treatment includes s<strong>of</strong>t tissue massage, trigger
point therapy and both passive (e.g. PIR) and active
(e.g. proprioceptive neuromuscular facilitation
(PNF)) stretching techniques.
Rehabilitation via sensorimotor training and cervical
stabilisation produces several key benefits to
the chronic neck pain patient. Firstly, the efficiency
and effectiveness <strong>of</strong> common movement patterns
involving the cervical spine and shoulder girdle are
improved. This makes daily tasks less demanding,
both in terms <strong>of</strong> conscious effort on the patient’s
part and by preventing over recruitment <strong>of</strong> compensatory
muscles. In whiplash, the cervical flexion
pattern is particularly important, being tested
supine to work against gravitational resistance.
<strong>The</strong> correct and incorrect cervical flexion movement
patterns are shown in Table 2. 30 Improving the
speed and accuracy <strong>of</strong> the eye—head—neck—upper
extremity reflexes maximises neurological integration
and control, providing a protective function for
the system as a whole. Strengthening key muscle
groups acts to improve the stability <strong>of</strong> the cervical
Table 2 Correct and incorrect cervical flexion
movement patterns. 30
Correct flexion Incorrect flexion
Controlled movement Jaw juts forward
Chin tucked in Hyperextension at
Balanced activation
<strong>of</strong> both deep neck
flexors and
sternocleidomastoid
(SCM) muscles
No muscle fatigue
(‘‘shuddering’’)
cervico-cranial junction
Weak deep neck flexors
with strong SCM
Muscle fatigue leading to
unsustainable movement
spine, preventing extreme end ranges <strong>of</strong> motion
that can lead to long-term complications.
Disturbance <strong>of</strong> eye-head-neck co-ordination and
oculomotor reflexes resulting from cervical trauma
has been well documented. 31 <strong>The</strong> cervical spine
has an extremely high afferent input into the Central
Nervous System (CNS), particularly from the
muscle spindles <strong>of</strong> the intrinsic muscle groups. This
information is used to mediate various locomotor
activities, with the most important connection
being with the vestibular nucleus. This pathway
mediates both the activity <strong>of</strong> individual muscles,
and the overall posture, balance and stability
mechanisms. 24 <strong>The</strong>refore, cervical dysfunction
can disrupt these mechanisms causing functional
compromise within the CNS. <strong>The</strong> Tonic Neck Reflex
(TNR) constitutes one <strong>of</strong> the most significant
reflexes that can be affected by cervical dysfunction.
In normal circumstances, this reflex acts to
distribute muscle tone throughout the locomotor
system as a result <strong>of</strong> cervical movements. 32 <strong>The</strong>
TNR is usually quiescent, only manifesting itself
when a high degree <strong>of</strong> skill or power is required.
Fukushima and Hinoki 33 showed that the TNR might
also manifest in the presence <strong>of</strong> cervical dysfunction
and pain, the result being that certain trunk
and extremity muscles became either hypertonic
or inhibited.
Compromise to the vestibular nucleus also
affects balance, with many patients who have cervical
dysfunction also reporting vertigo or dysequilibrium.
<strong>The</strong> adaptation required in overcoming
these symptoms places further strain on the locomotor
system, lowering the margin <strong>of</strong> error in the
system and predisposing to the susceptibility <strong>of</strong>
injury and dysfunction in other areas <strong>of</strong> the body.
<strong>The</strong> Saccade and Smooth Pursuit oculomotor
reflexes are also affected. 34 Muscle imbalances in
the cervical spine, particularly in the cervical rotators
(SCM, upper trapezius, splenius capitus and

<strong>The</strong> <strong>impact</strong> <strong>of</strong> <strong>rehabilitation</strong> on chronic whiplash 135
obliquis capitus inferior) create disruption in the
normal afferentation from the mechanoreceptors.
This imbalanced input conflicts with the afferent
input from other sensory structures and creates
alteration in the oculomotor reflexes. Some evidence
exists that oculomotor dysfunction may be
a factor in the perpetuation <strong>of</strong> chronic cervical
pain. 35
Conclusion
This case illustrates that SMT alone does not always
provide full functional recovery and pain relief.
Within the Chiropractic pr<strong>of</strong>ession, ergonomic
advice has become standard practice, but <strong>rehabilitation</strong>
is still in its infancy. Some Chiropractors
have embraced the concept, whilst others debate
whether <strong>rehabilitation</strong> should remain the work <strong>of</strong>
physiotherapists and specialised practitioners. To
date, there is limited research available but some
preliminary studies have suggested that sensorimotor
and cervical stabilisation training have important
roles to play in the <strong>rehabilitation</strong> <strong>of</strong> chronic
neck pain patients, whether the cause is post-traumatic
or not. 36 Most chiropractors do, however,
agree that patient education in taking active
responsibility for their daily environment is essential
to maintain progress between treatment visits.
By accurately identifying those patients who require
<strong>rehabilitation</strong>, we can move towards maximising
the effectiveness <strong>of</strong> the management <strong>of</strong> each
patient’s clinical condition.
Acknowledgements
This case is published courtesy <strong>of</strong> the College <strong>of</strong>
Chiropractors’ Pre-Registration Training Scheme
(PRTS) for which it formed a part requirement. I
would like to thank Dr. George Carruthers for his
guidance and encouragement as my PRTS trainer.
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