The impact of rehabilitation on chronic whiplash

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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
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The impact of rehabilitation on chronic whiplash

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