The impact of rehabilitation on chronic whiplash

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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.
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The impact of rehabilitation on chronic whiplash

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