Whiplash associated disorders treatments | Comprehensive Prolotherapy
In this article we will discuss whiplash injuries and the possible chronic myriad of symptoms related to damage of the cervical ligaments and focus on repairing the damage caused by the sudden extension, flexion and rotation – that is the whipping of the head back and forth and side to side.
- If you have questions about whiplash, get help and information from Caring Medical
Early in my career, while I was waiting for my Prolotherapy practice to build, I did hundreds of expert medical reports, reviewing patient’s medical records who were in car accidents. I did my best to be honest and render expert opinions about what I felt the injuries were from the car accident and what was appropriate care. Most patients, lawyers and even doctors involved in both the healthcare aspect and legal aspect of whiplash injury often don’t understand some of the key concepts of whiplash that we will discuss below.
Whiplash causes more pain than imaging studies can verify
In research published in the medical journal Spine and reprinted in the Journal of manipulative and physiological therapeutics, Linda J. Carroll, Ph.D, of the Department of Public Health Sciences, School of Public Health, University of Alberta lead a study from The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) came up with this conclusion in regard to patients suffering from whiplash-associated disorders (WAD).
In examining 226 articles related to treatment course and prognostic factors in neck pain and its associated disorders, the team discovered that the evidence suggests that:
- Approximately 50% of patients with WAD will report neck pain symptoms 1 year after their injuries.
- Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.
- Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, post-injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.(1)
Dr. Michele Sterling of the Centre for National Research on Disability and Rehabilitation Medicine, at The University of Queensland interpreted these findings in the The Journal of manual & manipulative therapy as:
“Whiplash-associated disorders are a common, disabling, and costly condition that occur usually as a consequence of a motor vehicle crash. While the figures vary depending on the cohort studied, current data indicate that up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by their condition.”(2)
Writing in the European Pain Journal, Norwegian doctors found that whiplash caused more pain in other regions of the body than other pain causes. For example whiplash associated disorders caused:
- greater intensity back pain than chronic back pain did,
- greater intensity shoulder pain than chronic shoulder pain did,
- even greater intensity neck pain than chronic neck pain did not associated with whiplash.
- Women with WAD also reported pain in the hip, arm, hand, stomach, chest and genitalia more often than women with chronic pain originating in other joints.(3)
With individuals with WAD also reporting pain in a wide range of bodily locations, a higher number of painful locations and higher pain intensity than individuals with chronic pain from other causes AND no differences were not accounted for by differences in pain tolerance than with control subjects, clearly there is something causing more pain for these people.
This theory was also supported by research from The University of Sydney in the medical journal Injury which looks at why some patients recover more quickly than others and why some patients remain with chronic problems.
In this study the researchers followed patients so they could detail the not well understood course of recovery whiplash patients take.
- Some people recover within months and others report symptoms for extended periods.
This study aimed to identify recovery trajectories (or predict recovery projections) based on disability, pain catastrophizing and mental health and, secondly, to examine developmental linkages between the trajectories. For instance does mental health concerns cause more pain catastrophizing.
- 246 people were enrolled in the study on avergae 72 days after injury.
- Three trajectories were identified for the measures used and their prevalences, respectively, were:
- for disability they were mild (47%), moderate (31%), and severe (22%);
- for pain catastrophizing they were non-catastrophizers (55%), moderate-low catastrophizers (32%) and clinically significant catastrophizers (13%);
- and, for mental health they were good mental health (40%), moderately low mental health (42%) and severely low mental health (18%).
- All groups showed no further recovery beyond 12 months after injury.
- The significant baseline predictors of the severe disability trajectory were:
- lower (that means worse) bodily pain scores when when mental health challanges was present;
- high pain catastrophizing; and, self-reported fair or poor general health.
The researchers then found strong and plausible association between severe disability, clinical levels of pain catastrophizing and low mental health.(4)
Understanding these characteristics can help the clinician understand the patient’s problems and a realistic path to helping the patients overcome their symptoms.
Whiplash-associated disorders – first step in treatment? Have doctors believe Whiplash-associated disorders are real. Second step have them believe something more can be done than pain management
In December 2017, doctors at University of Queensland and Griffith University, in Australia published their findings on the Whiplash associated disorders patient experience with healthcare in the journal BMC musculoskeletal disorders.
- Whiplash associated disorders are the most common non-hospitalised injury resulting from a motor vehicle crash.
- (As mentioned above) Approximately 50% of individuals with WAD experience on-going pain and disability.
- Results from intervention trials for individuals with chronic Whiplash associated disorders are equivocal and optimal treatment continues to be a challenge. (What the researchers are saying here is that treatment studies and outcomes are open to interpretation, and optimal treatment continues to be a challenge. They do not see a gold standard in conventional medicine).
These researchers, were looking for hope. A main finding of this study was to see IF the patients were actually benefiting from any treatment but did not know how to say say in study questionnaire format.
- Twenty-seven individuals with chronic Whiplash associated disorders participated in a one-on-one, semi-structured individual telephone interview.
- Two themes emerged that described the experience of living with chronic Whiplash associated disorders.
- First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to ‘find the right healthcare practitioner (HCP)’ to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems (These would be insurance coverage complexities).
- Second, participants described a journey of realization, and the trial and error used to establish self-management strategies to both prevent and relieve pain. (The patients took an active role in their own health care, possibly because pf less than hoped for results in their doctor driven treatments).
- Participants described trying to understand the impact of their initial injury in relation to the gradual realization that there may be on-going residual deficit.
- Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies.
- Recovery from a whiplash injury is an adaptive process and more than elimination of pain or disability, therefore may be different from common clinical patient reported outcomes.
- (In this statement the researchers are suggesting that people with whiplash associated disorders, benefit when they come to terms that there is no likely curative treatment for them and that they would do better at managing their pain and disability. Obviously this is not a statement we would agree with unless Comprehensive Prolotherapy failed).
- Early identification of patient understandings of pain, expectations of recovery, symptoms and therapy may help merge patient and health care professional understandings. (The patient and doctor are not on the same page, and it would be helpful if the patient found a doctor who understood what they are going through). This was followed up by this statement: “acknowledgement and validation of the whiplash injury by health care professionals is seen by many as a necessary step in the recovery process.”(5)
A treatment of interest: Prolotherapy for cervical ligaments damage and neck instability
The above research shows us where medicine is in regard to the difficult to treat patients with whiplash associated disorders. Treat the depression, treat the fear, treat the anxiety, keep looking for answers. Prolotherapy doctors have known for a long time that the best way to treat these problems is to treat and stabilize the cervical neck ligaments.
In our opinion, prolonged symptoms of whiplash – neck pain, headaches, dizziness, burning or prickling sensations (paresthesias), back or shoulder pain, and difficulties with concentration and memory are usually not problems solely correlated with the cervical discs damaged in whiplash but a problem of damage to the cervical ligaments.
When ligaments are subjected to quick forces, as occurs in whiplash traumas, it does not take much to tear or overstretch them. All whiplash traumas have the potential to significantly injure cervical ligaments and cause neck instability.
If it is not a problem of discs, but ligaments, cervical fusion is the wrong treatment
Research has shown that a small percentage of patients with whiplash associated disorders, cervical fusion can be successful. Dr. Bo Nystrom, a surgeon whose work we often cite, published a study in 2016 that suggested fusion may be of benefit in a group of carefully qualified patients whose problems came from segmental mobility issues, that is, functional problems in the disc.(6) Even so, this is a small group of patients and success was 2 out of 3 achieving pain relief. One out of three did not and had an unsuccessful surgery.
We like to see patients before the cervical neck fusion surgery when the problems of a failed surgery compound a pre-existing problem. Unfortunately we do not always see the patient first and see them after a cage, screws, and other fusion materials are already in place and the pain remains.
Fusion creates the same problem it is trying to fix
Another problem that can be manifest in fusion patients looking for relief from their prolonged whiplash syndrome is that the fusion may mimic the problems the fusion was trying to fix. It is interesting that doctors from the University of Pittsburgh writing in the medical publication The Spine Journal discussed similar characteristics between whiplash and patients who underwent cervical fusion. What they found was that when the head moves, up, down, side to side, or in rotation, the forces of motion come into play throughout the cervical spine.
Patients who have limited range of motion from whiplash injury and patients who underwent cervical spinal fusion, exhibited the same problems, not only reduced range of motion but increased segmental instability (meaning that the vertebrae above and below the fusion and near the points of injury in whiplash were under stress to help provide movement and neck stability).
The medical advice: “the clinician may advise the patient to avoid end range of motion positions to lessen the demand on the discs.”(7) Please refer to my article Cervical pain, adjacent segment disease following neck surgery for a more detailed understanding of this problem.
So a surgery to help patients with whiplash injury, the cervical fusion, in this case and for many patients, does not alleviate the problems of pin-free neck movement. In fact it contributes to it.
Researchers want answers for perplexing and challenging whiplash patients
Most head traumas and whiplash injuries result in flexion and rotatory stress onto the upper cervical vertebrae, which disrupts the capsular ligaments (cervical facet joints).
There are four basic mechanisms of neck injuries:
- flexion (head snaps forward),
- extension (head snaps backwards),
- rotation (head snaps top left or right or both) and
- compression (impact).
Most often head and neck trauma contains all four mechanisms. Any trauma that involves a rotatory component of the neck will then by definition injure the capsular ligaments.
Doctors in Belgium writing in the Journal of manipulative and physiological therapeutics acknowledge that difficulty in diagnosing cervical neck injury lies in the fact that major injury to the cervical spine may only produce minor symptoms in some patients, whereas minor injury may produce more severe symptoms in others. Here is what they wrote in regard to MRI, CT Scans and X-rays.
“There seems to be no correlation between the amount of hypermobility or subluxation and the presence of clinical signs or neurological signs. The clinical signs can vary from relatively diffuse complaints, no symptoms and signs to serious ones.
Radiology does not seem to be a reliable diagnostic mechanism in relation to upper-cervical instability. Conventional X-rays fail to give adequate information about atlanto-axial stability. CT-scan and MRI can visualize much more because of the direct sagittal projection (basically a cross-section view) but neither is an absolute standard. Furthermore, in relation to upper-cervical hypermobility, the validity of radiology is under debate.”(8)
Dr. Bengt H Johansson in the medical journal Pain Research and Management wrote: Damage to cervical ligaments from whiplash trauma has been well studied, yet these injuries are still often difficult to diagnose and treat. Standard x-rays often do not reveal present injury to the cervical spine and as a consequence, these injuries go unreported and patients are left without proper treatment for their condition.
“Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint [CCJ] complex). Studies indicate that injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headache, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light and pronounced fatigue.”(9)
Cervical ligaments and chronic whiplash associated disorders – the answer is in the examination
Here is a study from the journal Traffic Injury Prevention: What the doctors were looking for was how the placement of the head at the time of impact affected long-term symptoms. In other words – how stretched were the neck ligaments at the time of impact – and how much more did they get stretched during the impact. They key here is injury to the ligaments and future impact on neck instability.
The doctors then came up with a model that would predict ligament damage. Here is what they concluded:
- Higher potential for injury when the head was turned (ligaments will be stretched in head turned position). This time of impact position could lead to a higher potential for whiplash injury by as much as 50%.(10)
This is agreed to and embellished in a paper from Fort Lewis College and Colorado State University researchers who suggested doctors can be mislead in their diagnosis and treatment by not fully understanding the complexities of range of motion in the neck. To find the cause of cervical instability – doctors need to increase the physical examination of the neck ligaments.(11)
Evidence closing in on untreated ligament injury as the cause of whiplash associated pain
In a research from December 2016, doctors in Sweden used nerve blocks in Chronic Whiplash Associated Disorders looking for evidence that the problems related to whiplash were coming from cervical vertabrae’s facet joints – a sign of ligament instability. They tested the C2-C7 joints and begin with a bupivacaine based nerve block and for control also tested with saline.
The results showed that:
- 29% of patients had pain relief with nerve block
- 60% did not responder,
- and 11% placebo responders. (Saline injections do work)
The doctors concluded: A substantial amount of patients with Chronic Whiplash Associated Disorders have their persistent pain emanating from cervical zygapophyseal joints.(12)
It can be suggested then that 3 out of 10 patients who would normally be sent to fusion surgery, would be sent to an uneccesary surgery.
Caring Medical Published Research
This is also confirmed in our own published research spearheaded by Danielle R. Steilen-Matias, PA-C. In this research that appeared in The Open Orthopaedics Journal we showed that conventional treatments for chronic neck pain remains debatable, primarily because most treatments have had limited success because they did not address the cervical ligaments.
Multiple studies have implicated the cervical facet joint and its capsule as a primary anatomical site of injury during whiplash exposure to the neck. Others have shown that injury to the cervical facet joints and capsular ligaments are the most common cause of pain in post-whiplash patients.
In our study we were able to conclude and document Prolotherapy injections to be an effective treatment for chronic neck pain and cervical instability due to whiplash, especially when due to ligament laxity in the cervical joints.(12)
In 1984, doctors at the University of Iowa produced a study that is often cited in the medical research even today. Here the researchers examined the relative motion between various vertebrae of multi-level cervical ligamentous spinal segments. They found an that when there is an injury to a particular capsular ligament, say at C5-C6, it produces a significant increase in relative motion at the next superior vertebrae, in this case C4-C5, as well as at the level of injury.(13)
In over two decades of experience specializing in cervical spine cases and reviewing the medical research on whiplash and cervical spine instability, we developed Caring Cervical Realignment Therapy (CCRT). For patients who are struggling with post-traumatic injuries to the neck and have been trying everything from rest to physical therapy to medications and even surgery, CCRT makes the most sense for long-term relief of pain and symptoms, as well as restoring the normal curve to the spine!
In other words, injury or ligament damage instability, at one level of the cervical neck impacts the whole neck and the whole body.
If you have questions about whiplash, get help and information from Caring Medical
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