WHIPLASH INJURIES TREATMENT RELATED TO PATHOLOGY AND STAGES OF HEALING ■ by Helen David, BSc (Physiotherapy) Witwatersrand, Private Practitioner, Johannesburg T he term "w h ip la sh " is used to d escribe neck injuries resulting from rapid acceleration-deceleration forces, usually due to m otor vehicle accidents (M V A 's). W hiplash patients present a form ida­ ble challenge to physiotherapists becau se o f the extrem ely vari­ able range o f clinical presentations and ow ing to the unpre­ dictability o f the end result o f treatm ent. W hiplash patients have b een labelled hysterical, neurotic, if not frankly d isho nest1 as they often continu e to com plain o f pain and other sy m p tom s for unexpected lengths o f time, even well after the settlem ent o f any court cases. R ecent literature has provided som e clues to this problem . In ad dition to the injuries to m uscles, ligam ents and jo ints, Tw om ey and T aylor have show n that there is a strong possibility that w hiplash m ay cause rim lesions o f the discs. These rim lesions are linear clefts w ithin the cartilage plate near the vertebral rim and extend ing into the annulus. A ccord ing to an experim ental study in sheep by O sti et al3, such lesions do not heal (except for the ou term ost p art o f the annulus) b u t continu e to extend w ithin the disc over the year follow ing the injury ie., a process o f d egenera­ tion is set in m otion. T his is one possible explanation for persistent sym ptom s in w h ip lash patients. Another possibility is that injuries m ay be m ore extensive than suggested b y rad iographs and m ay include disc lesions and frac­ tures o f b ony elem ents. Jo n sso n et a f i studied 22 cervical spines from M V A victim s w ith fatal injuries. They describe injuries found at autopsy w hich had been m issed on post-m ortem X-rays. In total, there w ere 245 bone and d iscoligam entous lesions and even on re-evaluation o f the radiographs, only four o f these defects w ere detected. Coles"’ m entions an instance o f an unde­ tected fracture-d islocation o f the C 6/ 7 vertebrae in a w hiplash p atient w h ich w as subsequently found on further X -ray, six w eeks after the M VA. 2 Tw om ey and T aylor also found cases o f blood w ithin the outer annulus (bruising) and haem arthrosis and capsular tears of ^ABSTRACT " Whiplash patients present a challenge to physiotherapists because of the variability of clinical presentations and the unpredictability of the outcome of treatment. Recent literature, which may provide some clues to this situation, is discussed. The clinical implications are that physiotherapy treatments should be carefully graded and non-aggressive. Twelve whiplash patients were treated according to these guidelines and their data were analysed. OPSOMMING Pasiente met ’n sweepslagbesering is ’n uitdaging vir fisioterapeute as gevolg van die wisselende kliniese beeld en die onvoorspelbaarheid van die effek van behandeling. Onlangse literatuur wat moontlike redes vir die situasie aanvoer, word bespreek. Die kliniese implikasie is dat fisioterapie baie versigtig toegepas moet word en glad nie aggressief mag wees nie. Twaalf sweepslag pasiente is behandel volgens hierdie riglyne en hul resultate is ontleed. the facet jo ints, w hich would not show up on routine X-rays. The im plication of these studies is that w h ip lash patients should be handled w ith extrem e care as they m ay have extensive injuries to m any structures. Any aggressive treatm ent including m anipulations w ould thus be strongly contra-ind icated at all stages as this m ight cause fu rther d am age to stru ctures, in p ar­ ticular the disc w hich does not heal readily, and m igh t precipitate early degeneration w ith associated pain and other sym ptom s. In the treatm ent o f w h iplash patients, in ad dition to con sid er­ ing all possible elem ents o f the n euro-m u scular-articu lar system s w hich m ay have been injured, it is also vital to consid er w h ere the w hiplash patient is in the total spectru m o f the Stages o f H ealing as described b y M cG onigle and M atley6. Briefly sum m arised these are: 1. Inflam m atory Stage - w ound sealing, p h ago cy tosis o f b acte­ ria and dead cells, re-establishm ent of b lood su p p ly so that repair b egins. This stage lasts from 24-48 hours to tw o w eeks or more. 2. Fibroblastic Stage - re-epithelialisation, w o u nd contraction, collagen production. This stage starts from a few d ays after injury and continues for 2-4 weeks. 3. R em odelling Stage - final orientation and arran gem ent of collagen fibres. This takes from 6-12 m onths and successful heal­ ing results in a scar o f sufficient tensile strength and sim ilar to normal tissue in length, alignm ent and m obility. H ow ever, at the beginning o f the rem odelling p h ase the tensile strength o f the collagen m ay be as little as 15% o f norm al and this im plies that the treatm ent progression should be carefu lly grad ed. In p articu ­ lar, excessive loading or overstretching should b e avoided. AIMS 1. To analyse the data o f a group o f w h iplash synd rom e patients w hose treatm ent w as based on the principle taking into ac­ cou nt any possible dam age to n euro-m u scular-articu lar sy s­ tems. 2. To suggest an appropriate approach to treatm ent in these cases. MATERIAL AND METHODS Tw elve w hiplash p atients w ere selected retrosp ectively, w ith their consent, for this study. They w ere selected on the basis of their arrival for the initial treatm ent d uring a particu lar time period. Detailed records of their treatm ents w ere kept and a follow -up was carried ou t approxim ately on e year after treatm ent had been term inated. T here w ere ten fem ales and tw o males. T heir ages ranged from 17 to 68 years, w ith all except one being below 45 years o f age. The treatm ent p rogram m e follow ed the b asic guid elines as described in A ppendix A. Specific treatm ents w ere based on the concepts o f M aitland , Q Q O Q i n E dw ards , Janda , Elvey , Butler , Knott and V oss , Travell and Sim on s11. R ocab ad o12. RESULTS As expected, the patients varied enorm ously in all aspects, viz.: a. presenting sym ptom s b. length of time from M VA to com m encem ent of physiotherapy c. num ber o f treatm ent sessions to recovery* d. time to recovery* SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o 1 F e b r u a r y 1996 P a g e 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) (*"recovery" w as defined as: Subjectively: "fin e " O bjectively: fu ll-range pain free active m ovem ent; pain free passive accessory m ovem ent to IV (but not IV++); norm al length o f m uscle, connective tissue and neural tissue.) Based on a com bination o f points a), c), and d) above, patients w ere classified into four categories o f w hiplash injury, viz., M ini­ mal, M ild, M oderate/Severe and Severe. See Table I. Points b), and d) above w ere considered in relation to the stages o f H ealing (See Figu re 1). Follow -up contacts w ere m ade approxim ately one year after com pletion o f p hysiotherapy treatm ents and the results are sum ­ m arised in Table II. DISCUSSION A n analysis o f this sm all sam ple o f W hiplash Injury patients supports the com m only held view s that these patients differ greatly in their clinical presentation, in the am ount o f treatm ent required and the length o f tim e to recovery. Patients also arrive for physiotherapy treatm ent at very varying times after the date o f the M V A ie., at differing points in the stages o f healing. These differences m ake it im possible to lay d ow n firm rules for treatm ent, such as for how long a soft collar should be w orn or w hen to start w o rking into resistance. H ow ever, based on the 2 3 4studies o f Tw om ey and Taylor , O sti et al and Jonsson et al , a treatm ent regim e w as planned and has been in use by the author for som e tim e. The 12 patients w ho w ere included in this study w ere all treated according to these guidelines, viz.: 1. T here should be a balance betw een rest and im m obilisation on the one hand and a carefully graded m ovem ent program m e on the other. 2. A ny aggressive treatm ent including m anipu lation Should be avoided at all stages. 3. All elem ents o f the neuro-m u scular-articu lar system s should be considered in the program m e. The study b y M cG onigle and Matley^ states that it m ay take up to 6-12 m onths for h ealing tissue to attain full strength and this supports the conservative approach w hich had b een follow ed in these 12 cases. In this stud y the follow -up o f the 12 patients, approxim ately one year after term ination o f physiotherapy treatm ent, indicated good results in the m ajority o f cases, (see Table II). Both patients from the M inim al classification, tw o from the M ild group and two from the M oderate/Severe group had been absolutely fine since term ination o f treatm ent. (One o f these had suffered a fracture o f the C 7 vertebral body). These results were classed as good. O ne patient from the M oderate/Severe classification had been sym ptom free for six m onths, then developed a local ache one day after sitting w ith his head in an aw kw ard position for hours. This responded im m ediately to postural advice from a chiropractor and did not recur and w as thus considered to be a good result. A nother patient fro m this category w as sym ptom free except after a very long d ay 's drive, w h en she would develop mild local pain. Her occu pation involves a lot o f driving and as she had a history o f tw o M V A 's, the second ju s t as she w as recovering from the first, and as she runs, cycles and does a g reat deal o f driving, this w as also considered to be a good result. O ne patient in the M ild group w as sym ptom free for four m onths after term ination o f p hysiotherapy b u t then developed a local pain and stiffness. H e w as treated by a chiropractor w ho TABLE I: SUM MARY OF 1 2 WHIPLASH PATIENTS Classification Minimal Mild Moderate/severe Severe Number o f cases 2 3 4 3 Symptoms Locol pain & stiffness Lacal pain & stiffness headaches variable: Local pain & stiffness Headaches, dizzy etc. paraestheisa variable: dysfunction neurological cord Treatment commenced day 2 day6 Day 1 day 4 day 7 Day 4 week 4 week 5 week 6 Week 3 month 2 month 6 Number o f treatments to recovery ± 3 + 6 1 0 - 1 2 > 1 2 -o n g o in g maintenance) Time to recovery l week 10 days — 3 weeks 5 weeks - 3 months (ane case 2nd MVA after 3 / 1 2 , thus 6 / 1 2 total) > 3 months incomplete recovery . TREATMENT PERIOO FOR A PARTICULAR PATIENT » — C< K E Y m a i n i a in a n c e o n l y --------------------------------- » PRASES OF HEALING £ > I I I ► >1----- » I - - ---- (C - « 2nc M V A ---- > <