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A Treatment for Whiplash, Chronic Neck Pain and
Headaches
Vladimir Djuric, M.D.
“Whiplash” is a term used to describe traumatic injury to the neck typically
resulting from rear-impact motor vehicle accidents. It is one of the most common
causes of chronic pain in developed countries with a prevalence of 1% in the
general population. Typically, the prognosis after common whiplash is quite
good. Three-quarters of those injured recover completely within six months.
Unfortunately, for the remaining 25% persistent
neck pain,
headaches,
shoulder
pain, and a variety of other symptoms can become a permanent fixture in their
lives. In 10% the symptoms are severe; 4% are unable to return to their previous
occupation.
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Until recently our understanding of the pathophysiology of whiplash has been
very limited. Thanks to several key researchers this has changed immensely over
the past decade. Bogduk and his colleagues in Australia have conducted excellent
studies identifying cervical facet joints as a primary cause of ongoing pain.
Small tears in the intervertebral disc wall have also been implicated as
residual “pain generators”. The usual diagnostic tests
x-rays, CT,
MRI, and EMG) are typically normal, giving little insight into what is responsible for
the ongoing pain. This can prove to be quite frustrating for both the patient
and his physicians who are searching for a diagnosis. Only provocative spine
injection procedures done under fluoroscopy (X-ray) can reliably and objectively
identify the exact source of pain.
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Even so, once identified the treatment options remain quite limited. Medications
such as non-steroidals,
Narcotic
medications, and muscle relaxants only treat the symptoms;
most of the time inadequately.
Physical
therapy and chiropractic may provide a
considerable degree of symptom relief, but many times these benefits are
temporary, prompting frequent return visits. Even the latest treatment,
radiofrequency thermal ablation, a procedure which destroys the nerves supplying
the painful structure, works for only about a year before the nerves grow back
and the procedure needs to be repeated.
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A relatively unknown yet very effective treatment for cervical spinal pain is
Prolotherapy. Also known as non-surgical
ligament reconstruction, prolotherapy
works by addressing the cause of the pain: ligament and tendon relaxation and
joint instability. The usual early diagnosis, cervical sprain/strain, although
non-specific, is appropriate in that it implicates soft tissue as the injured
structure. More specifically, it is the
connective tissue, rich in pain
sensitive nerve endings, which sustains the brunt of the injury. Structures
including ligament, tendon, joint capsule and the intervertebral disc wall are
all made of this connective tissue. In cases where the stretch capacity of the
connective tissue has been exceeded, laxity and incompetence may result,
rendering the intervertebral segment unstable. The excess motion leads to
irritation of the nerve endings and thus pain.
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What may start as a very localized problem can spread to adjacent areas and even
the contralateral side. This “regionalization” of symptoms is due to
compensatory postural and movement abnormalities; unsuccessful adaptations made
by the body in an effort to minimize pain (similar to a limp due to a painful
hip or knee).
Sleep disturbances, difficulty with concentration, depression, and
anxiety are other complications of whiplash. Buskila and colleagues found that
over 20% of individuals sustaining neck injuries went on to develop symptoms
consistent with
fibromyalgia, making whiplash one of the most common traumatic
causes of this condition.
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Based on the history, pain diagram, and physical examination findings, a
specific cervical segment can usually be identified as the probable cause of
pain. Individuals with segmental hypermobility or recurrent somatic dysfunction
of the upper cervical segments (C2-3 and above) usually complain of pain at the
base of the skull and headaches. Middle cervical dysfunction tends to produce
primary neck discomfort. Lower cervical involvement (C5-6 is the most commonly
injured segment) leads to lower neck and
posterior shoulder pain. These symptoms
are commonly attributed to
myofascial pain syndrome, suggesting muscular
etiology even though the symptoms are directly related to spinal dysfunction.
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Prolotherapy involves the injection of a proliferant solution, usually 15%
dextrose mixed with anesthetic, into the damaged connective tissue. Once
injected, the proliferant elicits an
inflammatory response. The first step in
the natural healing cascade is thus initiated. After an initial “clean-up”
by various white blood cells,
fibroblasts migrate to the area to begin the
repair process. These cells produce
collagen which repairs and reinforces the
damaged connective tissue. As it matures, the collagen shrinks, slowly
tightening the hypermobile segment. As with any painful condition, early
diagnosis and intervention is extremely important. As chronicity progresses,
pain centralization and multifocal involvement make treatment much more
difficult and time consuming. Even so, even the most complicated whiplash
sufferers stand to benefit, at least to some degree, from prolotherapy.
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The treatment involves a series of injections spaced 2-4 weeks apart. In the
neck, the spinous ligaments, facet joint capsules and muscular attachments of
the trapezius, levator scapulae and suboccipital muscles are usually addressed.
Surprisingly, the multiple injections are very well tolerated by the patient,
although some are premedicated prior to the treatment in order to ease some of
the discomfort.
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Significant improvement, defined as a 50% drop in pain score, should be realized
by the fourth treatment. Patients with localized symptoms and cervicogenic
(tension) headaches, usually have the earliest and most impressive results.
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Prolotherapy is not a first line treatment for whiplash. However, in cases where
most other interventions have failed, it is surprisingly effective. Because new
collagen tissue is created and the weakened segment is strengthened, the
treatment is in many instances permanent. For many patients it is the only
treatment likely to provide lasting benefit and improve quality of life.
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