Multidisciplinary Management of
Chronic Whiplash

Patients with acute neck pain develop chronic neck pain in 15% to 40% of cases.¹ After a whiplash injury, the cervical facet joint becomes the most common source of chronic neck pain, and some patients experience pain from both the facet joint and the disk.^2,3 People suffering from chronic neck pain after an injury would do well to find their way to a chiropractic physician. Research shows that manual therapy including spinal manipulation and joint mobilization helps cases of facet joint pain / cervical facet syndrome.^4-10 Therapeutic exercise also helps.8,10 Gross et al found manipulation combined with therapeutic exercise to be more effective than either alone.¹¹ However, none of the research suggests that any of these treatment options are effective 100% of the time. Lawrence Wyatt, DC, DACBR writes that chiropractors should consider referral for medial branch blocks when patients are not progressing with chiropractic treatment alone.¹²

Numerous studies now support the efficacy of treating chronic neck pain with blocks of the medial branch nerves.¹³ Medial branch blocks even create significant pain relief when pain has proved refractory to other conservative approaches (i.e. chiropractic adjustments, physical therapy, rest, drug therapy, exercise).¹⁴ Pain relief from a single treatment lasts an average of 12-13 weeks, and many patients experience relief lasting well past three months.^14,15 Manchikanti and colleagues found a trend toward longer lasting relief (by 2.5 weeks) when the blocks included anesthesia plus steroids, but steroids are associated with unnecessary side effects. At his private practice in Charlotte, Dr. Taub finds that blocks performed with small amounts of phenol provide low-risk, long-lasting pain relief.

All studies of medial branch blocks also find that the pain relief effect outlasts the pharmocological effect of the drug. Many experts propose that the local anesthetics interrupt the pain-spasm cycle and reverberating nociceptor transmissions.¹⁴ In the smaller percentage of cases that do not respond to chiropractic for unknown reasons, it also stands to reason that using a block to interrupt the pain-spasm cycle might make a patient’s body more responsive to future manual therapies.

Doctors of chiropractic may also consider using Dr. Taub’s medial branch blocks for diagnostic purposes. Medial branch blocks are prone to false positives when diagnosing facet joint pain of the cervical or lumbar spine. However, when scans are not positive, medial branch blocks can be very informative. They are also safer and easier to perform than facet joint blocks.

Please refer to Neal S. Taub, MD, Physiatrist
for pain management & rehabilitation.

References

1. Schofferman J, Bogduk N, Slosar P. Chronic whiplash and whiplash associated disorders: an evidence-based approach.

2. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995 Jan 1; 20(1): 20-5.

3. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine 1996 Aug 1; 21(15): 1737-44.

4. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996 Aug 1; 21(15):1746-59;1759-60.

5. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health. 2002 Oct;92(10):1634-41.

6. Wood TG, Colloca CJ, Matthews R. A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction. J Manipulative Physiol Ther. 2001 May;24(4):260-71.

7. Giles L, Muller R. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther. 1999 July/Aug;22(6):376-381.

8. Evans R, Bronfort G, Nelson B, Goldsmith CH. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002 Nov 1;27(21):2383-9.

9. Korthals-de Bos IB, Moving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, Koes BW, Vondeling H, Bouter LM. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ. 2003 Apr 26;326(7395):911.

10. Sarig-Bahat H. Evidence for exercise therapy in mechanical neck disorders. Man Ther. 2003 Feb;8(1):10-20.

11. Gross AR, Kay T, Hondras M, Goldsmith C, Haines T, Peloso P, Kennedy C, Hoving J. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002 Aug;7(3):131-49.

12. Wyatt L. Facet syndrome in the cervical spine. J Amer Chiropr Assoc 2004 Mar;41(3):32-37

13. Boswell M, Colson J, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007 Jan; 10(1): 229-53.

14. Manchikanit L, Manchikanti K, Damron K, et al. Effectiveness of cervical medial branch blocks in chronic neck pain: a prospective outcome study. Pain Physician. 2004; 7: 195-201.

15. Manchikani L, Damron K, Cash K. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006; 9(4):336-46.