Whiplash Injuries

This paper was presented at the BMAS Spring S.tnttfic Meetng held tn Bn.t.l n May 1996

SummarySites frcnnl which whiplash injury pain (acute necksprain) may arise include ntyofascial lrigger points(MTtPs), facet joints and the intervaftebral discs.Thete are various methods af deactivating MTrPs; thatrecommended is superlicial dry ncedling. Painreferral pattems fram facet jaint and MT\P naciceptotstt, , imtl. . t ,o [. ' i ]r tre to obt"in "pp'r ' , p$]e p"in rel ictfrom MT\P deactivation recessitales a diagnastia,fluoroscopically cantrolled, facel joinl block. Dis.paiD may occut either because ol damage la lheinnervated annulus fibrosus of an intacl disc, olbecause af nerve root pressure when a disc ruptLnes.Most whiplash palienls (75%) become pain lree

within 3-6 months. The rcnainder are sai(l to havelhe lale \"/hiplash syndrame. This was tormerlylhauBht to be du-a to neuroticistit or compensationseekinB avar;ae, but it is currently considered tohave a genuine orgaDic basis. Possible causesinclude overlooked facet joint dana1e, undetecteddisc damage and various self perpetuating MT|Ppa i n persi sti ng mecha n ism s.

Key wordsAcupuncture, Neck pain, Trigger poitrts, Whiplash

IntroductionWhiplash injury is exceedingly conrmon, bul severalrecent, extensive surveys (Evans, 1992; Fricl ion,1993; Mersl(ey, i993; Shapiro and Roth 1993;Teasell et a/-, 1993; Barnsley e1 a/., 199,1) havesho\,vn that there is considerable contro!,ersyconcerning the cause oi the varioLrs symptomsrvhich nray develop as i ls result; also disagreementas lo why sorne people recover relativey quicklywhilst olhers, even rrhen sLrbjected to apparentysimilar lraLrma, suffer long term disabil i ty: the scrcalled late whiplash syndrome. There are alsoIundamental di{ferences of opinion as to how itshoUld be treated. I wil l consider each of thesecontenlioLrs rnatters in turn, but before doing so Iwil i comment on the term whiplash, because thefeis -.ven dispute about that.

TeminologyThe term whiplash injury \\ ,as f irst ir ] troduced by

Ac0prn.nrc in Me.licine

Crowe in 1928, at a meeting of the WesternOrthopaedic Association in San Francisco, when hewas discussinB traff ic accident induced headjr] luries. His employment of the term was specif i-cal ly to describe the movement of the neckproduced by a sudder, acLrte, rnotion-related injury.' fhirty

six years later, he had to admit regret for everhavinfi jntroduced what he called, "This unfortunateterm" for, as he explained,

"This expression was intended to be a descriptionof maliotl but has been acc:epted by physicians,palients and attorneys as the name ol a disease"(Crowe, 1964).Moreovef, even if the medical profession and

others employ the terrn whiplash for the specif iccl inical entjty of a sudden, movement producedneck injury such as that sustained, for example, byfal l ing down stairs, by d'ving into shallow watcr, ormost commonJy of alJ in a car accident, i t is str ict lyonly correct to do so when the movements of theneck are lhose taken by a whiplash, Le. acutehyperextension lol lowed by iorceful f lexion, thescquence of rnovernents carried out by lhe neckw,hen, for example, a car at a standsti lJ is hit fromthe rear. Howevet as Porter (1989) has pointed out,only 8'/ . of cars in col l ision are struck {rom the rear.Equally commorly an injufy of exactly the sameLype, but with movements of the neck opposite toLhose laken by a whiplash, i .e. hypedlexionfol lowed by forceful extension, occurs when aslal ionafy car is hit from the front end. Porterlherefore argues that the term whiplash used collec-t ively for al l types of sudden movement producingneck injury is inaccurate. He alscr believes that i tsuse is undesirab e, as the genefal public have cometo look upon an injury given this name as onewhich invariably goes on to lasting disabil i ty andtroublesorne I i t igation.

He thefefore would l ike to see the term discontinued and replaced by that of acute neck sprain.There is undoubtedJy much m€rit in this suggestionas it serves to draw attention to the predornjnantpathology, which is stretching, bruising and learingof the muscles, tendons and l igamefts In the neck.With scvere trauma, there may in addil ion bedamagc to the intervertebral discs, facet joints andvertebrae.

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Despite Porter's conrm-^ndable sugElesl ion, thelarge nurrber oi papers recentiy published onwhiplash injuries shoh/s lhat the term is nol l ikely tobe readiiv abandoncd.

Muscle damage and consequent myofascial tiggerpoint activityIt is Benerally agrccd that the musclcs oi lhe neckand shoulder gircl lc bear the brunt of lhe damage.U,/ i l l ) moderate trauma they becomc stletched andw/i lh severe trauma the,v becomc part ial lv or.omp ete y torn. Despite this, the physical signsreierred to in rnost .rccounts of this cl isorcler areremark;:b]y few For example, oul oi 136 pdtienise ran r ined by Fa rbmar l (1973) , on l y 14 , / . we re ioundto have physical signs. And out ol 6l pntientsexarnined by Norris and Watt (198:l l , onl,v 10,1,were said to have physical siBr)s. Clne of thccommofest signs is restr ctcd Jleck movements.Anothef is swell ing of the soft t issles oi the neck;though evcn this is reported iar less irequent y thanmight be cxpe.led, consideriJlg lhat the trauntacauses thc muscles to bcconre oeclematous andhaemorragic.What, howev-.r, is most str iking about the ntajoritv

- , , , o ' t r . . l $ L r i , , l ' . \ i r ' . u r r r . t \ e r o * r , e o I rrelefcncc lo myolascial tr igf ler point {MTfP) activi ly,dcspite lraLrma to muscles b,^ing such a constantlcalufe oi this disordcr. Yales and Smith (1994), forcxample, in a rcccnl wide ranging compreh-.nsivereview oi the subject, make no mcntion oi thedeve opment ol activi ly in myofascial tr iEiger pointsand irom a rev clv oi the i terature i t is . lear thatlhose w,ho do so, sucf as Bonica .1nd Sola (1990),Evans (19921, Fricron (1993) and Sol,r (199,+), arcnotable cxceptions. MTfPs arc oi r:ourse invariablyIound in this disor(ler by thosc rvho care to look Ior' I * h . " rF r , L r \ h , r " i r r I r r . l , u . , . q r . r .fai urc to do tf is.Somc of lhe mnny misco|ccplions that have arisen

about this disorder need io be discussed, but bcforedoing so varous possible reasons for thedcvclopment of pain, visUai defects and spatialdisoriental ion rvi l l be considered.

Pain is l i .ble to arrse in this disordcr as a result ofclar1lage to musclcs, iac-.t joints, intravertebral discsar)d vertebfae.

Muscles of thc feck are stretched, torn and bnrisedby whiplash lrauma; and althoLrBh it woutct trcreasonable lo expect damage of thnt type to hcalaltef a lcw rveeks and for anv pain cdused by i t tojrst as quickly dis.ppeaf, thc pain in practice otlcnpersists ior severdl months. There is reason lobelievc thal i t is becausc ol the activation oinociccplors nt MT|P sitcs thal f i is pain continues I.)be ielt iong after hcaling ol the t issucs has takenpla.e.The r 'rruscles in which active MTrPs are l iab e to be

found inclucle the posterior cen,ical grorp ofmuscles an(l stefnoclcidornastoid, \ ! , i th paif fromMTrPs in lhese musclcs beif8 reierred to the head.Also the levaior scapulac, \^, i th paif f fom MTrPs inthis mLrscle being rcfcned up the sidc ol t lre neck,along the medial borcler oi the scapula afct downthe arnr. Activatcd MTrPs lf thc supra andjnfraspjnalus may also cause pain to be relerred

MI rP ac l i v i t y i s a l so l i ab le to dcvc lop i n t hepcctoral is minor and scalene musclcs; and theshortening and abnornral tautness oi these musclesthal oc(urs as a rcsLtl l , causes pressure lo be exeftedon lhe lower trunk of lhe brirch ai plcxLrs, with theconseqLrent cleveloprner] l of the thoracic outletsyndronre.

Thora( ic outlct s)/n.lrcneThe thofaclc outlcl syndr.rme is l iablc to r levelop inafyone \,! , i th a poor posture, bul one ot thecornmonest causes is i f j l rry to thc neck. Ross afdOwens (19661 found lhat in one third ol 1 3B casesoi this syndror.e, i t rn,as brought on by cervtcaltrauma. Trav€ll and Simons f l98la) described hor\/MTrPs in the sca enus aftcrior r 'nav cause thissy r rd rome to deve lop . Hong and S imons (1991)have morc rccenlly drawn attcf l ion to Ine f lafnerin which MTiP induced shortening,rnd tautncss oithe pcctoral is.f inor contf ibules to the syfdronte.

Thc symptoms.rfe mainly due to comprcssior oiihc lo\ 'ver trunk of the brachial plerus with resLrl l inspain dorvn the innef sidc ol the arm, togethcr \r, i th a"pins and ne-^dles" ser sation on the ulnar side oltheforcarm, hand, and ring and l i t t le f ingcrs; . lso atI imes, rneakness and numbness ol thcse two i ingers.

As a result of a whiplash injufy, subluxarion of thelncet joinis and excessive strctching of the joint(apsu es ta<cs p lace (Bon ica and So la , 1990) , w i thdevelopmcnt oi p,r in. What is of part iculdr rntercsLabolt this paif is th.t Bogduk (BoSduk nnd Simons19931 has shown that the patterns of pain fcfcn'alfrom cervical facet joints and from MTrPs in ncarbymuscles are slr ikinBly similar. l 'hL]\, Ior examplc, thereferfal oi pain irom a C2 3 iacet joint and fronrMTrPs ir) l)osteriof ccrvical mLrscles ncar lheirattachment to the occjput, is to the s.rmc parl ol lhehcad. The pntiern of pain referral from M]iPs ir] thelcvalor scapulae and lrom C4,5 facct joif ls nlsocon'esponds. Agajn, pain reierred from spleniusccrvicis MTrPs in thc lower part of thc ne.k andpain from the C3 4 af. l ,1-5 i ircet iolnts has the sirmedistr ibLrt ion.This similari ty of pain relerral pattefi ts is because

lhe i.cet joints ancl the muscles in the vicinity ofthem have similar seSmental nefve s!ut)res.Coniirmation thal pain is from a damaged facet jointcomes from alleviating i t e thcf by injecting a localafaesthctic into the ioiJlt or into the ncrvessupplying the joint (Bogd!k anrl Marsiand, 1988).This diagnoslic test carried oul or 5O consecutive

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cases of whiplash injury was posit ive in 54o1, otpatients (Barnsley ct a/., 1 995).

Pain due to disc damagePain r. lay result from a u,hipiash injury that hascaused a tear in the richly innervated annulusfibrosus of a disc, or avulsion of the disc from thevertebral end plate (Davis et a/., 1991). Disc pain-o1 , l - o a r -e n \ ^ r rn end p l r ' a ' ompr . ' confracture causes destructive enzymes to be releasedinto the nLrcleus pulposus (Cerwin, I995). Inaddit ion, ruptLrre of the annulus f ibroslts withherniation of the nucleus pulposus may Bive rise toa radiculopathy. In the investigation of disc damagc,magnetic resonance imaging is the procedLtre oTchoice (Davis ef al., 1991). At one t ime rl wasthought that cervical discography would be helpful,but i t has been found to havc an unacceptably highfalse posit ive rate (Bogduk and Apri l l , 1993).

Spat i al d i so / i entati o nIt is not uncommon for a patjent to suffer spatialdisorientation fol owing a whiplash iniury. This mayat t imes be a tfue vefigo, blt often it takes the forr.of dizziness, ight headedness and sudden loss ofbalance. Such disturbances may cause the patient tofal l or veer to one side when walking.

This spatjal disorientatiof is at t ir .es due to verte-brobasilar artery insuff iciency either due tothrombosjs of the vetebra artery or as a result ol rtscornpression by a contfacted deep cervical tascia(Compere, 1968). A far less well recognised cause,and yet one that is far more feadily trcatable, jsinterference with proprioceptive mechanisms in thec avicular part ol the sternocleidomastoid due to i tsshortening throuBh MTrP activity within the muscle(Travell and Simons, I983b).

visual defectsThese are not infrequeni. The commonesl isoculomotor nerve dysfunction: this ls believed to beduc to lmpaction darnage to the midbrain(Hildingsson et a1., 19n9). Blurring ol vision anddiff iculty in focusing may also be complained of:these may be due to increased sympathetic effereniactivity (Barnsley er r/-, 1994).

Factorc influencing the prognosis of the disorderFrorn various prospective fol low-up sludies (Nofrisand Watt, 1983; Miles et a/., 1988; Pl]nnje andABambar, 1991), and retrospective ones (Deans eta/., 1987i Maimarjs et a/., 1988; Cargan andBannister, I 990; Watl<jnson et a/., 1991) i l has beendeduced that between I4 and 42% of patients w'thwhiplash injUries d€velop chronic pain and thatapproxirnaiely 10'1, of these have constanL sevcrepain indefinitely (Barnsley ei a/., 1994).

Broadly speaking thcrefore, /57o of palients wilhwhiplash injuries recover within 3-6 months, butapproximately 25% develop \!hat is known as thelate r,vhiplash syndrorfe, a condit jon in whichsymptoms persist for more lhan six months. There is

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a widespread feeling among sorne doclols andlawyers thal becausc a lvhiplash injury rs no morethan an acute muscle strain, a patient shouJdrecover frorn i t in a nratter of a few r.onths, and thcpersistence oi sympto..s for onger than thal mLtslbF d . * t o , rFU o t i , .m : rd /o r I . . b . u . n i o r - .even conscioLrs desirc ior f inancial compensation-Pearce (1989) has even gone so lar as to sa, "Most

victitlts al whiplash injurl, have ... suslaitled nomore than a minor sprain to the solt ils-tues andunusually severe or pratracted conplaints maydemancl explanations ',^,hich lie aLttside the fields alorgani. and psychiatric iIIness".

Emoti o na I d i stu rba nc esothers who have attr ibuted the late whiplashsyndrorne to neuroticism include Cay ancl Abbotl( l 953 ) , Fa rbman (1973) and Ba l l a (1980)

It is, howevet now LJecoming increasin8ly wellrecognised that i t is not emotional instabil i ty whichcauses the pain to persist, but conversely i i isbecause of severe unrenrit t ing pain that anxiety anddepression develop (Merske, 1993). Mofeover, i t isthe job insecufit t rnarital disharmony and socialdisruption that arise as a resLrlt of organical ly basedpain that make these affective disorders worse.At thc same time it has to be admjtted that up to

70% of people who suffer injury lo the neck tromcar accidents develop trauma-induced phobias anda small nLrmber get a ful ly developed post traurnaticstress disorder with vivid dreams abo!t me acctoentand distressing daytime rnemories oi i l (Shapiro andRoth, 1993). l t also has to be admitted that thc painis l iable to be made worse by any part icularlyanxiety inducinB expefience, such, for exarnple, as apatient may be subjected to when seekinS compen-sation,This having been said, lhere is no support lor the

view put forward by MiI ler (1961) that thepersistence of symptoms by accident vict ims lsfostered by a desire for cornpensation/ and that suchsymptoms resolve once this has been achieved, foras Mendleson (1982) has clearly shown, compensa-Lion claimafts are "not cured by thc verdict"l

A. \c{ md ( | ( :1 .0 hd. .drd Con- ioL ' , o ,unconscious fabricatian ol symptonts u ndaubtedlyoacurs ... but experience shows thal iL is usually thepe\istence af sytnptoms that leads a patient tolitig,ation and not vice versa".It is therelore now generally aSreed lhat patients

with whiplash injuries who exaSgerate or malingerare in a dist inct minority (Evans, 1992) and that inthe rnajority ol cases the injuries resull in reaL,organic lesions in Eenuinc patjents (Barnsley el a/.,

The late whiplash syndrcmeAs al l recent evidence is against attr ibutirB thepersistence of pain tor more than six months, lhelatc whiplash syndror.e, to neuroticism and/orcompensatjon seekinS avarice, i t is necessary tocofsider alternative explafal ions. Factors which

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Radanov et a/. (1991), in a stLr. ly prif lari lyconccrncd !vi lh psychosocial ini luefce!, identjf iedas being productive of symptoms lasl ing ior morethan six monlhs included sevcre i f i t i ,r l pnin,jncrcasing aBe, and cognit ivc distu )ances such asimpaired attention, concenlratior] afd memory.Thcsc cognil ive changes arc thought to be broughtabout bv the dinracting inf lueJlcc of severe p.r in, theanxicty and del)ression produc€d by this and theeffects of druBs errployed to contbal i t (Radanov efa/., 1992; Shapiro et a/., 1993; Merskey, 1 993). Theyare therefore related to the sevefity of the init ialpa jn .' l-hc

sev-.r i \ , of the i f i t ial pain mLrst be related tothc j f ten\i t), of the trauma. With r. i ld to rnodefatcinjury lhe onset of the pain is delayed for 2.+ 48hours and when it docs come on, i t is often no ntorethan a widespread dull ache. l t is only v"'hen thetraLrma is considerablc that the pain is both scvereafd present from the beginfi f€i.

In olher studies, ccrv'cal spondyosis has be€ncited as being indicativc of a poor proSnosis (Noff isand Wdtt, 1983; Maimaris er ,/ . , 19BB; Milcs el .r/ . ,19BB; \ /atkinson el al. , 1991). Radiographicallydemonstrable, symplomless cervical spondylosis,hor,,,,^ver, is <nown 1() L)eaome commoner and mor'eextensive with advancinS years, so this f inding maysimply signify thal the protnosis in this disorder isage relatcd, as stated by Radanov et a/. (19911.Clearly their f indings indicatc f iat one of ther - . r ' on \ I n r l r a n - . . , - r . F o i . ) n rp to | | r . . . - \F tFtfauma, buI late w,hiplash syndrome may deve op inthose who have been subjectcd to no more tharmild injury, fhus some other possible reasons lof thcdevelopment of this syndrome have to beconsidered. The1, include the sett ing up of sel lperpetuating MTrP painpersist inS mechanisms,unsLrspected lacet joint injury ar]cl undetectcd discdamage .

Se If- pe r petu ati n g MT.P p a i n-pe rci sti ng me ch an ;smsMTrP pain is init ial ly pfoducecl as a resu t ofnociceptors at MTrP sites undergoing high inter]sit), ,trauma induced activation. This lraLtma alsoclamages the surrolrnding t issues, \\ / i lh fesult ingrelease of srLrstances such as prostaglatldins andbradykinif w,hich sensittse thc nociceptofs, l .e. i tlowcrs th-. ir threshold enabling lhem to respofd iolow intensily st imuli such as i irrn pressLrre with thc, ' J l o " r r r8 f i , 1 * . ' , l l . d o a r , h rn . r , . . " . r . rphenomenon which accounls for active MTrPs beingso exquisitely tendef. Thc sensory afferent barragc\ e r u o l r . , t , , . d . , 1 , 1 . p . r . . n u , i , . p r . . . lMTrP sites is thcn responsible for the dcvelopntentof pain persrstini l neuronal changes in thc spin.r lcord, but befofc discussin8 these it is neccssary lo, o r . d* lo , , r od I o r . r . t r - , - tp , t - o t 1a, i , e f osensit ising subslances (NSSs).

NSS-induced ischaemic changes at MT.P sitesNSSs such as braclyl<inin and prostaglandins have avasodilalory ei iect. This causes oedenla to develop

at M_liP sit-^s with resultanl compression of veinsand pfoduction of ischaemia. The ischaemiaproduced in this manner encoura8es thc release ofyei more N55s and thus the perpctuatron otnociceplor pain prpducing sensit isation. This NSSinduced ischaemia also caurses thc mLtscles to bedepleted of adenosinc tr iphosphate with cons-6quentcalcium pump fai lure and thcrefore thedevelopment of muscle spasm. The muscie spasrnmakes lhe ischaemia worse; the lowered oxygentension at MTrP sites encourages yet rnore NSS5 tobe released and, by so doing, enslrres thepersrSlence ol urc parn.

Self-perpetuating circuils between MTrPs andneurones in spinal cordMoto r-ne u ro n c c i rc u i tsThe sensory affcreni barraSe set up by activatecl andsensit ised nociceptors at MTrP sites gives r ise toactivity in ventral horn situated motor neurones withconseqLrent motor eifefent activity. This in tufncauses development ol rnuscie spasm, with theresultant ischaenria' encouraging l iberation of NSSsand perpctualion of the pain.

5),m patheti c neu n; a I c i rc u itsThis scnsory afferent barrage also activatessympathelic preganglionic neurones, which in lufnactivate postBanglionic ncurones. The sy..patheticcjterefl aci ivity which arises as a result causes nora-drenalire to be released at MTrP srres \, \ ,rLn ai o r .oq !a l t r , t r r - ' L . r i o ' l . t VT tP 1 ( ] , t , pp tu lacuvly.

Dotsal horn neuronal plasticityThis sensory afferent barrage front activated andsensit ised MTrP nocic-^ptors also causes neuropeptides, such as Substance P and calcrrorrrrr gerrerelated peptide, lo be released from lhe dorsal horntermifals of Croup lV sensory aiferents and thescneuropeptides, loSether with cxcrlatory amino acids,such as glLrtnmate al ld asparlate, bnn€j aboLtt, h r1 t . . \ .m t l \ | D . -p r t , , t * ,NMn \ ' - , . p o ' .that lead to rhe sett ing up of a state of excitabi l i ty i fwide dyfanric range transmission feufones: ap i . 1 . n a O r k O \ ' t , . , , T l _ o l . a l . . I U r

l l . - " r u r r l . P 1 - : , . r . : r \ . r . - t o(i) an increase in thcse feurones' receptive i ields,( i i) the developr.cni oi A-[] mediated pain, l-e.pain produced by normally innocuous mechar-rical' l r r l . l i u r u C F l o r , . ! , , p \ F , n o i , l( i i i ) the pefsistencc oi MTrP nociceptor medtateclp a f .As Mensc {199:l) h.rs poinicd out, these pain

persist ing mcchanisms are no ntore than workingh \ o u t L p . - \ b . . J ^ r r r n r o n l " d B p i . n , p j Sthe neurophysioloBy of muscle pain. How,ever, atleast they offer seeir ingly plausible explar]ations asto v"'hy in sonre cases MTrP acl ivity is sel l- l imjt ingand disappears spontancously aitef a re atively shor|period, but in others i t pcrsisls irdefinitely Such con-sidcrations have impotant therapeLrt ic implications,

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because what we do not know, and only cl inicaltr ials wil l answer, is whether the repeated deactjva-t ion of MTrPs at an early sta8e of any MTrP paindisorder not only pfovides syr.ptomatic pain re iet,bot also serves to prevent MTrP activ'ty frombecoming chronici and thus whether i t is capable ofdecreasing the incidence of the late whiplashSyndrome.There can be no doubt that mlch of the pain in the

late whiplash syndrome comes from persistentlyactive MTrPs, for in my experience deactivatingthem invariably provides pain rel ief. This, however,is usually only for a l imited period of t irne and inorder to keep the patient out o{ pain lhe procedurehas to be repeated about once a monlh on a longterm basis.

Facet joint damageAs stated earl ier, Bogdul< has drawn attention to thepossibi l i ty that some ofthe pain in a whiplash injurymay arise from activation of nociceptors in the facetjoints. The investigation of this by seeing whetherthe pain is al levialed by nerve blocks to the jointshas to be done under radiological control andrequires a certain amount of expetise, However, i tshould be undertaken in any case where the moresimple MTrP deactivation technique fai ls to haveany wothwhile effect. At the same time it has to beadmitted that the results of attemptinB to obtain lonSterm rel ief from the pain with intra art icuJar steroidshave been disappointing (Barnsley et a/., 1994).

Disc damageThat disc damage can be a source of pain is c]ear, aswe now know that the annulus f ibrosus is r ichlyinnervated; and where there is a neurologicaJ deficiton cJinical examination, and magnetic resonanceimaginB (MRl) shows a bulge at the level expectedfrom the physical signs, rernoval of the ruptured discis essential.Another possibi l i ty is that some of the pain in the

iate whiplash syndrome comes from an annulusfibrosus which, although damaged, has not rupturedsuff iciently to al low the nucleus pulposus to extrudethrou8h it . Proving this, however, js dif l icult becalrselocalised dar.age of this type may not be readilyobservab e on an MRI scan, and discography unfor-tunately is known to have an unacceptably hi: lhialse positive rate.

Treatment of acute whiplash injuryCallarsSplint ing of the neck in a col lar is highly controversial- Mealy ef ai. (19B6) compared earlymobil isat 'on of the neck usinB Mait land typeexercises in one group, with the use of a colJar inanother group and found that those treated by earlymobil isation did better, with a siBnif icantly greaterreduction of pain and sti f fness.Pennie and Agambar (1991), however, who

compared two groups treated either by col lar or byactive exercises found the results of the two types of

Acupuncturc in Meclicinc

treatmenl were similar; and as treatment with activeexercises provided in a physiotherapy departmentproved to be rnore expensive, came down in favourof the use of a col lar alone. They recommended,however, that this should be an individuallymoulded, thermoplastic, polyethylene foam collar,which keeps the neck sl ightly f lexed, rather than thestandard type which tends to spl int i t in a sl iShtlyextended posit ion.The use of a colJar thefefore continues Lo be

popular, but there is general a: lreement that i tshould never be worn continuously for more lhantwo weeks. This is because prolonged use of a col larcauses weakenin8/ wasting and shortenin8 oi th€neck muscles. ln addit ion, the patient becomesunduly rel iant on it and increasingly reluclant toleave it off. After lwo weeks of continuous use,therefore, the patient should gradually be weanedoff i t and it should be worn only whilst carrying outtasks which place persistent strain on the neckmuscles, such as when operating a computer for anylength of t ime, or travell ing in a car for anappreciable distance.

Neck muscle srreichin8 exer"c/sesExercises designed to si length€n the muscles of theneck should be avoided, as they do no more thanoverload already dama8ed muscles and mayincrease the pain.

Exercises, howev€r, designed to stelch the musclesthat have been shortened as a result of M_frP activityshould be carried out fol lowinB each MTrP deacti-vatrnE treatment sessron.

TtactionTraction has long been popular with physiotherapists, but Newman (1990) considers i ts use to beil logical and Teasell ef a/. ( l993) state that they havefound mechanical forms of traction often make painworse by further damaging the t issues- Theytherefore prefer manual traction carried out by aphysiotherapist, but, as they say, far bettef than thisare muscle stretchinS exercises.

Deactivation of myofascial triqger pointsThe only control led tr ials of methods of deactivatingMnPs in whipJash injuries are those which havebeen carried out by Bryn and his co workers. Theyfirst showed that i t is possible to rel ieve the MTrPpain of a whiplash injury by injecting water into theskin overiying MTrPs {Bryn ef a/., 1991). As anintradermal injection of water is extremely painful,they decided to compare the effectiveness of subcutaneous injection of water with that of subcutaneoussaline at MTIP sites. They found that althouSh \r 'r 'aterinjected into the subcutaneous t issues gives rise to abrief but intense burning sensation, i ts MTrP painrel ieving effect 's signif icantly better than thatobtained with sal ine (Bryn et a/., 1993).

It would seenr that any pain rel ief obtained u,hen\r 'r 'ater or sal ine is injected into the superf icial t issuesimmediately overlying a MTrP, must be due to

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stimulation of 4-6 nerve f ibres brought about byeither of these substances and also by the needleused for injecting i i . For there are : lrounds forbeJieving that the sensory afferent banage set up asa result of this causes opioid peptide mediatedinhibitory interneurons in the dorsal horn to becomeactivated and that the effect of this is to blocl< the Cafferent input to the spinal cord from Croup IVnociceptors at MTrP sites; a pain rel ieving effect thatcan be brought about just as well by means ol dryneedle st imulation of the 4-6 f ibres in the t issuesoverlying a MTrP (Baldr, 1993). This procedure hascome to be known as superf icial dry needling(SDN), in ordef to dist inguish it from deep dryneedling (DDN) (Cunn, 1989), a form of treatrnentin which the needle is inserted into the MTrP ;tsejf.DDN has the disadvantage of being a somewhatpainful procedure and there is a need for large scalelr ials to be carried out by cl inicians experienced inthe use of both SDN and DDN in order to determineobjectively the comparative safety, simplicity,patient acceptabil i ty and above al l the pain rel ievingeffectiveness of these tlvo forms of acupuncture(Ba ld ry 1995) .

ConclusionThe treatrnent of whiplash injury depends on therebeing three principle sites from which the painemanates: the muscles, the intervertebral discs, andthe lacet joints-

Pain t'rcm muscleThe pain from muscle is part ly due to tears of themuscle f ibres and bleeding into the t issues, but painthat is simply due to this should quickly disappear.The pain, however, almost invariably persists for anappreciable period of t irne due to trau..a inducedactivation and sensit isation of nociceptors atrnyolascial tr iSger point sites.

Pa i n from i ntervertebra I d i scsThe only part of the disc that is innervated is theouter area of the annulus f ibrosus. Localised discpain may therefore arise from trauma induceddamage to the annulus. In addit ion, morewidespread pain involving the neck and arm maydevelop if the annulus ruptures with herniation otthe nucleus pulposus through it- Disc radiculopathypain has to be dist inguished from thoracic outletsyndrome pain brought about by MTrP inducedshortening of the scalenus anterior and pectoral isminor muscles causing pressure to be exerted on thelower part of the brachial plexus.

Pain ftom the lacet jointsIt is now recognised that trauma induced injury tofacet joints is a cause of pain, with the pattern ofpain referral {rom individual joints being similar tothose fron MTrPs in adjacent muscles. To estabJishthat pain is from a facet joint i t is necessary toabolish i t by perform;ng a facet joint nerve block, aprocedure that has to be carried out under f luoro-scopic control.

Late whiplash syndromeRetrospective and prospective surveys have shownthat approximately 75% of patjents lose theirsyrnptoms, part icularly theif pain, within 3-6months. The remainder however continue to havepain for longer than 6 months: the so called latewhiplash syndrome. The development of thissyndrome has been considered by sorne to be dueto neuroticism and/or compensation seekingavarice. The current consensus/ however, is that ithas an organic basis.

There is a high incidence of the syndrome in thosesubjected to part icularly severe trauma, with paincoming on immediately rathef than the more usualI or 2 days after the injury. However, ;t is also seenin those with mild to moderate trauma. Suggestedreasons for this include overlooked facet jointdamage or the sett ing up of self perpetuating MTrPpain persist ing mechanisms. These include theproduction of bradykinin induced ischaemicchanges al MTrP sitesj the development ofsympathetic and motor efferent activity; and ofdorsal horn neuronal plasticity.

TreatmentSplint inE of the neck in a col lar is highJy controveGsial. l f i t is worn, i t should be for only the {irst I or 2weeks. MTrP deactivation is of considerableimportance. The treatment of choice for this issuperf icial dry needling, which if started at an earlystage and repeated at regular intelvals providessyrnptomatic pain relief. The question, however, thatneeds to be answ€red by cl inical tr ials, is whether i tprevents MTrP pain perpetuating mechanlsms lromdeveloping and whether by so doing it reduces theincidence o{ the late whiplash syndrome.

Peter Baldty FRCPMillstream House, Old Rectoty Creen

Fladbury, Pershore, Worcs (UK) WRl0 2QX

1. Badry PE (1.191) A.upur.llre, tigqe. points and mLlsculaskeletal pain, 2nd edition. Ch!rchill Livingnone,Edinburgh

2. Badry PE (1995) Supe ic ia l dry n-"edl ing at myofascia ltriEser point sites. laurnal of Mus.uloskeletal Pain. 313):117-25

L Bal a l l (1980) The l r te whip lash syndrome. Aort ra l ian ardNew Zeatand Journa I af Su eery. s0:61a 4

4. Bamsl€y L, Lord SM, Bosdlk N (1994) Whipash ln jury.Pain. 58:283 3O7

5. Barnslcy L, Lod SM, Wal l is BJ, Bo8duk N (199,1) Lack ofeffect of intra anicu lar .o rtjcoslefo id s lof chronic pain in thecervical zySapophysia joinrs. Ne\| England lauthal afMediclne. 330: 1447 5A

6. Barnsley L, Lord SM, $/a l ls 8J, Bogduk N (199s) Thepr-"valence of chronic cervical zy8apophysial joint pain afterwhip ash. splne. 201l):20-6

7. Bosduk N, Apr i l l C (1993) On th€ nature of neck paindlscosraphy and cervical zysapophysial joint b ocks. Pal,.5 1 : 2 1 3 7

8. BoSdu< N, Mars land A (1988) The cerv ica l zygapophysia ljo n ls as a source. , f neck pain. sprne. /? i610 17

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9 . B o B d u < N , 5 n r o f s l l C ( r 9 9 1 ) N e c k P a i n . i o n t p a i n o rtrigBer poinG? n: Vreroy H, Me6k-"y H, eds. ProErcss trFihn nqlgia an.l Mptas.iai Pain. tlsevicr 5ciencePrb isheE BVr267 7 l

l i l Bonica J l , so la N (19901 Neck f ' i l r . l f : Bonica l j , ed 1]1ci\lanagcncnt af Pain, 2nr1 e.l;1io,r le.r anf Febiger,Phi ladclphia:8; .1 6

l l . Bryr C, Bo.efne. l l L i .der Lt (1991) l l€atmcf l o t ncckrn i l s l ,oukler pain n i ,h p lash syndromc wth rnt racutan-"oLs srefi e s,ar.r intcclions. A.ta AnaesthetioloutcrS.eDdinavi.a l5:5) )

l2 Bryn C, Osson FaLheder l , l i fd) M, HosLer-ay V,foSelberg M ( l99l l 5ubc! t . f€ots sLer i le $,a lef i i le . to fsior .hronic re(k nfd shoukler p. . p 'o onswh Lr lJsh in j ! r ie5. l t r . - . / . j , ,17 r . ,1 ,19 52

l l ao pere WE l l9r ,8) E e. t fonystagnro8rapl r ic r lnd lngs inpar -"nts M,ith lrh plash ifjfr cs. Laryn\atu)pe. 76:1226'33

l .1.Crowc l l (19611 A ne\ ! d iagnod( s ls f ln feck . j t r ies.Cal itamian Medn I ne 1 0A: 1 2- -l

l5 Dal is 5 j , Teresi LM, Urndley \ !Cl , Z ie i rba MA, Bloze AE( l991r Cer! ic i , l sp i fe,yperel len\ i .D i iur ies. N1 R Fnd nEsRr. lh lo l r t80:215 i ]

l6 .De.nr Gl . ,Vagal ad lN, Kctr N.1, Ruther iord WH 1l !87)Ne.k pa n a major a6c of d isJb i ty to owi fg cafaccidcnts. , r lu ,L /6 j l0 2

l7. t ! .ns R\ / ( 992r Sof)e observ. lons on wh p lash n i l r ics.Neutulo9i.irl Cl i n.:s t 0(1) : 1)7 a 97

l8.FJ 'bmaf A

{197J1 Ne.k spra i i aso. ia l .d fa. tors.ldirtal ai th," Anetkin Me.li.al Asn.iatian. 221:1014 5

r 9 . r r i c l o n l R ( 1 9 9 1 ) N l y o t a s c i a p a n a f d w r i p a n r . - 5 p t r e :Stete oi thc Att Rcricrrs. 7ll):103 21

20. Cargan Ml , Bain in. r CC {1990) LonB teror proBnos s o i so l ltisslc nlurlcs oi ihc nec(. k\rrrl ot Bote.nJ laint Su"aett)(BR) 72:941 1

2l . Cay IR, Abl rot t l (H ( l9 i l ) ( ,odi rnon whip ash in j l r es ot thenc,c<. /.r!."a/ ot the Anetk:an Me.lical A$ociatian7 5 2 r 1 6 ! ) 8 - l 7 0 l

22 ! ie^\ , in l { ( l9 l r5) , lyo ias. ia l pan and n.ck pain Spi ie :State o i th€ At Rcr icws. 9 l3t :1 11

2:r .Cuin CC t19E9) I r ta t i ry nrvolas.r : , / pr , ' Lr f ivefs y .Waehington, Scat t e .

2: r . l l ld ing$on [ , WcniBren t ]1 , t l r inE C, Too;nc.r C (1989)O.!lonrotor Lrrob ems Jrier cerv cir sp.r inj!ry. ,l.ri( rthapa.-.i n:a S..rrlinnvk t.60:51) 6

I 1 . . - / , t . t " , I ' o 6 t , n , o , , i opecl . 'a is m nor mvolas. ia pan syndromc ai t . r whipash.launil of NlLs.ulaskel€tal Pain 1i1):a9 131

z6.Malnrar is C, Darnca MR, Ad. i Ml (1988) Whip.sh i f lur iesoi thc icck: a r . t rospcct ive st (dy. / r l r ry 7t ,19:16

27.Mca ) K, Sre inan H, Fenelor CC {r986) hf ly nrob iTal ionoi ac! te wr ip l ish in j ! , ies. Br ln l , t r ledki l t \nnal . 292:656-7

28 r \ lende soi C 119{ l2 l Not ' .urcd by a vcrd ic l ' . f ic . t o i eSr lselllemenl on .ompensation c aimants. Me.li.?/ /orfnri o,Aust la l ia . 2:11) 1

l . r . r \1ense 5119! l l Noc ccpt ior f rom s(c etJ n) !sc le i f 'e r t io .t o . l n i . a n r u s . c p a n . P ; r i n 5 1 : 2 1 I t

l0 .Mc6<cy J ( l99 l l Psy.holos ic . r l cofse. tuences o i $,h p lashinj!ry. -trDe, Jrrre o///re ,4 tL Rer ie\\,s. 7t J ) : 47 t t\t)

l l . Mi les KA, Mr i fDr s C, F in la) ' D eL a l . ( r 9 l i lJ t Thc i .c idcn. .i .d prcgion . s gni i l .an.e o i rad o logical abnornra l l t ies lso i l l$ue ntur es n ihc.ov ical sp ine.ste/e l . r / Rr i l ;o /or l

17. Por ter KM 1 98!) Neck srr ra i fs a ler . , r f . . . i . len1s. Brr rshMedi.al Jaxt n.t. 2t8: 9r r1

l8 leh.ov Be S.h indr 8 A, St . iano C, St !zc icsg.r 1 ( l992)lfess beha! o!r afto comnron nh Lrlash Lan.et. ll9:

19. Radano! Be Slr iaro C,Schncdr lg A, t lJ l l rnr f '1 99r)Rr leoi ps-vchoso. i , s t rcss n recolcry i rorr w r ip rs , i f l r ryLancet . 318:7 2 5

.+0 Ro$ )B, a l$,ens lC l l ! l , l , r lh . t r r . . o l le t sudromcAr.hlvcs at Sur9cry.93:71 3

, l l .Shapiro AR Rodr RS (1991) The c i t . , .L o i lL i r r t ior ofrccolcry irom whlplasr. .!p,rer sl.,le oi 1/'-- /1fi /ierp'!s.713) :531 56

.+2.50a A (199.1) Upper e\Lrenr i ty p i in r :Wal l t 'D, 1e za.kR, eds. Ierlborl oIht,, :r,rl -"./r/lor. Chlr.h Li! ngnonc,Fd nbu'8h: .172- ,1

,11. l 'e is-" ] RW Shaplro AP. Mai l is A (1991) Medlc. lnranagemcnt o i whip as l r i f j l r ies: J r o le v er ' . .5r ) t ,e j .S/ . r r - .ot tha Aft Reviefs. 7(3):18 9,

,1.r.Travcll lC, Sinrois LIC ll!8-lr Mpl,ls.ittl t',it) .ndDysfunctian fhe htBet Pai .Vr.drl W iifis and\ ' ! i lk ns, Unl l inro 'e: r 1 ,19, h 207

.45 Waik inron A, CafSan 1F, Bani ncr ( )C t l99 l l Prognonicf . . l06 n sol t I * !e in tur ics o i thc cc^, l . i l sp ine. in lo4r 221

.+6. \ /e k Pt (199.+) Mnnip! . tve PtucedL'es. rn: $re ls PE,I'ramploi V Bowrer D, els. t'itn M.D,1E-"neDt 1JvP\rchathefrev 2nd .".iiti r BllleN,ofih llcincmann,O\ iddrchJpter l7

.,17 \tles llAH, Smilh 4A (r99,1) Odhopacd c paii afterl f iuma. In: Wal l PD, Me za.k R. .ds. Ic \ tboot , i Pr t r , lde./lrior. Chlr.h ll L linSstonc, [dinb! tsh: .+] 7 2 |

i 2 . M i l e r l l r l . l a l i A . c i d c f t r c u r o s i !l a u n a l . l : 9 1 9 ) 5 , 9 9 2 I

l l .Norman PK (1990) WhipJsh i i ju '1 , .l.n, n.l. 3A1 395-6

1.1 No is SH, \ 'V. r r i (1981) The prognos s or ncc< i i lurcsres! in8 ironr r-"arend lehl.le ..ll sians laurnal af Donee' . lb int Sutg-"ry . 658:6t)8 11

l i .P-"af .e lM (198.r r Wh plash n j ! ry : a rcapprJ isr . /ourra l o/Neoology, Neorcsurycrf and Psychia \,. 52: 1129 3l

l l i Pcnnlc I , AEanrbar LJ (1991) Pat tc ns o i in l ! ry . r fd re.overyin whlp l !sh . / " iur .? : ,57 9

A.upunctute h MediLine 28

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ACUPUNCTURE TREATMENTmakes Clinical and Economic sense

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rel: 01925 730727 Fa* 01925 ?30492

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