Whiplash

453 Pages·2002·72.322 MB·English

by  Gerard A Malanga, Scott Nadler

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LibraryofCongressCataloging-in-PublicationData
Whiplash/ editedbyGerardA.Malanga,ScottNadler.
p.;cm.
Includesbibliographicalreferencesand index.
ISBN-13 978-1-56053-438-9 ISBN-IO: 1-56053-438-9(alk.paper)
1.Whiplashinjuries. 2.Spine-Woundsand injuries. I.Malanga,GerardA.
II.Nadler,Scott,1964-
[DNLM: 1.WhiplashInjuries. WE725W57232001]
RD533.5.w482002
617.5'3044-dc21
2001039767
ISBN-13:978-1-56053-438-9
ISBN-IO: 1-56053-438-9{alk.paper)
Whiplash
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•
Contributors
•
Leslie Bamsley,Bmed, GradDipEpid,PhD, FRACP,FAFRM(RACP)
Associate Professor, Department of Medicine, University of Sydney; Senior Staff
Specialist,Concord Hospital,Concord,New SouthWales,Australia
AndreaJ.Boon,MD
AssistantProfessor,DepartmentofPhysical Medicineand Rehabilitation/Department
ofNeurology,MayoClinic,Rochester,Minnesota
NikolaiBogduk,MD, PhD, DSc
Professor, Department of Anatomy and Musculoskeletal Medicine, University of
Newcastle, Newcastle; Director,NewcastleBoneand Joint Institute,Royal Newcastle
Hospital,Newcastle,NewSouthWales,Australia
ChristopherM.Bono,MD
SpineFellow,DepartmentofOrthopedicSurgery,UniversityofCalifornia,SanDiego,
California
DonaldS.Ciccone, PhD
AssistantProfessor,DepartmentofPsychiatry,University ofMedicineandDentistryof
NewJersey-NewJerseyMedicalSchool,Newark, NewJersey
DavidW.Chow,MD
Director, Interventional Spine, and Assistant Professor, Department of Physical
Medicineand Rehabilitation,UniversityofCincinnati,Cincinnati,Ohio
AnnC.Cotter,MD
Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation,
University of Medicine and Dentistry of New Jersey-New Jersey Medical School,
Newark;MedicalDirector,AtlanticMind BodyCenter,MorristownMemorial Hospital,
AtlanticHealth System,Morristown, NewJersey
Ronald PatrickDellanno,DC
Chiropractor, Director ofSpinal Biophysics Research Center, Bloomfield; President,
Cervigard,Inc.,Bloomfield,NewJersey
ToddA.Edelson,MA,PT,DipMDT
AssociateFaculty,NewYorkMedicalCollege,Valhalla,New York;Faculty,McKenzie
InstituteInternational,Waikanae, New Zealand;Owner/Director, MontclairPhysical
TherapyAssociates,Montclair,NewJersey
DeborahK.Elliott, BS
ResearchSpecialist,DepartmentofPsychiatry,University ofMedicineand Dentistry of
NewJersey-NewJerseyMedicalSchool,Newark, NewJersey
Joseph D.Fortin,DO
Clinical Professor, Department of Physical Medicine and Rehabilitation, Indiana
UniversitySchoolofMedicine, Fort Wayne;Medical Director, Spine Technology and
Rehabilitation,FortWayne,Indiana
vii
viii .. Contributors
MichaelB.Furman, MD,MS
Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation,
TempleUniversity,Philadelphia;TheCenterfor Pain Managementand Rehabilitation,
York,Pennsylvania
RalphE.Gay, MD, DC
Instructor, DepartmentofPhysicalMedicineand Rehabilitation, Mayo Clinic, Mayo
SchoolofMedicine,Rochester,Minnesota
Roy C.Grzesiak,PhD
ClinicalAssociate Professor, Department of Psychiatry, University of Medicine and
DentistryofNewJersey-NewJerseyMedicalSchool,Newark;ConsultingPsychologist,
NewJerseyPainInstitute,UMDNJ,New Brunswick,New Jersey
Robert F.Heary, MD
Director, The Spine Center of New Jersey, Neurological Institute of New Jersey,
University Hospital, Newark; AssociateProfessor,DepartmentofNeurologicalSurgery,
University of Medicine and Dentistry of New Jersey-New Jersey Medical School,
Newark, NewJersey
GaryM.Heir, DMD
AssociateClinicalProfessor, DepartmentofOralPathology,Biology,and Diagnostic
Services, University of Medicine and Dentistry of New Jersey, Newark; Attending
Physician,St.BarnabasMedicalCenter,Livingston, NewJersey
NancyKim, MD
ChiefResident, Departmentof Physical Medicine and Rehabilitation, University of
Medicineand Dentistry ofNewJersey-NewJerseyMedicalSchool,Newark,NewJersey
StevenC.Kirshblum,MD
AssociateProfessor,DepartmentofPhysicalMedicine and Rehabilitation, Universityof
Medicineand DentistryofNewJersey-NewJersey MedicalSchool, Newark;Kessler
InstituteforRehabilitation, WestOrange,NewJersey
Robert S.Levine,MD
ClinicalAssociateProfessor,DepartmentofOrthopedicSurgery,WayneStateUniversity
SchoolofMedicine;AdjunctAssociate Professorand Medical Director,Bioengineering
Center,CollegeofEngineering, WayneStateUniversity,Detroit,Michigan
CraigLiebenson,DC
Private Practice,LosAngeles,California
SusanM.Lord,BmedSc,Bmed,PhD
DivisionofAnaesthesia,Intensive Care,and Pain Management,JohnHunterHospital,
Newcastle, New South Wales,Australia
GerardA.Malanga,MD
Director,Sports,Spine, and OrthopedicRehabilitation,Kessler Institutefor Rehabili
tation, WestOrange; AssociateProfessor, Department of Physical Medicineand Re
habilitation, UniversityofMedicine and DentistryofNew Jersey-NewJersey Medical
School,Newark,New Jersey
Paul Robert McCrory,MBBS, PhD,FRACP,FACSP,FACSM,FASMF, Grad
DipEpid Stats
Director, Head Injury and Headache Clinics, BoxHill Hospital, Melbourne; Brain
ResearchInstituteand Centre forSportsMedicineResearch and Education,University
ofMelbourne, Parkville
.. Contributors ix
PietroA.Memmo,MD
ChiefResident, DepartmentofPhysicalMedicineand Rehabilitation, Universityof
Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New
Jersey
GregoryJ.Mulford,MD
Chairman, DepartmentofRehabilitationMedicine,MorristownMemorialHospital,
Morristown, NewJersey; AssistantClinicalProfessor,DepartmentofRehabilitation
Medicine,ColumbiaUniversityCollege ofPhysiciansandSurgeons, NewYork,New
York
Scott F.Nadler,DO
DirectorofSports Medicine, and AssociateProfessor,DepartmentofPhysical Medicine
and Rehabilitation, UniversityofMedicineand DentistryofNewJersey-NewJersey
MedicalSchool,Newark,NewJersey
BenjaminN. Nguyen,MD
AssistantProfessor,DepartmentofPhysical Medicine and Rehabilitation, Universityof
CincinnatiMedicalCenter,Cincinnati,Ohio
YongI. Park,MD
StaffPhysiatrist,DepartmentofPhysical Medicine andRehabilitation,Kessler Institute
forRehabilitation, WestOrange,NewJersey
KirkM.Puttlitz,MD
TheCenterforPainManagementand Rehabilitation,York,Pennsylvania
StevenRoman, MD
Resident, DepartmentofPhysical Medicine and Rehabilitation,UniversityofMedicine
andDentistryofNewJersey-NewJerseyMedicalSchool,Newark,NewJersey
ScottR.Ross,DO,DC
Senior Associate Consultant, Department of Physical Medicine and Rehabilitation,
Anesthesiology!PainMedicine, MayoClinic,Rochester,Minnesota
Richard B.Rubenstein,JD
Faculty,InstituteforContinuingLegalEducation,NationalBusinessInstitute,Living
ston, NewJersey
AllanPeter Shapiro,MS, PhD
AdjunctProfessor, DepartmentofPhysical MedicineandRehabilitation, Universityof
WesternOntario,London; Psychologist, St.Joseph'sHealthCentreandLondonHealth
SciencesCentre, London, Ontario,Canada
ClaytonD. Skaggs,DC
Adjunct Faculty,WashingtonUniversitySchoolofMedicine,St.Louis,Missouri
CurtisW.Slipman,MD
Director, Penn Spine Center, Chief, Division of Musculoskeletal Rehabilitation,
Associate Professor, Departments of Rehabilitation Medicine and Orthopedics,
UniversityofPennsylvania,Philadelphia,Pennsylvania
JaySmith,MD
AssistantProfessor,DepartmentofPhysical Medicine and Rehabilitation, MayoClinic,
Rochester,Minnesota
x .. Contributors
Robert W.Teasell,BSc,MD,FRCPC
Chief and Chair, Professor of Medicine, Department of Physical Medicine and
Rehabilitation, St. Joseph's Health Centre and London Health Sciences Centre,
University ofWesternOntario, London,Ontario, Canada
Edward C.Weber, DO
Adjunct Associate Professor,DepartmentofAnatomy, Fort WayneCenterforMedical
Education,IndianaUniversity SchoolofMedicine,and theImaging Center,FortWayne,
Indiana
J.BradleyWilliams,PhD
Co-Director, Pain Management Program, Kessler Institute for Rehabilitation, East
Orange; Assistant Professor, Department of Physical Medicine and Rehabilitation,
University of Medicine and Dentistry of New Jersey-New Jersey Medical School,
Newark, NewJersey
StuartA.Yablon,MD
AssistantProfessor, DepartmentsofNeurologyand Neurosurgery,and Director, The
Brain Injury Program, University of Mississippi School of Medicine, Jackson,
Mississippi
Acknowledgements
Withgreatthankstomy coauthor,ScottNadler,anadmiredcolleague
andfriend
WithlovetoCarrie,Tara,Grace,andLuke
Withdeeprespecttomyfatherandwithgreatadmirationofmy
mother'sinnerstrength
G.A.M
Tomy wifeJodianddaughterSydni,whobringmeaningtomy life
Tomy parents,whoinstilledinme theconfidenceandworkethicto
completethisbook
Tomy teacher,mentor,andfriend LizNarcessian,MD,whobelieved
in me-youwill neverbeforgotten
S.F.N.
•
Preface
•
The topic of whiplash continues to be surrounded by controversy and
heateddebate. Asinmanyfacetsoflife,eachofus bringssomebias-basedon
our prior experiences, our training as professionals, and our beliefs arising
from what we have heard, read, and seen. In the case of whiplash injuries,
treatingpractitionersmay bebiasedduetotheir trainingandexposureas ther
apists, chiropractors,primarycarephysicians,physiatrists,painspecialists,or
surgeons. Ourbehaviormay alsobereinforced byfactors includingpraisefrom
patients,recognitionby fellowpractitioners,andmonetarygain.
Because of the manyissues influencingtreatmentdecisions, we mustnot
forget the importance ofbasingourmedicaldecisionson good science. Over
time,however, many treatmentsbasedon nonscientificmedicinehavebecome
accepted as the standardofcare.Thisprocess continueseven whenthere isev
idencesuggestingthat the treatmentmaybenomore effectivethanthepassage
oftime,and insomeinstances may evenbeharmfultopatients.Generally,nor
malizationof activityafter a whiplash injuryis in thebestinterestofthe pa
tient. Overemphasis on passive treatment mayin realitydisable the patient.
Physicianeducationisthe keytosolvingthis difficult problem.
The purpose of this bookis to provide a current review of the important
issues facingpractitionerswho encounterpatientswhohave sufferedwhiplash
injuries.Amultidisciplinaryconsortiumofauthors wasemployed to accom
plishthis task. Theywere instructedto providecurrent,scientific information
and not theiropinions or anecdotalexperiences. Wewould like to thank the
contributingauthorsof this book for theirexcellentchapters. Webelieve that
this textbook will be a valuableasset to those involvedin the care ofpatients
with whiplashinjuries. Wehope that the informationprovidedwill ultimately
lead toimprovedoutcomeinthose whohave sufferedthese injuries.
GerardA. Malanga,MD
ScottF. Nadler, DO
EDITORS
xiii
~iPlaSh
Injury: AContinuing
Dilemma In the 215t Century
Scott F. Nadler, D.O., andGerardA. Malanga, M.D.
Whiplashisacommon occurrence associatedwithany hyperflexion-exten
sion injury. The mechanism of injury is an acceleration-deceleration event
such asmay occurinamotor vehicleaccident orwithincontact sportingactiv
ities.Injury occurs tomultiplestructures,includingmuscle, tendon, ligament,
bone,joint,and nerve tissue,and cantherefore result insignificant impairment
and disability. Diagnosingthese injuriescan be a sourceofsome controversy
because there are often limited objectivefindings. Subjectivecomplaintsneed
tobecarefullyreviewed formany reasons butmost importantlyto avoid miss
ing a potentially serious injury and to avoid overdiagnosing and treating a
more simplecondition. Unfortunately,the monetary potentialassociated with
motor vehicleaccidents creates an environmentofmistrust,falseexpectations,
and inappropriate care. Whiplash in rare circumstances causes severe life
threateningor life-alteringconditions, such asspinalcord and traumaticbrain
injury.Theseinjuries are the source ofsignificant economic and socialburden,
most commonlybecause ofthe limited resourcesallocated for themost trau
matically injuredindividuals. Many stateshave adopted a monetarycap on
how much the victim ofa motor vehicle accident isentitledto fortreatmentof
injuries. Thissystemisa resultofthe multitudeoffrivolous lawsuitsbrought
about in the quest for dollars. This is a disturbing phenomenon for such a
highly advancedsocietyand, unfortunately,thetruly injuredindividualsuffers
asaresult.
Making the appropriate diagnosis and providingthe correcttreatmentis
the goal of any clinician who manages patients suffering from whiplash
injury.Taking aproperhistoryandperformingacomprehensivephysicalas
sessment is the hallmark of any such evaluation. The history is invaluable
because the treating providercan ascertainfactors suchas the mechanismof
injury, preexistingproblems that may have been aggravated, and steps the
individual has taken in regard to self-treatment. The physical examination
needs to include a comprehensiveneurologic assessment, which should in
corporate elements of strength, sensation, reflexes, and other provocative
maneuvers.
Unfortunately, thereiswide variationwith regardtotheperformanceofthe
physical examinationand interpretationoffindings. Educationis the key to
solvingthis problem. Ultimately,withoutaproperphysical examination,diag
nostic testing isorderedbasedon subjective complaintsalone. Thisstrategyis
fraught with problems, and this is most especially apparent in individuals
2 .. WhiplashInjury:AContinuingDilemmainthe21stCentury
with significant psychosocial overlay. Overinterpretation of complaints in
these individuals may set in place a vicious cycle of inappropriate testing,
treatment, and risk ofiatrogenic injury.An exampleof this phenomenonis an
individualwho presents1monthafter amotorvehicle accidentandcomplains
ofisolated neck pain. The treating cliniciantakesanx-ray, which isnegative,
and does not perform a comprehensive physical examination. Based onthe
patient'scomplaintsofneck pain,the treatingproviderorders magnetic reso
nance imaging (MRI)ofthe cervicalspine. The MRIis reviewedbya radiolo
gist who, without a clinical assessment, interprets any possible findings. In
light ofasignificantfalse-positive rate in asymptomatic subjects,'> adiagnosis
of a herniated disc is made based only on the MRI finding of subtle disc
bulging.The treatingproviderinitiatesatreatmentprogramofpassivemodal
ities, including traction, electrical stimulation, massage, and ultrasound for
the patient; it feelsgood during therapy, butthe patientis in realitygettingno
better. Thepatientisnext referredfor variousinjections, whichdo not provide
much in the way ofsubjective improvement. Finally, the patientends up as a
surgical candidate.
This case follows a paradigm in which a nonspecific historyand physical
leads to nonspecific diagnostic testing, nonspecific treatment strategies, and
ultimately to a nonspecific (poor) outcome. An evidence-based approach to
this case would not support MRI testing based on subjective complaints of
axial pain.Aprogramthat mayconsistof flexibility exercises,strengthening,
mobilization/manipulation, and the use of an appropriate analgesic or anti
inflammatory drug would first be indicated."The use of modalities such as
electrical stimulation and ultrasound would not be supported as providing
any significantimpacton functional recoveryand therefore would notbe the
focus of treatment.s-' Appropriate therapeutic spinal injections may be of
some potential benefit in an individual who has failed treatment, but they
would have no place in an individual who has had no progressive, goal-di
rected program. Finally,surgical intervention should be reserved for carefully
selected patientswithobjective findings withoutsuperimposedpsychological
issues. As clinicians, we mustcautiously evaluate the diagnostic and treat
mentwe recommendbecause inappropriate utilizationcan lead to disastrous
outcomes.
This book isacompendiumof knowledge regarding whiplashinjury. We
believe that preventionshouldultimatelybe the focus in this century. The au
tomobile industrymustbe at the forefront in this regard. Newer, morebiome
chanically sound head and neck restraints and, also, seating systems with
specializedcrushzones toabsorbthe forcesgeneratedatimpactneedtobe de
veloped and implemented. Newer technologyshould additionally focus on
the structureandmaterialsused toconstructthe underlyingframe ofthe auto
mobile to makeit betterable to absorb impact. Finally, thesechangesneed to
be made to all automobiles manufacturedand should notbe reserved for the
privileged few whocan afford the more expensive, technologically advanced
automobiles. Prevention is the goal; however, in the face of injury we need
properassessment through detailed historyand physical examination, judi
cious use of diagnostic testing, and treatments thathave some scientificevi
denceofefficacy.
.. WhiplashInjury:AContinuingDilemmainthe21stCentury 3
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