If you are reading this article, I suspect you are a chiropractor currently treating patients with back pain, neck pain, and/or headaches. You may be caring for patients with neck pain following a motor-vehicle incident. Most likely, these patients have been whiplashed and are presenting with whiplash-associated disorders (WAD), including spinal sprains and strains, spinal joint dysfunction, cervical radiculopathy, or even worse, cervical disc herniations.
If you fit this description of a chiropractic physician, you have accepted the responsibility to rigorously evaluate and manage these patients presenting with WAD, which includes an examination that determines the diagnoses and an appropriate treatment plan. So, I now pose a question to you. “Is spinal manipulation indicated or contraindicated for whiplashed patients?
If the patient presents two months post-trauma with acute neck pain and headaches post-whiplash and no previous neck pain or headaches, the majority of chiropractic physicians would consider a differential diagnosis that would include WAD conditions. The patient was taken by ambulance from the scene of the motor-vehicle collision to the ER.
Following a brief examination of the neck and a radiographic examination (AP cervical and lateral cervical views) at the ER, the patient was given a diagnosis of neck strain, and prescribed NSAIDs and physical therapy. She advises you that the PT increased the neck pain and headaches. She wonders if chiropractic care would get rid of the pain.
You suggest a physical examination be performed. The examination demonstrates a second-degree cervical sprain/strain with testing of active, passive, and resistive range of motion. Motion palpation reveals hypertonicity of the paravertebral cervical muscles and restricted range of motion of the upper and lower cervical spine. Hence, you diagnose cervical spinal joint dysfunction at several levels.
As a result of the recent trauma, poor response to care, and medicolegal implications, you order an additional imaging study prior to spinal manipulation.
It is my opinion that the majority of chiropractic physicians would order imaging of patients presenting with WAD. Wouldn’t a competent, evidence-based, patient-centered clinician order imaging prior to performing spinal manipulation? I suggest that a seven-view Davis series with an AP cervical, an open-mouth AP cervical, two oblique cervical views, and three lateral cervical views with neutral, flexion, and extension views of the cervical spine might be ordered to rule out fractures and dislocations, and determine if there are degenerative changes in the spine or possibly cervical spine hypermobility or instability.
If there are no degenerative changes or signs of hypermobility revealed with the Davis series, would it not be indicated that spinal manipulation of the dysfunctional cervical joints be performed?
When Additional Imaging Is Needed
Consider this putative case in summary form that demonstrates additional imaging is necessary to rule out post-traumatic hypermobility or instability of the cervical spine.
The patient is diagnosed with a grade 2 cervical sprain/strain at C2-3 and C5-6 following a whiplash-type injury two months prior to the initial visit with you. She is a 25-year-old female with no history of cervical injury, neck pain or headaches. Following a series of 12 gentle cervical manipulations, the patient complains that the neck pain and headaches are getting worse! In addition, she is now experiencing dizziness, loss of balance, and numbness and tingling in arms and legs.
Why? Was cervical manipulation contraindicated? Unfortunately, the evaluation did not reveal upper-cervical spine instability as a result of the whiplash injury. Even a seven-view Davis series is not adequate to determine cervical spine instability, most especially of the upper cervical spine.
Remember that a whiplashed cervical spine is deformed at impact. The normal “C” curve becomes an “S” curve, which sprains the upper-cervical spine ligaments. The sprained upper-cervical spine ligaments may cause an unstable condition, known as “atlantoaxial instability.”
The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. The functional result of the joint is two-fold: (1) providing support for the occiput and (2) providing the greatest range of motion and flexibility possible while maintaining stability. The instability in this joint is usually congenital, but in adults, it may be due to an acute traumatic event or degenerative disease.1
During my 33 years of practice in New Mexico, I enjoyed the expertise of two chiropractic radiologists, Drs. James Mertz and Michael Montileone. They used both standard radiography and video-fluoroscopy examinations to evaluate our whiplashed patients.
Consequently, our patients with hypermobile or unstable cervical joints were not manipulated. It was contraindicated, but manipulation above and below unstable joints could be gently manipulated without negative outcomes.
It was my standard operating procedure to order cervical motion studies to determine if the cervical spinal joints needed spinal manipulation or if the procedure was contraindicated because of the laxity of the surrounding ligaments.
If you are evaluating and managing whiplashed patients, I highly recommend that you do a Google search and learn more about the use of motion imaging of the spine of whiplashed patients. A motion study of the patient offered in this article was indicated. Specifically, an open-mouth upper cervical study with lateral flexion to the right and left would indicate if the atlantoaxial joints were stable or unstable.
If your whiplashed patients are not responding appropriately to your spinal manipulations, the procedure may be contraindicated.
Quiz Time
1. Which examination of a whiplashed patient rules in or rules out atlantoaxial instability?
2. Is spinal manipulation of unstable cervical joints contraindicated?
Answers: 1. D; 2. A – True.
Reference
Dr. Louis Sportelli received the Lee-Homewood Chiropractic Heritage Award during the annual conference of the Association for the History of Chiropractic (AHC). During his nearly 60-year career, Dr. Sportelli has embodied the spirit of the award, given to “living individuals who have made outstanding contributions to the chiropractic profession.”
Presently there is no consensus on the best treatment for Achilles tendon rupture; and its management is still controversial. The treatment options are conservative treatment and surgical repair. With either treatment, be it conservative or surgical, Achilles tendon tears necessitate prolonged recovery and rehabilitative management.
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