MEDSCAPE VI

Whiplash Care and Present Reality – Picking some bones

The greatest inestimable merit is a complete appreciation of the usual.

Henry James

I had intended moving on from cervical care when two MedScape CME’s, followed by a paper published in AAOS Now, restrained me. I’m honored that Resurrecting Traction (MedScape V) was selected among the 10 most read articles, and I want to best assure that its value isn’t diluted.

Anything in print may influence. Nothing replaces fundamentals, and we all need constant reminding. It’s the human condition, and in this discipline, comfort with fundamentals requires accepting anatomy and structural function as they are however that may require shaving away ingrained doctrine.

I had thought that somewhere in this series I had related a story about a sign on the pilot’s gate at Santa Barbara Airport, California. I searched but couldn’t find it, and it’s a foundation story, so I’ll risk the possibility of repetition.

I’d landed, exited the gate and turned back to close it when I read what became a trademark in my teaching and a passport to some of the most influential relationships of my life. The expensive, enameled sign read:

Keep This Gate Closed At All Times

I have no idea how many had passed it by, smiled, blandly tolerated, accepted it unconditionally, ignored the inanity while falling under the Emperor Has No Clothes spell that no one could possibly have written a sign unless it made sense. It had to, and who could be so presumptuousness as to question it? So it had to be magically or otherwise inherently imbued with a truth simply because it was! (If you haven’t seen the sign before and you still haven’t smiled, at least a little, don’t beret yourself. But please don’t proceed. Stop here and reread it until you do. It holds a critically important lesson.)

It must be assumed that it was written with the best of intentions, as were the CME’s and the AAOS Now paper that I will discuss.

But intentions are not the issue. Fundamental clarity is. If any writing denies reality, tempts a restriction of constructive thinking, or unsoundly narrows a perspective, then it devalues a fundamental, then that needs to be scrutinized.

This discussion unleashes a stream of memories about how easily essentials can be obscured – or had to be obscured - because to illuminate them would expose the Fundamental Flaw - the historic blunder when traditionalism repudiated the basic of hands-on examination and treatment of injured tissues. One of my most vivid occurred, decades ago, at a large orthopedic surgical meeting in Southern California.

One of the speakers had made a statement prompting me to respond with an essence of Resurrecting Traction MedScape VI. Dr. Mason Hohl, a former professor of mine at U.C.L.A. when I was a medical student, who later served as President of the AAOS, happened to be sitting a few rows behind me, and he rose to refute my comment, ending with “We don’t traction ankles so there is no reason that we should traction necks.”

I shouldn’t have left it at that because I knew better, and when its ghost appears I relive my lapse with regret. Perhaps this telling will put it to rest. I should have answered with this story that would have settled the issue.

I had begun to develop reputation in Orthopaedic Medicine while I was still in general practice in Wilmington, California, the port of Los Angeles, A few years before I examined him, a man had fallen from a collapsed scaffold about ten feet above the street. He’d landed on his feet, and thereafter, he experienced intense pain after standing only a few minutes. Throughout that time, he’d been unsuccessfully seen in numerous orthopedic clinics, and all his examinations had been completely normal. The x-rays, of course, were completely negative. It was a big case, a young man permanently disabled from his occupation, the insurance company having to allot big dollar reserves. A claims examiner for the company had sent me some cases before and figured she had nothing to lose.

My examination also was completely negative. Except I had done one procedure no one else had done. With him seated on the examining table with his legs apart, I’d sat “into him” facing the same direction, taken each leg in front of me, each ankle in my thumb web space forming a sling first superior to the talus, then talo-calcaneal, my elbows close in to my body. Thrusting forward, I’d sequentially applied traction, opening the joints of the forefoot and testing their respective passive ranges. There was no restriction, no pain, nothing.

I was returning to my desk to write my notes when I was startled by the sudden pounding of his repeated jumping up and down on the floor while shouting, “The pain’s gone! The pain’s gone…..!” He was cured. He returned to work the next day completely relieved.

I had no idea what I’d done. Then, the exact same pain occurred to my associate as he was getting out of his car to enter the office. He thought he’d fractured his foot and asked me to x-ray it. I checked him the same way, again found nothing I could discern and told him I’d meet him in x-ray. When he didn’t come, I went to find him, and he laughingly told me that whatever I’d done had relieved it.

In Release From Pain I describe a number of such experiences involving the hip, elbow, and likely the relief from a number of vertebral manipulations. In a word, I’m certain that I’d released entrapped synovial tags. As well, I am confident I have more rapidly rehabilitated many injured ankles by helping relieving the stiffness using the same method.

I wish I’d described that to Dr. Hohl. Perhaps he’ll read this and remember the incident. I hope a number of those present then will now belatedly become aware of this now. Success depends on our developing our concepts to fit the anatomy, physiology and biomechanics. There is so much still to discover. Now to the issues I opened with although I’ve still another tale to relate.

The recent Medscape CME’s focus on the ubiquitous mischievous “Whiplash.” The first compared three therapies. I tried to read them through the eyes of a strictly traditionally trained clinician responsible for treating such cases, therefore frustrated, and seeking to understand the relevant issues. Then I considered the obligations of a clinician who decides to write such a paper, and, again, a powerful memory claimed my attention:

Sudek’s Atrophy, Reflex Sympathetic Dystrophy (RSD), Complex Regional Pain Syndrome (CRPS) is a dread emergency condition even at its onset. The dynamics are so destructive that it requires immediate, active, compound therapy that is as directed as possible. While it comes in various sizes and degrees, the havoc RSD can wreak is a fact to any experienced clinician who may well have tasted the bitterness of failure despite best attempts including sympathetic blockade, Baer blocks etc.

One fact we do know is that RSD does not respond to “simple” modalities. But one doctor’s literature search didn’t yield a specific paper that proved that ultrasound alone doesn’t work. So she decided this was her claim to fame. How she obtained departmental authority for the study still disturbs me because I had enormous respect for it.

She assembled a series of such sufferers of lower extremity RSD, randomly divided them according to strict scientific protocol and then treated them exclusively with ultrasound either turned on or off. And, she did indeed prove that ultrasound doesn’t work. There was no difference in the two groups.

Both miserably suffered equally as their disastrous afflictions progressed towards chronicity. Her day came, and she presented her paper to the Academy and proudly descended the podium. Yet what of those patients who had come in trust needing earliest mobilization, sympathetic blocks….. active therapy… all delayed…?

I was outraged and expressed it, distressed even further by the seeming passivity of the audience – another face of the failure – a remoteness, a reluctance - to intimately, confidently, comfortably move in close to tissues where the signs are waiting to be elicited.

Perhaps unfairly, but reading this paper provoked a hint of that memory despite that much here is different. So why was it invoked? And here, I think, is a crux of this issue: because the institutional failure to appreciate fundamentals persists. Therefore many readers lack the understanding to realize the skew of the paper and that potentially valuable options have not been included in the study.

So, unless something triggers them to suspect the lack, the habit to rush to the proverbial bottom line will likely result in the erroneous conclusion that doing nothing is just as good as any therapy. I would be very grateful to be wrong in that comment and be repudiated, but after 50 years in medicine I know how busy doctors want immediate answers from their reading and how serious the trap is.

Let’s look at the paper:

The main author of the paper is Alice Kongsted, DC, PhD. There are several M.D. co-authors. The study compares three approaches to whiplash and concludes: “Immobilization, act-as-usual, and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after whiplash injury, according to the results of a randomized, parallel-group, controlled trial reported in the March 15 (2007)issue of Spine.” …The active mobilization program consisted of “Mechanical Diagnosis and Therapy; physical therapy twice weekly for 3 weeks.”

“At the 1-year follow-up, 48% of participants reported considerable neck pain, 53% reported disability, and 14% were still listed as sick. There were no significant differences noted between the 3 intervention groups.”

"We find our results adequately sound to conclude that earlier recommendations of active treatment regimens cannot be supported. Moreover, taking the per protocol analyses into account, use of a stiff neck collar should be discouraged as a standard approach."

“Study limitations include poor compliance with treatment, frequent use of treatment other than prescribed, and more participants lost to follow-up in the act-as-usual group.”

"The present trial shows clearly that active intervention in the first weeks after an injury does not result in a better outcome than an 'act as usual' program when prescribed to a high-risk patient group," the authors conclude. "There might be subgroups that respond to treatment, but in a large group of patients the prognosis was not improved by active treatment. (bold mine) Until such subgroups have been identified, our general recommendation is that advice to act as usual, the less expensive intervention, should be the preferred treatment."

Of course the loophole is the subgroups disclaimer. But, it only further obfuscates. Of the scores of whiplash injuries I have treated, once I formulated my understanding that a major component that must be resolved is any disorder of proprioceptive sensors, then only twice a week therapies don’t make sense; leaving the neck alone doesn’t make sense, and “immobilization” with a hard collar presumably while the individual carries on with normal activities doesn’t make sense. In the latter case, a collar may help for a short time, but in the upright position the proprioceptive reflexes click in, and they’re dyscoordinate they would tend to propagate the neurological dysfunction. They need balanced rest. Low poundage traction can provide that. Please refer to Resurrecting Traction Medscape V.

Examine the statistics concerning residuals. They are damning. They should cause the reader to immediately suspect that something is remiss. Regardless, the paper seems to conclude that there is nothing useful to be done. And that perpetuates the quandary of a frustrated clinician and a justifiably unhappy, disabled patient.

As well,

In the special circumstances of each whiplash, the potential for persisting ligamentous damage must always be considered for which Prolotherapy may be an excellent therapy.

Any treatment, such as manual therapy, that is standardized to a particular time schedule gives no cognizance to individual need, such as a twice-a-week session. The prompt relief of spasm should be done as soon as possible after its recurrence. And – the very common occurrence of injury to the anterior neck structures needs to be emphasized and not blended into a generic “mobilization” regimen.

In summary, whiplash must be understood through study of the active pathological processes in each case. Only then can success be best assured. That fact must be a habitual imprint in the clinician’s consciousness. A study such as this greatly enhances the chances of continued confusion.

When the cost of care is discussed as a reason for not doing anything because nothing worked, the issue becomes even more confused. Now we have to question of validity of any therapy if overall misdirected costs become part of the decision process. Countering that argument, how long does a condition have to persist with all its attendant disability costs before the cost of directed intensive, individualized care is considered reasonable?

I’m reminded of the old aphorism, “If you think education is expensive, try ignorance.” The trick, of course, is to select therapy that will be cost effective because of its inherent efficiency. The subject of (rational) costs, incidentally, never comes up with diagnoses such as appendicitis. The question seems legitimate mostly when the therapies are ritualistic and have a history of being ineffective, so the condition becomes a iatrogenic nuisance.

The second MedScape Whiplash CME is also excerpted from Spine. 2004;29:182-188: Acute Whiplash Subjects Demonstrate Generalized Hypersensitivity: The CME needs to be read in its entirety to appreciate my concern about it. It’s a mass of test results performed on patients with varying degrees of whiplash that demonstrates irritable sensory phenomena in a number of categories from which the author theorizes that an early disorder of central processing explains some of the syndrome’s symptoms. The tests are several and the data here is abbreviated.

I’ll discuss this issue very succinctly. In medical school, I became aware of the, “Oh, hell” reaction. It’s what happens when the mind is so overwhelmed by information that it can’t correlate or accept as valuable, or absorbable, that it just turns off. In a phrase, it’s too much. A clinician who reads it, who is unequipped with the anchors of treatment fundamentals can become one exponentially increased distressed doc. I plead with my hosts to forgive me, but I plead that such a CME in this area is not helpful. Research is certainly entitled, but to seem to open a path to a needful clinician that leads only to a maze that can further discourage the effort to competence is a problem, especially when it is close to the first CME. Fundamentals, fundamentals, thou shalt pursue! (And until they are satisfied, there is no other place worth going to.)

The third paper, from AAOS Now: A New "Pain in the Neck" is a real nutcracker.

As the Editor’s note states, submissions are acceptable where members can “sound off” free from peer review. The author, Jerrold M. Gorski, MD titles his contribution A new “pain in the neck.”

Dr. Gorski contends that since the term “whiplash” was coined, “researchers have never been able to prove the existence of the condition, which affects millions of unhappy patients. Chronic neck pain and whiplash-associated disorders continue to cost up to $20 billion annually, without any hope for a cure…perhaps until now.”

The beginning of the report reads: “Whiplash is not a favorite subject of orthopaedic surgeons, principally because a pathologic lesion has never been found in the neck. We can understand the whiplash mechanism resulting from acceleration/deceleration forces acting on the head and neck in a rear-end collision. We note that the number of whiplash claims continues to increase, despite modern head restraints, seat belts, and airbags. We are disappointed and perplexed when patients don’t improve after surgery. Without a defined neck lesion, we frequently defer the treatment of these patients to others. Every conceivable anatomic structure in the neck has been repeatedly scrutinized for the whiplash lesion and it just doesn’t exist—in the neck.”

The author continues: “I think whiplash exists, and this is my hypothesis: No pathologic lesion has been found in the neck because whiplash—and most intractable chronic neck pain—is due to a shoulder problem. The pathologic lesion is asymptomatic shoulder impingement that presents as “neck” pain. In other words, whiplash is a shoulder—not a neck—condition!”

Wow! When I decided the necessity to include this paper, only now as it has simmered in my mind for awhile am I appropriately cognizant of its immense importance to my teaching. Dr. Gorski is an honest and courageous physician. Clearly having been deprived of all the fundamentals I espouse, his struggle to make sense of whiplash is as admirable in its intent as it is Sisyphusian.

For me, this is a Twilight Zone result of trying to force medicine into the epitome of frustrated preconception. The rest of his effort is available in the citation, but I’m going to dissect only those two paragraphs with the urgent intent to smash the idols and let the light in (and please review MedScape V) because we have in this extraordinary material the stuff for a dramatic shift in perception. Descartes said, “The truth lies in small distinctions.” In this, examining the gross distinctions, as well, is essential.

As I prepared my thinking for this exercise, I remembered two 35 mm. slides I frequently used in my teaching and searched them out. Both were quotes from the reports of orthopedic surgeons who had previously seen the patients I was consulting on, whose condition I had diagnosed and successfully treated. I could only find one but am well able to paraphrase the other.

Please! It is critically important here for you to impress on your mindset that I am not criticizing individuals! My criticism is directed at the surgically dominated system that sets up such futility through its refusal to recognize that a distinct orthopaedic medical perspective is essential.

My excerpt from the first orthopedic surgical consultation states: “In view of the fact that the patient’s entire general skeletal and neurological examination is normal now and has been consistently at this office in the past on repeated examinations, in view of the fact that her entire x-rays, brain studies, EMG, etc. are consistently normal, I would think that it only rationally, logically follows that there is simply nothing wrong with this patient that has been demonstrated by any of the objective means known to our present medical establishment.

The second (paraphrasing): ‘If findings cannot be reliably be demonstrated repeatedly by various examiners they simply do not exist.’

But an “x-ray” cannot visualize a joint sound or a warm joint. A “brain study” cannot elucidate a thought. And EMG reveals processes that, if not present, doesn’t mean that abnormalities consistent with the reality of the condition don’t exist. In all those cases, relying on inappropriate technology only obfuscates and further illustrates the confusion.

Orthopedic surgical examinations that are not designed to study the spectrum of symptom producing signs in orthopedic conditions come away with such sincerely intended but seriously erroneous statements as above. The price is incalculable. If you read my Release From Pain, you will read the whole the whole story. In cervical care, readers of my other contributions may remember the opening remark of the surgeon moderator of a symposium on neck pain at a national meeting: “Patients with neck pain are a pain in the neck.” Again, sincere, frustrated, an ultimate expression of ignorance about examination.

With distinct exceptions in every case, whiplash is not a discernible lesion! It is largely a disordered process!

Now, let’s dissect out Dr. Gorski’s initial paragraphs and drive the issues into fully conscious consideration.

“Whiplash is not a favorite subject of orthopaedic surgeons, principally because a pathologic lesion has never been found in the neck.”

I don’t know what the author’s definition of “lesion” is, but I don’t understand why the gross sign of flattening or reversal of the cervical curve apparently has no credence for him as a locally induced phenomenon. Frankly, I don’t know he would define the pathologic lesion of, for instance, acromioclaviculitis, which is an acceptable clinical diagnosis. The cervical spine is such a complex structure of multiple neurologically mediated articulations that I wonder at the singular “lesion” even being considered.

“We can understand the whiplash mechanism resulting from acceleration/deceleration forces acting on the head and neck in a rear-end collision.”

If that is understandable and the “whip” is visualized, why isn’t it consistent to be able to see how such a velocity driven process can damage connective and proprioceptive tissues and function at a microscopic level? And if the constant dynamism of the sensors having to constantly work when the individual is erect, and if there is an inherent “imbalance” – so that the tissues cannot find a status of rest and coordinated function – why is it so difficult to think neurophysiologically about the symptomatology? This dysfunction is often amenable to prolonged low-poundage traction, less than 2 lb., with an appropriate device.

And certainly the whiplash forces could overstress the Golgi system and lock lots of muscle fibers in protective symptomatic spasm – especially the anterior cervical musculature which is hardly examined. This condition that is essential to diagnose is often well relieved with CounterStrain manipulative techniques

And certainly such forces would likely damage ligaments that may well not fully heal in the limited time that the capillary bed remains open to provide primary healing. Lacking ligamentous balance, the disordered proprioceptors are further disadvantaged. Prolotherapy can be excellent therapy.

“We note that the number of whiplash claims continues to increase, despite modern head restraints, seat belts, and airbags.”

Shift happens. As well, with the seat belt restraining the pelvis, the “whip” easily rattles the spine to its inferior end where it comes to a sudden stop and disables the low back structures, as well.

“We are disappointed and perplexed when patients don’t improve after surgery.”

But the paper started stating that there is no pathologic lesion! So why the scalpel in search of adventure? How is it possible to even think that the diffuse injuries, such as I have described, could ever be susceptible to a surgery – unless there were clear indications to surgically relieve a specific situation such as a major disc herniation?

“Without a defined neck lesion, we frequently defer the treatment of these patients to others.”

That isn’t (necessarily) bad. Still, the principles of what appropriate care is about needs to be mutual ground for all who are responsible for such care. Surgeons have a constitutional predilection to operate. That’s understandable, but requires the balance of the non-surgical predilection, such as the dynamic relationship of the neurosurgeon and the neurologist. The medicine of orthopedics needs to be the responsibility of another specialty. (I discuss this comprehensively in Release From Pain. And this paper is the perfect foundation to stress the need.)

“Every conceivable anatomic structure in the neck has been repeatedly scrutinized for the whiplash lesion and it just doesn’t exist—in the neck.”

What? Sadly, the use of the word “conceivable” fully illuminates the extent of the problem. Conceivable in whose minds? There are serious limits of imagination in most practitioners who haven’t the concept that they are commonly seeing conditions whose core knowledge is outside the scope of their formal training. There are libraries on this stuff. But they aren’t in the orthopedic surgical books - yet.

In the last analysis, we see only what we have been taught to see. We will eliminate everything that is not part of our precedent.

Jean Marie Charcot

And so in a leap of another scope of imagination, the author offers the shoulder as the source of most whiplash pain.

I’m probably safe in assuming that I’ve treated more necks than the author. In whiplash, I have never had to suspect that the essential findings emanated from the shoulder. The wealth of valuable clues were right there for my hands – after I completed the traditional examination.

And so another day passes, closer, G-d willing, for a medicine that is restored to its foundations.

“That which we are, we are…

Made weak by time and fate,

but strong in will to strive, to seek,

to find and not to yield.”

Tennyson’s Ulysses