The rehabilitation of someone who has been involved in a motor vehicle accident can be anything but straight forward.  The best place to start however is with a complete and thorough assessment of all injuries sustained as a result of the accident.  The assessment is usually performed by medical doctor, physiotherapist or some other duly qualified health care professional. 

The term acceleration injury is perhaps a better term for whiplash because it is a more all encompassing term and better describes the injury mechanisms that potentially result in rapid acceleration and deceleration of the neck.  This type of injury is difficult to treat because in addition to affecting the musculoskeletal tissues, it can also lead to involvement of several other anatomical regions, such as the central nervous system, throat (esophagus/trachea), and jaw (temporomandibular joint).

There is marked difference in the outcome of acceleration injuries, depending on whether the impact resulted in excessive and rapid hyperextension motion or hyperflexion motion of the head and neck. 

With an acceleration injury, excessive forces are exerted on the neck and surrounding soft tissues.  With a good understanding of the science of soft tissue healing and the results of injury to the load capacity of tissues, the physiotherapist can teach initial positions of rest during the early stages of healing, followed by the introduction of controlled passive and active motions (gradual reintroduction of stress to tissues), and then progress to teaching patterns of movement to minimize excessive stresses to the injured region while establishing realistic short and long-term goals.

TREATMENT OF NECK PAIN

The treatment of neck pain is multifactorial.   The articular, muscular, and motor control (neural) systems may all or in part be implicated.  This triad can be influenced by non-neuromusculoskeletal factors such as the client's current emotional and psychosocial well-being.   As many physiotherapist treat neck pain, it is important to be aware of the most recent and up to date research investigating the efficacy of various physiotherapeutic techniques and interventions in the management of neck pain.  According to the Manipulative Physiotherapists Association of Australia (MPAA) the following conclusions can be made.

Manipulative Physiotherapy

Appropriate treatment depends on an accurate diagnosis.  Manual diagnosis by a trained manipulative therapist can be as accurate as the "Gold standard"  radiologically-controlled diagnostic blocks in the diagnosis of cervical "Z" joint syndromes (Jull et al 1988). 

Evidence suggests that manual therapy is effective in both the treatment of acute and chronic neck pain.  Manipulative therapy is a highly effective treatment approach that involves the application of specific therapies to reduce pain, restore normal movement and prevent future problems.  Manipulative therapy consists of passive joint mobilizations (gentle movement of individual joints and surrounding structures), manipulation (controlled quick thrusting techniques to the joint which produces at times an audible clicking or popping sound) and therapeutic exercise. 

 Traction

Traction has been show to separate vertebrae, hence it may be hypothesized that it could give relief from radicular symptoms by decreasing forces on sensitive neural structures. The efficacy of using traction for the treatment of neck pain has not been established.  Of five randomized control trials, two had positive and three had negative results. 

Exercise

There is recent level II evidence which supports the use of specific exercises in the management of neck pain.  So far there is no evidence in support of Pilates, Feldenkrais, or Alexander technique.

Collars

Level II evidence suggests that cervical collars are not helpful in the treatment of neck pain.  Furthermore, available evidence does not support the use of bed rest.

Electrotherapy

Evidence is limited.  There are a few studies that support the use of TENS, biofeedback, and pulsed electromagnetic therapy.  Despite its wide use, there is no support for ultrasound.  Laser therapy and infra-red therapy also does not seem to have much support.  There is some support for the use of acupuncture (primarily level I & II evidence).

Multimodal Therapy

Is multimodal therapy effective in the management of neck pain?  Some recent level II evidence seems to suggest that it is.  Hence, combining manual therapy, exercise and cognitive-behavioural therapy may be more beneficial than individual therapies on their own.

Summary

There is good evidence to support the use of manual and manipulative therapy in the short term management of neck pain.  There is also some evidence to support the use of modalities such as TENS, acupuncture, biofeedback and exercise.  In contrast, level I and II evidence seems to suggest that the use of bed rest, collars and traction does not seem to have any effect on neck pain and hence is not recommended.   The long term effects of manual therapy cannot be determined at this time due to lack of literature on this topic.  Research in this area is forthcoming. 

Treatment of Neck Pain and Headaches with Manual Therapy (Retraining the deep muscles of the neck) 

A "new" approach to the treatment of neck pain and headaches is upon us!  This new approach has been investigated quite rigorously and has been demonstrated to reduce neck and shoulder pain and headaches of cervical origin.  In addition, these conditions can be controlled in the long term.

The approach eluded to is revolutionary in that it focuses on therapeutic exercises that help restore both deep and postural muscle support in the neck.  A generalized exercise program is unable to achieve this.  What sets this treatment approach apart from more traditional therapies is its emphasis on precision and control.  Exercises given to the patient are low effort, and focus on endurance to train these muscles for their functional role in providing support.  In this way, a firm base of support is established which is vital to safe and stress free function of the upper quadrant.  Having established optimal internal support structures allows the therapist then to incorporate other exercise regimes in a safe and effective manner. 

Retraining of the deep muscles of the front of the neck in conjunction with the muscles of the shoulder girdle are essential to providing support and control to the joints of the neck.

The deep muscles of the neck include longus colli and longus capitis.  They are ideally suited to carry out a stability function, as their muscle attachments are intervertebral.  Poor endurance and control of these muscles results in abnormal forces being transferred through the upper quadrant (neck and shoulder girdle).  This can lead to joint approximation, degenerative changes, and strains of the joints and ligaments of the neck.  A milieu of symptoms may ensue, including neck pain, headaches as aching at the top of the shoulder.

Research has shown that people presenting with these neck conditions demonstrate poor control and function of their deep and postural muscles.  Therapeutic exercises designed to retrain the supporting role of these muscles has been demonstrated to decrease the signs and symptoms associated with many neck conditions, including arthritis and whiplash associated disorders (WAD).