Whiplash Injury | Case Report
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welcome everybody to the cbp nonprofit research video review uh this week we’re going to be going through a very nice case report this case report is a very interesting application of cbp techniques in a chronic whiplash associated disorders case and you’ll see the benefits of corrective care for this patient once we go through this particular report as you know if you’ve been watching these videos each week i pick a new cbp non-profit research publication to go through and we have many many to go through in fact the goal is to go through all 156 of our research publications uh in a video review so we’ll probably be doing this for roughly three years if not a little bit longer because if you’re paying attention once in a while i skip a week just due to my time constraints etc i’m not exactly going in order of year and date of our publications but i am trying to have a consistent theme of uh going through relevant cases as we build or relevant reports as we build for example what we’ve done before we went through this case report is we’ve gone through the reliability of cbp x-ray line drawing procedures for the lateral cervical view we’ve also gone through our cbp ideal and average spine alignment values for the lateral cervical curve and so that brings us to case application now that we have established reliability of our methods and we we have validity of our cervical spine model for the lordotic cervical curve we can now look at abnormalities in a much clearer perspective and then we can see what happens when we apply cbp corrective care procedures to cases that are indeed abnormal now understand that this is a case report however well done case reports especially chronic cases that have failed standard and detailed traditional types of care when we do a unique type of care if we see a result we can look at this and we can go wow this this is likely going to be consistent with randomized trials that are are done on the exact same population and in fact that’s known to be true if you look at case studies in the literature and level three reports what you’ll find out is well done case reports and level three reports which is uh cohort studies what you’ll find out is if they’re done well they are actually consistent with randomized trials on the same topic so while this is only one case and we need to build on that platform it is a very well done case report now this case was number one treated by and spearheaded by my good friend and cbp instructor dr joe farantelli this is when he was in active practice down in newport richie florida and if you know joe joe always had a passion for corrective care and for treating whiplash injured subjects okay so on this particular paper we have dr joe ferentelli we have myself deed harrison we have my late father donald harrison and then we have one of the treating md’s that dr joe was collaborating with at the time dennis stewart from the area this was published in jmpt the journal of manipulative and physiological therapeutics in 2005.
It is volume 28 it is page 205 e it through 205 8 and that’s uh online okay so online in the journal of manipulative and physiological therapeutics okay so background this is a whiplash injured case uh this individual was on the uh police enforcement law he was uh or excuse me he was a law enforcement officer in the police department uh he actually was treated traditionally with car or previously right after the injury with approximately 18 visits of standard diversified style chiropractic also some physiological therapeutics were used pt methodology in addition the patient received physical functional rehabilitation for strength and conditioning of the cervical spine as well as pain management medication the patient failed these things and turned into a chronic case the patient has will see disc herniations and their mild disc herniations at more than one level multiple level also a chip fracture of the lower cervical spine anterior superior vertebral body so we have mri we have a mild fracture and we have a patient that’s unresponsive to what’s called traditional or con traditional conservative care for whiplash injured subjects this patient then turned into a chronic case still suffering went to an md the md gave the patient a whole body permanent impairment rating of 33 percent due to the symptoms and due to the side effects from the motor vehicle collision okay these uh we’ll see what these all entail but there was some grip strength weakness there was uh abnormalities in the c5 c6 dermatome as well as chronic pain decreased range of motion etc uh so the surgeon that gave him the whole body impairment rating then said you know what you failed all these things chiropractic pt pain management now we we must do a discectomy infusion well fortunately this patient happened to be colleagues with a family member and other patients that were seeing dr joe ferntelli and they recommended that he go to dr joe ferentelli’s corrective care facility and joe took a look at him and said you know what your x-ray nearly looks identical to the one immediately after the crash so let me back up this lateral cervical image was taken at the initial chiropractors facility and you can see a large anterior head translation and you can see straightening and a lower cervical kyphosis and then here’s the mri and this mri was taken weight bearing although we flipped it to be consistent with the perspective of the x-ray so it appears to be upright but it’s not so the person is supine on their back you can see when they’re on their back the anterior head translation is improved and what you can notice is the cervical disc herniations the mild ones down in the mid and lower cervical region now they’re not making direct contact with the spinal cord but you can see the displacement or the effacement of the fecal sac in through here so we know that when this person’s upright it’s going to be much more severe we’re going to see that disc in contact you know with the the spinal cord not the spinal cord but the dura and it’s going to be likely putting direct shear load uh acting on that uh cord uh interface between the disc and the uh decal sac so when he goes to see joe this is after all this care okay and this is after the permanent impairment rating he’s now he comes to joe 33 whole body impairment rating neck disability index is 46 that’s severe disability on the neck disability index and at the time of the visit he’s a 5 out of 10.
that’s considered moderate chronic neck pain so his chief complaints are neck pain headaches scapular pain right arm pain into the c5 c6 dermatome and also abnormality in the reflex and the sensory distribution there at the c5 c6 dermatome also reduce cervical range of motion using inclinometry there’s the c5 chip fracture and then the primary herniation with c5 c6 but you noticed on the mri there was more than one level now why is this case still chronic why is he still suffering okay well you could say oh he’s malingering it’s psychosocial after the car accident he’s trying to get a settlement uh-uh you know what that’s all [ __ ] sorry for that but i just get so irritated with that you’re gonna assume that a police officer that’s in his prime that loves his job that is willing to go through all this care you’re going to assume that he’s malingering come on give me a break it’s psychosocial problems i don’t think so you know what there there’s reality when we look at these cases and then there’s made up perceptions okay the guy the psychosocial problems are coming from the fact that he can’t perform his activities of daily living and his job duties that’s why he’s got psychosocial problems not the other way around so we look at this case we go this guy’s head so far forward this is part of the problem let’s compare it to studies in the literature that have already been done on subjects that have whiplash compared to control population and what you’ll find out is the ones in a motor vehicle collision these are the ones that have much more significant abnorma abnormalities structurally and functionally psychosocially they’re not making up their anterior head translation so let’s look at this paper from advances in physiotherapy 2005.
what this did is this took a a group of subacute and chronic whiplash associated disorder sufferers compared them to a control group and they looked at let’s let’s identify what the magnitude of the anterior head translation is now this was done seated and it was using a simple angle to determine how far the ear is in front of the upper thoracic and lower cervical spinous process now the greater the angle the further the head is forward and you’ll notice here’s the whiplash associated disordered subjects this is the mean and standard deviation bars and then here’s the control subjects so you can see that we have a greater magnitude of anterior head translation and also it’s statistically significant it’s not just a greater magnitude it actually did reach statistical significance if you read the paper to me this is likely an explanation for why this person still hurts the head is way forward it’s putting load on the cervical spine tissues it’s putting load on the disc load on the facet that disc is already injured you increase the load on it it’s going to flare it up even more it’s going to stimulate and trigger excitatory you know chemicals in in the disc and around the tissues we’re going to get substance p we’re going to get matrix metalloproteinases they’re going to build up these increased pain they lower pain pressure threshold so the per person is more susceptible to pain from mild pressures and it also accelerates degradation of the tissue so you get a catabolic activity activity in the disc in the tissues instead of an anabolic activity that’s what matrix metalloproteinases do and that’s also what the long-term effects of substance substance p is so the other issue is this person’s got an abnormal cervical curve they’ve got a complete straightening if not a mild kyphosis in that mid and lower cervical spine what does that do well that’s also going to increase the load on the tissues and it’s also going to put load on the spinal cord okay so we’re going to see two things from this kyphotic neck it’s going to increase the load on the disc and the vertebral body and we know that through past research and maybe we’ll go through those projects in a future video in fact we will and we’re also going to load the spinal cord now when you do that we’re going to have sequela from that what is that well we’re going to have pain arm pain we’re going to have numbness and tingling grip strength weakness sensory and motor disturbances this is what this guy has right this is a problem for a law enforcement officer that can’t grip his firearm properly right okay it’s not psychosocial it’s coming from a biomechanical insult to the neck okay so uh past studies this one for example 2001 journal of spinal disorders kaya at all what they did is they looked at prospectively over a hundred subjects that were involved in a motor vehicle collision specifically a rear end impact collision and what they did is they looked at the ones that were suffering you know worse than the other subjects by worse in this case neurogenic thoracic outlet symptoms this is arm dysfunction coming all the way down from compression on the brachial plexus right well we also know it’s not just compression on the brachial plexus in here from the thoracic outlet it’s also internally inside the cervical spine you’ve got an abnormal curve it’s putting stress and strain on the spinal cord nerve roots that’s the initial problem then you add compression from the scalene muscles etc and a little vascular disturbance in through here now we’ve got thoracic outlet symptoms well what they identified is the subjects with neurogenic thoracic outlet symptoms in this population of whiplash injured subjects 44 of them had kyphotic configurations of the neck that’s huge 44 that’s almost half you look at the asymptomatic population that is absolutely not even close to that asymptomatic people don’t walk around with a kyphotic neck on average now once in a while you see it but you’re not going to see 44 of them so you get the idea right this is a big big deal this is a prospective study it also did a year-long follow-up and they found out at the year-long follow-up one of the risk factors for continued problems that means continued neurogenic thoracic outlet symptoms is having a kyphotic neck so this is a prospective longitudinal study very important also the disc herniation issue this particular project very nice came out in 2002 out of emergency uh radiology okay these uh guys what they did is they looked at sub-acute and chronic whiplash injured subjects rear in collision okay they have a hundred of them subacute means at least 12 weeks of symptoms or greater okay then they then match them to a control population of 100 subjects that did not have a history of of rear end collision or whiplash injuries what they identified on mri is huge differences in the the amount of or the frequency of occurrence of two things number one disc herniations right if you look how many of these subjects had disc herniations in the whiplash injured subjects look at this disc herniation is 28 percent of this rear end collision population 28 that’s 20 out of 28 out of a hundred disc herniations in the asymptomatic two percent you’re 14 times more likely to have a disc herniation in a motor vehicle collision do you think the cop is malingering that you think he’s making up a disc herniation it’s on the mri and it’s linked statistically to the crash mechanism of injury right then you look at it he’s got a chip fracture from it as well too so geez that was a pretty damn good acceleration impact and high force is exposed to the cervical spine tissues right the other thing is look at the frequency of loss of the cervical curve asymptomatic four percent sub-acute chronic whiplash subjects 98 of them have a loss of the cervical curve and this is on mri non-weight-bearing mri when you stand them up you’re going to see kyphotic configurations etc look at this 98 out of 100 have a loss of the cervical curve now you can’t tell me that’s not a relevant issue so so to me i look at this this data was pre-existing to this particular paper that we published in jnpt so we have evidence that says this is likely why this patient is still suffering nobody bothered to take into consideration the guy had three inches of anterior head translation in a severely straightened and kyphotic cervical curve to us this is why the guy’s still suffering so here’s what joe did he said look here’s what has not been done with this patient let’s take his posture forward head posture rounding protraction of the shoulder girdle area that means the scapula and internal rotation of the glenohumeral joint and let’s start doing mirror image meaning opposite positional procedures with him this is what my late father developed for cbp technique or chiropractic biophysics technique my dad said you know what let’s just do the opposite and apply forces to it in controlled manners so we lay the person supine on a drop table you’ll notice the thoracic piece is elevated what that’ll allow us to do is lower the head below the thoracic spine you’ll notice that the shoulder girdle is going into retraction so we’re pulling the shoulder blades back opening up the chest area stretching the pecs and then we’re externally rotating the glenohumeral joint then joe is in a very controlled manner he’s taking the skull and translating it backwards in the posterior head translation as well as creating cervical extension now at first we’re careful with the the amount of translation and extension we do however over time you can get people into these positions so what’s shown is not the first visit with people so you’ve got to realize this if you’re brand new to cbp technique or if you’re a patient that’s out there you got to realize we’re going to wean you into these procedures right they didn’t build rome in a day and we can’t change these postures in a day we’re going to slowly work you into we use drop table techniques and instrument adjusting techniques this is called a drop table maneuver it’s called a drop table because this head piece will [ __ ] about a quarter of an inch up in the air and when we push pressure down on it it drops that quarter of an inch now that drop creates uh an input into your system neurologically that helps us change posture in the cerebellum and you know from a neurological point of view we’re basically resetting postural balance with this okay if you want a background on that maybe i’ll give you a a review of neurological theories explaining why these techniques are known to change posture it’s called in graduate level mathematics it’s called renee tom’s catastrophe theory so we can explain how these positions and procedures and this drop with the drop table if done right will trigger a reset of your body’s sense of balance okay anyway this is what was done three to five times per week every day is recommended minimum of three times per week also we’re going to be doing extension compression traction now we went through our extension compression traction clinical trial and we know that this is an effective way to rehabilitate anterior head translation and loss of the cervical ordotic curvature you cannot start in this position day one so you start gently hanging the head back and over consecutive days you work the person into more and more translation more and more extension and then we start to add force on the forehead application or the forehead strap here right the forehead strap will pull back and down now shown here is after the patient has built up tolerance for this we’re going to start with one to three minutes the first time and then work our way to where we’re doing 15 to 20 minutes per session in this compression extension traction this is the exact mirror image traction that is recommended for this neck it translates the thoracic spine forward it extends the shoulder girdle and upper thoracic spine backwards it retracts the shoulders and it translates and compresses and extends the head so this will improve the cervical curve also mirror image exercises were done now the picture doesn’t show the exact position of the shoulders that’s correct however what is shown we translate the rib cage a bit forward we translate the head backwards and extend over this fulcrum here and then he’s required to retract and externally rotate his shoulder in scapular area okay when he does that he’s going to actively move as far as he can hold the position with a mild at first moving into a moderate or aggressive contraction he’s going to hold that for five to ten seconds he’s going to repeat that 50 times per session once he’s comfortable doing that now the first time we do it we might only be able to do five to ten repetitions of this however we’re going to work up to where we can do 5 sets of 10 or 50 repetitions at minimum in the office under supervision why under supervision well notice what he’s not doing in the photo well either the photo was taken when he was just modeling for the photo and they forgot to do it or maybe he actually forgot to do the shoulder component to this either way this is why we do it supervised in the office so we make sure it’s done right now today we know that we should also use a fulcrum strap to exercise the cervical lordosis while we’re doing translation and extension the fulcrum allows that curve to experience an anterior shear load or a transverse load so it’ll force a better curve to come back in while we’re doing this this wasn’t done in the paper i’m showing you this today because this is what we would recommend in today’s knowledge ten years later we figured out that you know in addition to doing this full body exercise we should also use a fulcrum type maneuver at the apex of that cervical curve since he’s got so much head translation forward and loss of the lower cervical curve and middle we’ll put the the force application down low and the arms go straight if it was more of a mid and upper cervical curve we would change the position to the mid and upper cervical spine and then we would raise the arms up in the air okay so again this exerciser called the prolordotic exercise was not done the one on the left was done with the patient and you’ll you’ll see you know in the outcome one of the results of perhaps not doing this fulcrum type of exercise the first re-examination so nine approximately nine weeks of doing this okay approximately nine weeks later we do a re-examination what do we notice a dramatic change in the posture of this person the shoulder girdle’s better the head alignment is better and we also repeat the x-ray and we see a great change in the amount of anterior head translation we see the start of a cervical curve forming now he started it about three inches forward this is approximately 25 to 30 millimeters forward this is a huge correction you’ll notice that the lower cervical spine has actually moved backwards relative to the cbp idealized model line part of that is due to the type of traction that was used the compression extension traction and also perhaps the lack of the fulcrum on the exercise however this is a great change also at this re-exam pain disability proper examination and range of motion were done i will show you those outcomes at the end the person is now better but they’re not totally done so what dr joe farantelli did is he recommended another program of corrective care when you see staged improvement in somebody that was chronic for a year this person was chronic and stable with you know what would be called permanent impairment by the orthopedic surgeon 33 now nine weeks later it’s not so permanent impairment you’re seeing improvements so what do you do you keep going because you have exam and documentation findings that that say hey we are improving this person they have not plateaued we’re continuing to make change so let’s keep going so now we have a new alignment that we’re starting with this is where we want to change things up this is where we’re going to have to add a fulcrum to the mid and lower cervical spine so we get that area to bend properly right in essence we want this lower cervical spine to move forward a bit and start to curve backwards so what joe did is he put this fulcrum or transverse load strap on the compression extension unit from dr dwight to george in saugus massachusetts now this is called the total target target force unit and this strap you can control how much pressure is is pulling forward in the neck and you can control the location so this is what dr joe did if we had had the prolodic exercise band it would have been a good idea to to use this as well so now the patient is going to continue with these procedures with a modification of what we’re doing with the traction also we’re going to modify the adjustment it’s not shown but what we would do is instead of putting the person on their back now we can put the person face down we can elevate the head up and extend and we can contact with our hands this lower cervical spine and due to a p to a toggle type of application which will increase theoretically the curvature in the neck now we know that when we do that that’s not necessarily going to totally change the cervical curve but we certainly believe it enhances it it’s logical to do it even though doing that by itself is not necessarily going to make consistent changes okay we know that from our past study that we did however we think it’s a good idea to do it anyway here’s the range of motion evaluations the patient was treated a total of 3.7 months okay and those treatments were three to four times per week 3.
7 months first re-examination this is the inclinometry negative rxh is extension first re-examination second re-examination approximately two months later third re-examination approximately four months later and then we have a long-term follow-up that’s another thing with this case we have a long-term follow-up evaluation okay not only do we show we improved them but we show we maintained that improvement at long-term follow-up after care was terminated and the patient was put on supportive care look at the extension 36 degrees 51 65 long-term follow-up we’ve lost a little bit of that flexion 54 54 50 68 and then back down to 57.
Lateral flexion to the right 30 degrees 40 degrees 55 lost a bit of that lateral flexion to the left this one was more more significantly impaired 20 degrees to 30 to 58 to 42 head rotation to the right okay 30 60 90 and 78 head rotation to the left 28 45 80 89. now look at this you’re seeing staged improvement in the range of motion yes at long term follow-up approximately a year later we’re losing a little bit of that improvement in range of motion but the most dramatic ones lateral flexion to the left head rotation to the right and head rotation to the left are still dramatically improved even with limited care over a year however this shows a couple things number one staged improvement in the range of motion was identified as this person’s spine was corrected this is not a permanent loss of range of motion it’s it’s permanent only because his posture was permanently impaired there’s a connection between abnormal alignment and abnormal movement in mechanics it’s called structure determines function right it’s obvious it’s common sense i’m going to show you a study that confirms this people for some reason they don’t believe it so you got to show them a research paper that shows you know what if you take people and you look at the magnitude of their head translation and then you have them undergo range of motion maneuvers and you quantify it with today’s technology what you’ll find out is functional range of motion is dictated and determined to a great deal by the alignment in the sagittal plane of the person’s head relative to their thorax this particular paper came out in 2006 by fernandez at all in the journal cephalgia and what they were doing is comparing a headache chronic headache population to a normal population now keep in mind our patient does have chronic headaches after a whiplash injury so the the fernandez paper does apply to him in terms of a pain issue as well however the biggest issue is what did the fernandez group find well they found out when they looked at range of motion that there’s a linear correlation between the magnitude of forward head translation and the magnitude of reduction of your cervical range of motion in lateral flexion and y-axis rotation this is exactly what our patient has it’s linear okay so you look at this finding number two from fernandez linear correlation between forward head posture and range of motion also they identified as forward head posture increased in this patient population compared to the controls the headache frequency increased so there’s a linear increase in headache frequency with a linear increase in head translation no wonder the guy didn’t have any improvement from traditional care because the traditional care didn’t do anything to change his alignment it’s just you know to me it’s like obvious common sense here’s the 3.7 month follow-up this is the second evaluation that dr joe ferrantelli did with radiographs looking at the outcome so this is the initial compared to the end of corrective care 3.7 months later look at the remarkable change in body postural alignment as well as radiographic alignment the head translation is entirely improved the cervical curve is within normal limits yes there’s still a c5 chip fracture but look at what happened to the permanent impairment 33 percent down to a 4 4 now the important thing is this patient was sent back to the same orthopedic surgeon that did the initial permanent impairment rating so the same surgeon now looked at him goes whoa it’s not permanent anymore it’s down to four percent what did you do well you know what what he did was he got his neck fixed like should have been done the first time look at the ndi it was 46 percent severe disability down to zero the nrs zero out of ten range of motion is normal at the final uh or the end corrective care re-examination not the long-term follow-up okay this case is a very nice case it demonstrates clearly that in this case the correction of the sagittal plane abnormality of the cervical spine in the posture was what was exactly causing his improvements okay we would suggest to you that this his abnormality is the reason he was continuing to have these chronic pain and impairments we then did cbp corrective care that was directly related staged over time to his improvements in his pain his disability and his range of motion it’s directly correlated this was a stable chronic abnormal patient chronic defined by non-responsive to traditional care and pain management the orthopedic surgeon gave him a 33 whole body impairment rating surgery was recommended after 3.7 months of corrective care no longer was he suffering those same things his pain and disability was actually zero it was zero right ndi zero pain zero range of motion within normal limits right goes back to the the orthopedic surgeon well you know what you still have the disc herniation you still have the fracture so you still have a four percent whole body impairment right this case clearly shows what happens when you don’t do corrective care versus what happens when you do do corrective care and there’s a one-year follow-up showing that the patient maintained those improvements in pain and disability although mild reduction of the cervical range of motion was identified specifically in flexion extension right had he kept up more consistently with the maintenance care likely that would have been improved too right so again case report but you know what well done case reports are consistent with randomized trials on this topic so if you took a randomized trial or you took 40 subjects that had the same condition this patient had you did a randomized trial or 20 of them you just let them do standard care or no care and 20 of them you do what we did here you will see that the results will likely be the same as what this case report showed so well done dr joe ferrantelli and you know what there are so many patients there’s thousands and thousands of patients out there that are still suffering they’ve been labeled malingering the malingers they’ve been labeled psycho psychosocial problems right still wanting to get some kind of money still wanting to get settlement well you know what they’ve already settled their case the insurance company already paid them now they’ve moved on from that but they still have pain and disability what do you do for those well you know what if you’re one of those people out there and you’re watching this video find a cbp trained chiropractor go to cbpatient.com and look up a cbp trained chiropractor and you’ll find somebody there that can help you and get your spine corrected right and if you’re a patient out there watching this video sorry for swearing but got pretty excited at the beginning of this you know what it’s just it’s one of these things that i’m so frustrated that patients have to suffer when there’s a logical answer for the problem that’s the purpose of me doing these videos to try to get this out there not just to the doctors but you know what patients can get on here and look at these youtube video research presentations by me as well again i’m dr dean harrison i’m president of chiropractic biophysics technique i’m president of chiropractic biophysics nonprofit research and this is a formal research publication that was done in 2005 in the journal of manipulative and physiological therapeutics if you like this type of work please consider supporting us and helping us we want to continue helping the public at large and improving the type of health care conservative care non-surgical that these patients get right if we can stop a certain percentage of patients from having surgery then what a deal we’ve saved certain people in in many of their health disorders we’ve prevented a cervical spine surgery surgery that we know is beneficial for some people but in the long run it may not be so fun when that surgery breaks down or your segments break down above and below that and you have to get a second and third surgery so if we can prevent it we’ve done a great service to humanity we’ve also saved a lot of health care dollars and costs by this so if this interests you please continue to support our efforts through chiropractic biophysics nonprofit you can go online support us directly on our website or you can do it indirectly through amazon smile and just select chiropractic biophysics as your non-profit charity hey thank you for your time and attention until next time i look forward to talking to you be safe you