QuestionJuly of 2006 I was in a car accident..i was hit on the drivers side, back door, my head hit the driver door window..i suffered from severe whiplash. i was put on pain meds (hydrocodone, muscle relaxers) and put into physical therapy. i have had xrays, ct scan, and a mri that show no physical damage. i now have severe headaches and neck pain that can get so bad to the point that i lay in bed and cry because moving hurts. when my neck is hurting i use my shoulders to gaurd it which cause shoulder pain stiffness and soreness. and of course affects the rest of my body.
after about 6 weeks of pain and no help from physical therapy i went to see an orthopaedic surgeon that told me to keep tryin physical therapy because i was still in the acute stage. a month or so later i returned to him and he said there was nothing that could be done and basically tried to make me feel like it was all in my head and i was making it up. soon after that my doctor referred me to a neurological surgeon. he sent me to a new physical therapist who also tried to make me feel like it was all in my head, until she felt this swelling in my neck. she mentioned trigger points? and said she had never felt anything like it..that it was the ligaments that get stiff and swollen because the nerve is sending the wrong signals to the brain at random times.(this lump is very tender and sore..the headaches feel like they originate here..and the more pain i am in the bigger it feels, less pain it seems smaller) after no help from this therapist (touch just seemed to irritate it) the neurosurgeon decided to try nerve block tests. we did 2 of them to the c2-c3 facet joints and i responded very well to both. He was convinced it was nerve damage to that facet joint..so we proceeded with surgery (April 13, 2007) a radiofrequency neurotomy. he was expecting anywhere from 3-12 months of relief. Instead the pain was back by the end of June full blown.(during these pain free months, the lump in my neck was not felt) i had the same surgery August 17, 2007..and the pain was back after about a month and a half. My surgeon thinks this might be because of my bone anatomy, he says i was born with a deformity. The bone that is supposed to overlap in that facet joint stops short, so he doesn't know for sure exactly where the nerve is. But he did notice as he pushed the needle in further it would stray toward my spinal canal risking further injury of course so he decided another surgery would most likely not benefit me. between surgeries I saw another therapist that had me doing stretches and strengthening exercises that seem to help with the shoulder pain..but not with the actual neck pain or the headaches. So I have been told I have an 8% impairment over the whole person and that taking pain medications and physical therapy for the rest of my life is the only thing for me. I am 19 years old now. my health insurance stopped when i turned 19, in my state i cant get medicaid because they cut the funding for my age group. any kind of insurance that i could get now will not cover any of this because its pre-existing, so i cant afford any more physical therapy. its going to be hard to find a job now because this limits what i can do. (lifting, pushing, pulling, walking or standing or sitting in one place for long periods of time, any movement itself if im already sore will make it worse) On top of that its going to be hard to prove a disability (so ive been told) because its a nerve and you cannot see it..and because of my age i could not get much from disability payments anyway. i also worry about having kids because of this. i am in pain everyday and im tired of taking medications. Is there anything that you think might help me with my situation that the others could have missed? sorry if i wrote too much but im trying not to leave out anything you might need to know. thank you so much for your time.
-Staci
AnswerDear Staci,
Sorry to hear of your collision and ongoing symptomatology. I completely understand your frustration with trying to get answers and solutions to your pain and problems. It is never easy to tolerate pain especially within the absence of true understanding. I know it has taken me a few days to respond, but please forgive me as I wanted to give you a detailed answer to your question. It is my goal to give you a more thorough understanding of the mechanism of injury, the anatomy involved, pain transmission, and possibilities of more accurate diagnostic possibilities and treatment.
The crash you were involved in is called a near side impact, and it is common in these types of collisions for the head to either strike the driver抯 window or the B pillar of the frame directly behind the driver抯 window. This may or may not result in concussion or mild traumatic brain injuries. Below is a description of how you most likely were injured in the crash.
Mechanism of Injury:
Upon impact, the target vehicle (your vehicle) begins to move laterally pulling the occupant, due to the vehicles restraint system. In accordance with Newton抯 1st law of motion, the occupant抯 inertia resists this motion. Initially, the thoracic curve (upper back) can be laterally flexed by the restraint, but door impact will reverse the movement and increase the effect in the cervical spine (neck). This results in a compressive force on the impact side and a tensile force on the opposite side, which is transmitted through the spine, again due to the restraining effect of the seatbelt/shoulder harness and the weight of the torso.
Meanwhile, as the torso is experiencing this bending, compression and tension, the head ?also acting in according with Newton抯 1st law ?attempts to remain at rest. The force extends upward into the neck, initiating lateral bending of the cervical vertebral segments. The compression then quickly gives way to tension as the opposite moving head and torso attempt to disengage.
Significant amounts of horizontal/shear force occur in the neck near the facet (spinal joint) line. As this is initiated under conditions of compression, the overall stiffness of the neck may be diminished as a result of the ligamentous slack, which offers less resistance to shear forces and thus less protective resistance to the side-impact vectored injury mechanism and the transfer of energy.
As the change of motion from side to side occurs (abruptly in this case due to the impact inside the vehicle), the direction of horizontal shear reverses rapidly to the opposite bending moment. Depending on the initial position of the occupant with respect to seat belt and shoulder harness, the seat and shoulder portions of the restraint system will halt the lateral and forward motions of the torso to the limits of the restraint system, and this rotates the upper torso to some extent and will effectively magnify the neck抯 bending moment due to the head抯 inertia. This is coupled with the addition of some angular motion forward and backward in the neck due to the yaw experienced by the vehicle. Therefore, it is more likely than not Staci, your injuries occurred in the initial phase of the crash and a double re-entry phase (includes door impact). Injuries are a result of head lag, compression, tension, and shear loading along the facet articulations and adjacent ligaments. Thus, injury can occur with or without a pathological range of motion.
Now, since you have some detailed knowledge of how the injury occurs, what tissues do we expect to be injured梩he soft tissue? If these soft tissue injuries not addresses early on after injury, abnormal scar tissue will form and can easily lead to chronic pain without a specific nerve injury.
揝oft tissue injuries?encompass anything that is not bone including organ systems, nervous tissue, cartilage, musculature, ligaments, tendons, and fascial tissue. Muscle has a high reparative capacity and sufficient regenerative capacity, but extensive damage results in scarring and atrophy of the fiber bundles. In contrast, tendons and ligaments are notably slow to heal! Even after forty weeks, collagen may still not be present in normal concentration and organization. Articular cartilage, which is found in every zygapophyseal (facet) joint in the spine, has a notoriously limited potential for either healing or regeneration. The ability of articular cartilage to heal will depend on the severity of injury. Patients requiring surgery are the least likely to heal. In relation to acceleration/deceleration type trauma from vehicular crashes, the cartilaginous surfaces of the facet, (a.k.a. the synovial folds), are exposed to tremendous loading moments with sheer, compression, tensile, and torsional forces. Major cartilaginous damage is probable throughout the spine along with ligament disruption and is responsible for sclerotogenous pain patterns experienced by patients. Sclerotogenous pain refers to overlapping pain regions corresponding to the disk and ligaments of the spine. They are diffuse and broad, and unfortunately many physicians do not understand the relationship to the anatomy. (Staci, you can look up sclerotogenous in the glossary section of my website for a more detailed explanation with illustrations)
Regarding patient care, immobility is a main factor that promotes degeneration. The restoration of mobility seems to curtail degeneration. Previous research has demonstrated that the tensile strength of ligaments and tendons respond to changes in physiologic stress and motion that aid the healing process. Improving mobility can even enhance cartilage healing after traumatic injuries as well as the strength and stiffness of ligamentous structures. Furthermore, after trauma, healing occurs by an unspecified form of collagen, scar tissue, which frequently causes adhesions and fibrotic changes that must be dealt with therapeutically.
Although physical therapy is a good start厃ou need the motion of repeated specific exercises, Chiropractic adjustments improve and restore motion and movement patterns in the zygapophyseal joint at the facet articulations, which include the ligamentous, myotendinous, and fascial complexes. With the addition of carefully progressed passive and active rehabilitation programs, further mobility can be achieved due to increased stretch and flexibility. I would recommend that you try chiropractic care as adjustive techniques ensure that the zygapophyseal joint biomechanics are proper as facets continue to articulate correctly and send mechanoreceptive information to higher brain centers, and to reduce the neoneuralization of scar tissue. Neoneuralization (new nerve growth) increases pain transmission to the brain via nociceptive input (pain transmission) from the synaptic arborization (spreading out) of c-afferent fibers (free nerve endings that only transmit pain). The goal is to limit and inhibit this process so that neurological wind-up (recurring pain) does not occur and lead to chronic pain and residual disability. Stretching/AROM, resistance training incorporating bands and weights, physioball training, dynamic spinal traction and postural exercises are utilized for maximum benefit.
In reading all of this, you should agree that your physical therapist was on the right track to implicate the ligaments in the neck, but not because the nerve is sending wrong signals, because the ligaments were torn and were scarring over. Trigger points however are the long-term effects of chronic muscle spasm...the muscles will try to stabilize the inured area.
The ligament injures could have been documented early on with the utilization of stress view x-rays. Two specific views should have been taken called flexion and extension views. Medical doctors do often not order these views and consequently ligament injuries are often missed. You have to realize that the ER and the surgeons are looking for larger more distinct injuries such as fractures, bleeds, dislocations etc卼hat require more immediate medical care. If the views were ordered, simple measurements could have been made to determine the extent of the injury. The procedure is outlined in the American Medical Associations 5th edition guideline to impairment. It is important to note that if even one area of the neck was found to be unstable (movement forward or backward of 3.5mm or more, then you qualify for a 25-28% whole body impairment rating). Furthermore, a special MRI view called a FLAR study will pick up on ligament injuries in the upper portion of the spine with pinpoint accuracy, but I highly doubt that type of MRI was ordered, and the radiologist probably did not concentrate on looking for a ligament injury卼hey usually look for disk, nerve and facet injury along with degeneration. These studies can still be performed. It is also important to realize that chronic headache pain after a crash is often due to torn ligaments in the upper cervical complex: C0/C1, C1/C2, C2/C3.
In relation to everything that has already been written, it is further likely that your spinal structure has become altered due to the force of the crash, the transfer of energy, and the resultant injuries. Therefore I suspect that you probably were also left with a damaged spinal curve卲ossibly a reversed curve, an S shaped curve, or a translated curve which means off to one side, or forward in relation to the chest. This is a common finding on x-ray after the crash due to the shear forcers and the abnormal spinal movements, and will lead to accelerated degeneration over time. This can be corrected or at least reduced with the addition on directional/dynamic spinal traction.
Dynamic spinal traction for structural remodeling and rehabilitation is utilized to maximize the physiological anisotrophic effects of creep, hysteresis, and set that occur in viscoelastic tissues such as ligaments. Basically, the ligaments will deform to stress like Silly Putty. They can be injured due to a quick accelerational stress, and they can be remodeled with a slow controlled stress. The ligamentous complex is the limiting factor in effective rehabilitation. Only sustained incremental loading of the ligamentous tissues with low force of long duration, in a consistently applied manner, will have the desired structural viscoelastic effect of plastic (permanent structural improvement) changes. Chiropractic Biophysics traction protocols are substantially researched and documented. There are more than 100 clinical papers in the index medicus, which substantiate this type of care, and I would suggest you look into it. Check out www.idealspine.com for more information. Cryotherapy (ice) is utilized in traction and post-traction due to research indicating that tissues stretched under heating conditions and then allowed to cool under tensile conditions maintain a greater proportion of their plastic deformation than do structures allowed to cool in the unloaded state. Cooling under load may allow the collagenous microstructure to stabilize at new stretched lengths, not to mention that it eases pain and reduced inflammation. Below are a few quotes I think you may appreciate. They further underscore the importance of the spinal structure and ligament complex.
揟he spinal injury weakens the spine and predisposes the patient to further injury, regardless of type and extent of damage. This phenomenon is especially true when protection of the injured part is not adequate. Ligaments and muscles heal only by scar formation, and the annulus fibrosis of the disk is almost powerless to heal tears of its substance.?David B. Levine, M.D., The Painful Back, Page 451, Chapter 92
揊or every inch of forward head posture, it can increase the weight of the head on the spine by an additional 10 pounds.?Kapandji, Physiology of Joints, Vol 3.
揕oss of the cervical curve stretches the spinal cord 5-7 cm and causes Disease.? Dr. Alf Breig, Neurosurgeon (Nobel Prize Recipient)
揊orward head posture leads to long term muscle strain, disc herniations, arthritis and pinched nerves.? The Mayo Clinic, Nov. 3rd, 2000
?0% of the stimulation and nutrition to the brain is generated by the movement of the spine?
Dr. Roger Sperry, (Nobel Prize Recipient for Brain Research)
Additionally, Dr. Sperry demonstrated that 90% of the energy output of the brain is used in relating the physical body to gravity. Only 10% has to do with thinking, metabolism, and healing, so when you have forward head posture and a loss of active range of motion, your brain will rob energy from your thinking, metabolism, and immune function to deal with abnormal gravity and posture relationships and processing.
Bottom line her Staci, is that you definitely need to focus on getting more care. I encourage ongoing physical therapy type care, but only if it is directed at the correction of your structure, and the ligamentous system. If that is the focus, the joint spaces will also be rehabbed correctly therefore aiding in the proper motion of the facet joints, which will minimize further cartilage injury and reduce pain. It may not be possible to completely eliminate your pain, but it should be possible to significantly reduce it so your quality of life can be increased. I would further suggest the use of nutrition: We use specific nutraceuticals such as pro-enzymes; malic acid, magnesium, omega III fatty acids, bromelain, tumeric, and zinc. These agents have been proven to inhibit and reduce inflammation, maximize the bioavailablity of repair materials for soft tissue healing, and provide neurological support.
Lastly, I don抰 know whether or not the crash was your fault, but if not, I would highly recommend that you seek out legal advice on this matter, as I believe you will need extensive care in the next few years which will obviously be expensive. If you have not settled with the at fault party you may wish to see if some of your expenses can be covered by their insurance. Only a personal injury attorney can advise you on those matters, and I would suggest that you interview 3-5 of them to get more than one opinion. This is your health and your future, be as informed as possible.
For additional information on crashes, I would also suggest that you check out the Spine research Institute of San Diego: www.srisd.com. They have a very comprehensive website. I wish I could give you more as there is so much I have not covered, but this is a good start. Please feel free to write back if you need more information or clarification匢 know some of this may be confusing. I hope this helps, and Good Luck.
Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net
