Many people that suffer with neck pain chronically have been involved in a prior motor vehicle accident, and have experienced a “whiplash” type injury.
In fact, many studies exists that examine the long term effects of whiplash type injuries from a car accident. One in particular determined that 55% of the people studied had residual consequences 17 years later(1). Sadly, many of these participants still continue to receive some type of ongoing rehab. Many of my patients ask me whether or not they should use a neck collar after an accident. With respect to this topic, a lot of controversy exists. The purpose of this article is to discuss the research related to this topic. So lets have some fun with this topic.
Think of it as a battle: In the red corner, we have the champion, the “SOFT COLLAR”, and in the blue corner, we have the challenger, the “Early Mobilization/early movement”. However, in order to evaluate the pros and cons of using a soft collar for the neck after a motor vehicle/whiplash type accident, it’s important to first talk about the basic fundamentals of soft tissue injuries and the healing process itself. John Kellet M.D, an Australian physician published a comprehensive review of the literature on this topic in the journal Medicine and Science in Sports and Exercise and titled it: Acute soft tissue injuries-A review of the literature(2). The article goes on to describe 3 phases of soft tissue repair when injured.
* Phase 1: The Acute Inflammatory or Reaction Phase
Lasting up to 72 hours immediately after the injury, it involves dilation of the blood vessels, increased blood flow with the accompanied immune response, cleaning up of the area by white blood cells, and the resultant inflammation. Pain is produced from tissue damage and the inflammation itself.
* Phase 2: Regeneration of Repair Phase
This phase lasts anywhere between 48hours to 6 weeks. It is in this phase that the injured tissue is trying to “repair” itself, thus the name. Collagen cells are produced and laid down at the injured site. However, the collagen that is laid down is weak, and laid down in an irregular pattern. These collagen fibers continue to strengthen between 3 to 14 weeks after the injury, and even up to 6 months.
* Phase 3: The Remolding Phase
Overlapping with phase 2, this phase may last up to 12 months or longer. In this phase, the collagen that has been laid down continues to be “remodeled” in the way that its strength is improved, and oriented along with the healthy tissue.
So in the words of William Shakespeare: “To Collar or Not To Collar?, That is the Question”
When a soft collar is recommended and used after an accident the goal is to immobilize the injured area. This supposedly prevents more trauma/injury to the unstable area, as well as lends support to the injured tissue. All things being equal, with no resultant bone trauma (ie, dislocation and/or fracture), the injury is said to be a “soft tissue” injury. So in the case of soft tissue injuries, immobilization with a soft collar would be detrimental to the process of healing as described by Dr. Kellet, as early mobilization and movement would seem to improve the timing and healing quality. If we think about the second phase of healing that we just described, where the collagen fibers that are laid down are trying to orient themselves along the line of stress, then it would make sense that it is the early mobilization and movement that is in fact responsible for its organization. Dr. Kellet expresses that immobilization of soft tissue injuries with the use of soft collars in particular, results in diminished endurance, that ultimately causes loss of strength and muscle wasting that may delay full recovery “for a year or more”.
Another study done in 2000 by Dr. Pekka Kannus, MD, PhD, adds to our understanding of soft tissue injuries. Published in the journal The Physician and Sports Medicine his article was titled: Immobilization or Early Mobilization after an Acute Soft-Tissue Injury?(3) Dr Kannus basically summarizes his study with the following: “Experimental and clinical studies demonstrate that early, controlled mobilization is superior to immobilization” This article too adds to the support focusing early mobilization following soft tissue injury and avoiding immobilization.
What about any studies that specifically looked at the outcomes of people who actually used cervical collars, and compared them to those that did not and utilized early mobilization, for treatment of acute soft tissue whiplash injuries?
Well, orthopedist K Mealy and colleagues asked this question and published their study in the British Medical Journal in an article titled (4): Early Mobilization of Acute Whiplash Injuries. In this study, 61 patients with acute whiplash injuries were studied. Of the patients studied, 31 received active treatment, while 30 received a cervical collar and were called the “standard treatment” group. The active treatment group received ice in the first 24 hours and then mobilization of the neck and daily exercises for the neck. These daily exercises were performed every hour at home, within the limits of pain, and no pain medications was needed. The other group that received the soft collar were advised to rest for 2 weeks before beginning gradual mobilization.
So what were the findings? Well, these authors concluded: “…more rapid improvement can be achieved by early active management without any consequent increase in discomfort”. Again, clearly early mobilization was superior to the cervical collar in this study.
With all these studies, they really point in favor of the the use of early mobilization, and discourage the use of soft collars.
So back to our analogy of a battle, it seems that the soft collar has been knocked out in the first round, and is down for the count vs its competitor of early mobilization of movement. But what kind of motion or mobilization is best?
It turns out, that from all the research I examined, that the rotation motion encourages regional blood flow, and facilitates the removal of exudate, thus allowing healing to occur by aiding nutrition of joint structures. So what should we take away from this lopsided victory? Well, again, all things being equal, with a soft tissue injury of the neck due to a whiplash type accident, soft tissue collar may promote inactivity which can delay recovery with patients with WAD. As well, early mobilization, and familiarity with proper exercises and movements to properly manage both the acute and chronic whiplash injured patient is supported by all the research, and is highly recommended.
References:
1. Mark Rosenfeld, RPT; Aris Seferiadis, RPT; Jane Carlsson, RPT, PhD; Ronny Gunnarsson, MD, PhD; Active Intervention in Patients with Whiplash-Associated Disorders Improves Long-Term Prognosis: A Randomized Controlled Clinical Trial; Spine 2003; 28(22):November 15, 2003: 2491-2498
2. Kellet J; Acute soft tissue injuries-a review of the literature; Medicine and Science in Sports and Exercise; October 1986;18(5): 489-500.
3. Pekka Kannus, MD, PhD; Immobilization or Early Mobilization After an Actue Soft Tissue Injury? The Physician And Sports Medicine; March 2000; Vol. 25 No 3. pp 55-63.
4. K Mealy, H Brennan, GCC Fenelon; Early Mobilisation of acute whiplash injuries; British Medical Journal; Vol. 292, March 8, 1986, pp 656-657
Till next time, watching your back, and neck.
Doctor Joel Rosen
