By: Jeffrey D. Olsen, DC
We see them every day. Patients, with chronic headaches that have not responded to traditional treatment, present with a feeble hope that “maybe a Chiropractor can help.” How I wish we were given the opportunity, earlier in the development of the condition, to restore normal relationships of the spine and extremities. Despite the months or years of compensation and adaptation, we are still able to work miracles with adjustments and rehabilitation. It may just take some time.
Curiously, while taking a history with these patients, we often discover untreated traumas related to auto accidents, dating two to five years prior to seeking our care. One would expect the attendant neck and headache pain following whiplash, but symptoms including dizziness, arm weakness, and low back pain often result in the patient being labeled a malingerer. However, in his review of 266 medicolegal cases, Mcnab found that 45% of the people continued to have symptoms two years after legal settlements were reached.1 This would tend to justify a genuine concern for and belief in our patients and their complaints.
A whole-body approach is very appropriate when this cadre of symptoms is highlighted by chronic tension headaches and related to obvious trauma. Where does one start? When patients turn to Chiropractic care for pain relief, few, if any, expect an area of their anatomy, distant from the perceived pain, to be at fault. However, in seven of ten patients with back pain, postural fatigue and spinal strain cause their discomfort.2 We find that the ultimate cause of pain may originate in any tissue or joint involved in the kinetic structure. The stress can even be traced to altered foot biomechanics which can lead to pelvic and spinal distortions.3 This is the exact scenario that, with time, produces the battery of symptoms we are discussing.
This type of approach fits nicely with my Chiropractic training, but I was astonished to learn what Doctor Fraser, M.D. heard at a meeting of the American Association of Orthopedic Medicine. He was instructed by an orthopedic physician “that it was mandatory to check the feet in all cases of car accident as the force comes up through the floor board of the vehicle and travels through the body to the neck.” He was also admonished to evaluate the tarsal bones, which may be “subluxed” after accidents, and to perform a “simple manipulation,” to restore the foot to its normal integrity.4 This “medical” evaluation and treatment was directed at the entire biomechanical chain, including consideration of the condition of the knees, pelvis, lumbar spine, shoulders and cervical spine.
Unfortunately, most of our patients receive treatment from their medical providers, which deviates substantially from this logical and global approach. Luckily, we don’t have to make the same mistakes!
Ideal cervical spine posture requires coordination of bone, soft tissue, and nerves to respond to and control forces of gravitational loading. Faulty foot mechanics, usually pronation, can affect all supporting joints above the foot and contribute to anterior translation of the head and neck. When the body is erect and weight is evenly distributed between the feet, there are minimal demands for muscle tension. While ideal posture would not involve muscle action of any kind, the fact that none of the supporting joints below the pelvis are locked means the slightest pathological shift in weight initiates excess recruitment of postural muscles and inefficiency.
The direct forces applied to the cervical spine during a whiplash accident can account for many of the soft tissue injuries during the acute phase. However, the long-term effects of improper posture initiated elsewhere in the spine are more likely linked to the chronic headache. The cervical spine, unlike the rest of the axial skeleton, exhibits greater ranges of motion. In addition, stability is maintained not by cervical musculature, but by the osseous and ligamentous structures. The muscles are responsible for the intricate movements and can also be recruited to act as splints following trauma to the cervical region.5
Consider the concept of muscular splinting in relation to new anatomical discoveries involving the cervical spine. In 1996 a group of researchers, including dentists, at the University of Maryland announced their discovery of an attachment of tissue connecting the rectus capitis posterior minor muscle (RCPM) with the dura in the region of the atlanto-occipital junction. The same structure has since been identified on MRI and even among Macaca monkeys. Since this discovery, additional muscle-dural attachments have been identified. These attachments are located between C1 and C2 and involve the rectus capitis posterior major and the obliqus capitis inferior muscles. One medical response to this revelation has been the development of a surgical procedure to sever the connection of the RCPM to relieve tension headache from dural irritation. Because these dural connections function to protect the cord from inward folding of the dura on the cord during extension, it seems more logical to simply relieve the irritation responsible for the muscle spasm.6
The following is a reasonable treatment protocol for the post-traumatic tension headache patient, recommended when Chiropractic care is indicated. Our analysis includes a pre-treatment surface EMG evaluation of the paraspinal musculature. (In this case involving patient E. B.) From this data, we can target areas of irritation which may be distant from the patient’s reported pain. We also correlate these irritations in the lumbar spine and pelvis with dysfunctions in the lower extremities.
In this case, we fit E. B. with a custom-made orthotic designed for use even in water (Foot Levelers’ AquaGuard™), allowing the patient to walk on the beach for exercise. Not only does the orthotic support the arches of the foot and help hold adjustments of the tarsals, but it also reduces the transmission of shock into the spine. Pathological shock occurs when normal walking on ridged surfaces exacerbates irritated structures. Force generated at heel strike can reach 5 to 7 times body weight with the musculoskeletal system itself absorbing a significant percentage of the total, under normal conditions.7
Chiropractic adjustments are directed to reduce the subluxations, especially in the targeted spinal areas, with ancillary procedures and therapeutic exercises as necessary. The NECKSYS® Home Care Neck System is a complete physiotherapy package. The equipment and specific exercises are designed to address the key goals of cervical spine rehabilitation, without regard to the stage of healing. All NECKSYS exercises are performed without pain. The prescribed motions stimulate joint lubrication, tissue repair with minimal scarring, and neuromuscular reeducation. We also provide every patient with a Foot Levelers MyFit® cervical support pillow to help normalize cervical biomechanics while the patient sleeps.
Following the recommendations of the good orthopedic doctor, we find that our success at reducing the effects of the chronic tension headache is a direct result of our whole-body approach. Response of the entire neuromuscular system to treatment can be objectively measured.
Chiropractic care, with its emphasis on comprehensive spinal health, is well suited to the complex, diverse symptoms and therapeutic responses that have contributed to seeming confusion regarding whiplash. Research indicates that only about half of all whiplash patients can expect to achieve full recovery.8,9,10
A Chiropractor’s systematic approach to treatment, including rehabilitation and support of affected extremity and spinal structures, can achieve better than average results for many satisfied patients.11
- Macnab I. Acceleration extension injuries of the cervical spine. In Rothman RH, Simeone FA (eds): The Spine, ed 2. Philadelphia: WB Saunders, 1982, Vol. 2:654.
- Brunarski DJ. Chiropractic biomechanical evaluations; validity in myofascial low back pain. JMPT 1982; 5(4): 155-161.
- Schafer RC. Clinical Biomechanics: Musculoskeletal Actions and Reactions. Baltimore: Williams & Wilkins, 1983.
- Fraser DM. Whiplash: a total body approach. J Neurol Orthop Med Surg 1994; 15:10-12.
- Kettner NW, Guebert GM. Radiology of cervical spine injury. JMPT 1991; 14(9):518-524.
- Hack GD et al. The Anatomist’s New Tools. Reprint from 1998 Medical and Health Annual.
- Voloshin AS, Burger CP. Interaction of Orthotic Devices and Heel Generated Force Waves. 9th International Congress on Applied Mechanics, Canada, 1983.
- Beutler C, England D, Masse J. Basic examination and documentation for whiplash injury. Today’s Chiropractic 1992; 21(6):50-52.
- Lewkovich GN, Wallenius R. Legal duty of doctors treating whiplash trauma. Digest of Chiro Econ 1990; 33(1):20-22.
- Croft AC. Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). ACA J of Chiro 1993; 30:41-45.
- Cassidy JD, Lopes AA, Yong-Hing K. Immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: a randomized controlled trial. JMPT 1992; 15(9):570-575.
About the Author
Dr. Jeffrey D. Olsen is a 1996 Presidential Scholar and summa cum laude graduate of Palmer College of Chiropractic. He has been in private practice, with his two brothers/partners since 1997, in Roanoke, VA. In addition to his practice, Dr. Olsen has instructed as an adjunct faculty member at the College of Health Sciences in Roanoke, teaching Anatomy and Physiology in the Physician Assistant department. He is currently serving as Technical Advisor at Foot Levelers, Inc.