Many people that suffer with neck pain chronically have been involved in a prior motor vehicle accident, and have experienced a "whiplash" type injury.

One of the longest studies looking at the long term effects of whiplash type injuries from a car accident 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 or 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.

In fact, Dr. Kellet states: "early mobilization guided by the pain response, promotes a more rapid return to full activity".

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.

Other benefits to early movement after an accident identified by Dr. Kellet are:

1. strengthening of bone and ligaments, which in turn reduces injury recurrence
2. stimulation of collagen fiber growth and realignment
3. joint awareness is maintained and developed earlier also important in minimizing recurrence of injury
4. better nutrition of cartilage

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".

The scar tissue that occurs after an injury is one of the main factors responsible for strength loss, elasticity loss, and resulting residual symptoms.

In there book entitled: "Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation"(3)physicians Steven Roy and Richard Irvin explain that early motion helps to prevent these fibrotic (scar) tissue changes.

They also go on to state "another reason for encouraging controlled motion is that any adhesions that develop will be flexible and will thus allow the tissues to move easily on each other."

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?(4)

Dr Kannus basically summarizes his study with the following: "Experimental and clinical studies demonstrate that early, controlled mobilization is superior to immobilization for primary treatment of acute musculoskeletal soft-tissue injuries and postoperative management"

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 (5): 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?

"At four weeks, a significant increase in cervical movement occurred in the patients given active treatment but not in those given standard treatment. At eight weeks cervical movement was significantly greater in the patients given active treatment than those given the standard treatment, indicating that the increase in cervical mobility occurred earlier and to a significantly greater degree with active treatment"

As well, these authors concluded: "our results confirmed expectations that initial immobility after whiplash injuries gives rise to prolonged symptoms whereas a 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.

Another study by Physical Therapist Mark Rosenfeld and colleagues was published in the journal Spine in 2000 tittle(6): Early Intervention in Whiplash-Associated Disorders A Comparison of Two Treatment Protocols.

They too looked at patients with whiplash injuries who either got a collar or did early mobilization. They studied 97 patients and were reevaluated at 6 months.

The authors mentioned that 3 studies show negative effects of rest and use of a cervical collars. Yet, oddly enough, this type of treatment is still commonly recommended to patients in early management of whiplash injuries.

The main finding again from this study was "that active treatment of Whiplash-Associated Disorders (WAD) resulted in a significantly greater pain reduction than standard treatment" and that "the current results confirm that frequent active mobilization exercises decrease symptoms more than a gradual mobilization program. Thus, a soft collar for the first period after injury is not the best treatment for WAD"

What was interesting about Mark Rosenfeld's study, was the fact that they published a 3 year prospective follow-up as to the clinical status of these 97 patients.

The authors concluded in their follow up:"The main finding in this study was that active intervention in patients with whiplash-associated disorders resulted in a significantly greater reduction in pain intensity, a greater chance to retain or regain cervical range of motion, and reduced sick leave compared with a standard intervention"

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?

Rosenfeld and colleagues propose that the most effective active motion is rotational.

They explain 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. Roy, Steven M.D,, and Irvin, Richard, Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation, Prentice-Hall, Inc. (1983)
4. 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.
5. K Mealy, H Brennan, GCC Fenelon; Early Mobilisation of acute whiplash injuries; British Medical Journal; Vol. 292, March 8, 1986, pp 656-657
6. Mark Rosenfeld; Ronny Gunnarsson; Peter Borenstein; Early Intervention in Whiplash-Associated Disorders: A Comparison of Two Treatment Protocols; Spine, 2000;25:1782-1787

Doctor Joel Rosen is health care professional and rehabilitation specialist.

He is Dedicating the Rest of his Life to Making Sure You Finally End Years of Neck and Back Pain Suffering While Super Charging Your Energy Levels and Getting Back Your Desire to Do All The Things You Haven't Been Able to... Because Of Your Pain.

Check out his website at: http://doctorjoelrosen.com