A Patient's Guide to Whiplash
IntroductionWhiplash is defined as a sudden extension of the cervical spine (backward movement of the neck) and flexion(forward movement of the neck). This type of trauma is also referred to as a cervical acceleration-deceleration (CAD) injury. Rear-end or side-impact motor vehicle collisions are the number one cause of whiplash with injury to the muscles, ligaments, tendons, joints, and discs of the cervical spine.
This guide will help you understand
AnatomyWhat parts of the spine are involved?
The cervical spine is formed by the first seven vertebrae referred to as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom edge of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine. This is where the chest begins.
Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.
An intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. The disc is a specialized connective tissue structure that separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.
Related Document: A Patient's Guide to Cervical Spine Anatomy
CausesWhat causes this condition?
Low back pain is a common feature after a whiplash injury. Studies show that there is significant electrical activity in the muscles of the lumbar spine when the neck is extended. This effect increases when there is neck pain, possibly as a way to help stabilize the spine when neck pain causes weakness.
More than anyplace else in the body, the muscles of the neck sense sudden changes in tension and respond quickly. Tiny spindles in the muscles signal the need for more muscle tension to hold against the sudden shift in position.
The result is often muscle spasm as a self-protective measure. The increased muscle tone prevents motion of the inflamed joint. You may experience neck stiffness as a result.
Risk FactorsEach year, about three million people experience whiplash injuries to their neck and back. Of these three million people, only about one-half, will fully recover. About 600,000 of those individuals will have long-term symptoms, and 150,000 will actually become disabled as a result of the injury.
There are many factors that come into play when a person is injured in a rear-end motor vehicle accident. Any one or more of the following factors can affect recovery:
SymptomsWhat are some of the symptoms of whiplash?
Ninety percent of patients involved in whiplash type accidents complain of neck pain. This is by far the most common symptom. The pain often spreads into the upper back, between the shoulder blades, or down the arm. Neck pain that goes down the arm is called radiculopathy.
Low back pain (LBP) can occur as a result of a whiplash injury. The Insurance Research Council reports that LBP occurs in 39 per cent of whiplash patients. Some studies found LBP to be present in 57 per cent of rear-impact collisions in which injuries were reported and 71 per cent of side-impact collisions.
Jaw pain as a result of temporomandibular joint (TMJ) injury can also cause painful headaches. The TMJ is formed by the bone of the mandible (lower jaw) connecting to the temporal bone at the side of the skull. The TMJ is a hinge joint that allows the jaw to open and close and to move forward, back, and sideways. Pain in this joint in called temporomandibular joint disorder (TMD).
Dizziness is quite common with a sense of lost balance being reported. It is caused by an injury to the joints of the neck called facet or zygapophyseal joints. When dizziness is reported, it should be distinguished from vertigo (also known as benign paroxysmal positional vertigo (BPPV), which results from an injury to the inner ear.
Other symptoms often reported include, but are not limited to: shoulder pain; numbness or tingling in the arms, hands, legs or feet; facial pain, fatigue, confusion, poor concentration, irritability, difficulty sleeping, forgetfulness, visual problems, and mood disorders.
It is not uncommon to have a delay in your symptoms. It is actually more common to have a 24 to 72 hour delay as opposed to immediate symptoms or pain. This is most likely due to the fact that it takes the body 24 to 72 hours to develop inflammation. Disc injuries may take even longer to manifest themselves. It is not uncommon for a disc injury to remain pain free and unnoticed for weeks to months.
Simply because there is little or no damage to your car does not mean that you were not injured. In fact, more than half of all whiplash injuries occur where there was little or no damage to one or both of the vehicles involved.
When we see visible damage to a car, it means that the car has absorbed much of that force and less force is transmitted to the occupant. On the other hand, if there is little or no damage to the car, the force is not absorbed but transferred to the driver or passengers, potentially resulting in greater injury.
DiagnosisHow do doctors diagnose the problem?
The diagnosis of neck problems begins with a thorough history of your condition and the involved car accident. You might be asked to fill out a questionnaire describing your neck problems. Then your doctor will ask you questions to find out when you first started having problems, what makes your symptoms better or worse, and how the symptoms affect your daily activity. Your answers will help guide the physical examination.
Your doctor will then physically examine the muscles and joints of your neck. It is important that your doctor see how your neck is aligned, how it moves, and exactly where it hurts.
Your doctor may do some simple tests to check the function of the nerves. These tests measure your arm and hand strength, check your reflexes, and help determine whether you have numbness in your arms, hands, or fingers.
The information from your medical history and physical examination will help your doctor decide which tests to order. The tests give different types of information.
Radiological imaging tests help your doctor see the anatomy of your spine. There are many kinds of imaging tests including:
X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, such as the amount of space in the neural foramina and between the discs.
X-rays are usually the first test ordered before any of the more specialized tests. Special x-rays called flexion/extension x-rays may help to determine if there is instability between vertebrae. These x-rays are taken from the side as you bend as far forward and then as far backward as you can. Comparing the two x-rays allows the doctor to see how much motion occurs between each spinal segment.
Magnetic resonance imaging (MRI)
Computed Tomography (CT)
CT scan is a special type of x-ray that lets doctors see slices of bone tissue. The machine uses a computer and x-rays to create these slices. It is used primarily when problems are suspected in the bones.
Digital motion x-ray (DMX)
DMX is a new fluoroscopic based x-ray system designed to objectively detect and document soft tissue/ligament injury most commonly associated with whiplash injuries of the spine. DMX evaluates biomechanical relationships and abnormal movements of the cervical spine. Specifically, DMX:
DMX uses digital and optic technology now available. DMX is the latest generation of videofluoroscopy (VF) that uses low doses of radiation. The images have improved clarity and resolution over VF and are recorded digitally on CD or DVD disc. DMX digital images can be replayed and studied on standard computer systems. DMX images are simply x-ray images taken at 30 frames per second to form a multiple radiographic array or series that can be run as a movie file to display real time motion of the joints of the body.
DMX radiographic series can be paused at any location and the measurements and interpretation common to radiology can be applied to the still images. These images would be identical to plain film images if plain film radiography were performed at the same location at the same moment in motion. DMX acquires approximately 2700 images for the same amount of radiation as seven regular x-rays.
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The myelogram is a special kind of x-ray test where a special dye is injected into the spinal sac. The dye shows up on an x-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that surgeons had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.
A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special x-rays of your neck. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem and other tests such as the CT scan or MRI scan are then used to look at the area in detail.
Grading the Severity of Injury
The physical exam combined with the imaging studies help determine the severity or grade of the injury. There is more than one way to assign a grade to a patients whiplash. Here are two examples of the more commonly used models used to classify or grade whiplash injuries:
Quebec Whiplash Classification
TreatmentWhat treatment options are available?
Whenever possible, doctors prefer to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.
Your health care providers will work with you to improve your neck movement and strength. They will also encourage healthy body alignment and posture. These steps are designed to enable you to get back to your normal activities. Conservative care may include:
At first, your doctor may prescribe immobilization of the neck. Keeping the neck still for a short time can calm inflammation and pain. This might include one to two days of bed rest and the use of a soft cervical (neck) collar.
Soft collars should not be worn after 48 hours without a physician-s approval. Studies show that prolonged immobilization can delay healing and promote disability. Wearing it longer tends to weaken the neck muscles and reduces the facet joints- sense of position called proprioception.
A cervical support pillow may offer some additional support while sleeping and helps to keep the neck in a more neutral position. Cervical pillows can be used any time by anyone for improved alignment while sleeping.
Your doctor may prescribe certain types of medication if the nerves are irritated or compressed and you have neck pain that travels down your arm (radiculopathy). Severe symptoms may be treated with narcotic drugs, such as codeine or morphine. But these drugs should only be used for the first few days or weeks after problems with radiculopathy start because they are addictive when used too much or improperly. Muscle relaxants may be prescribed to calm neck muscles that are in spasm. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen.
Pain resulting from irritation of the facet joints may be alleviated with injection of an anesthetic agent similar to Novacaine such as Bipuvacaine. This numbing agent both confirms the source of pain as coming from the joint and helps reduce or eliminate the pain.
Some doctors have their patients work with a physical therapist. If you require outpatient physical therapy, you will probably only need to attend therapy sessions for two to four weeks. Your rate of recovery helps determine the length of time in physical therapy. Patients with delayed recovery may need longer time in rehab.
At first, treatment is focused on easing pain and reducing inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Electrical stimulation treatments can help calm muscle spasm and pain. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or the therapist can apply the traction pull by hand. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.
Active treatments are added within the comfortable range of motion. The therapist will teach you specific exercises to help tone and control the muscles that stabilize the neck and upper back.
As your condition improves, your therapist will begin tailoring your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job. Your therapist can also provide ideas for alternate forms of work. You'll learn to do your tasks in ways that keep your neck safe and free of extra strain.
Chiropractic care also offers another opportunity for relief of pain from a whiplash injury. Chiropractors adjust misalignments of the facet joints and vertebrae to restore the nerve signals and improve spinal health, which can impact overall physical health. Many chiropractors make these adjustments using a thrust technique calledmanipulation.
Most people with lingering effects from whiplash or cervical radiculopathy from whiplash get better without surgery. In rare cases, surgery may be suggested.
RehabilitationWhat should I expect as I recover?
Nonsurgical RehabilitationYou should expect full recovery to take up to three months. Integration of rehabilitation and manipulative therapy is central in getting back to your pre-injury status.
There is a strong emphasis on keeping as active as possible, which includes incorporating manual treatments and exercise. Before your rehab program ends, your healthcare team will teach you how to maintain any improvements you-ve made and ways to avoid future problems.
*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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