What is whiplash?
Whiplash is a common bony and soft tissue injury to the neck caused by an “acceleration-deceleration” transfer of energy to the spine. In 1867, neck pain in railroad workers after rear-end collisions was first referred to as “railroad spine.” In 1928, the term “whiplash” was introduced to describe neck pain after motor vehicle accidents. We typically think of whiplash as occurring from rear-end or side-impact motor vehicle accidents but it can also be caused by diving accidents or collisions during contact sports.
What causes whiplash?
The initial theory was that injury to the neck occurred because the muscles, tendons and ligaments of the neck were “overstretched” after the neck was “whipped” first into extension and then into flexion during accidents. We now have a better understanding of how the cervical spine is injured in rear-end motor vehicle accidents based on tests performed on crash test models:
- As the car is struck from behind, the seat pushes the body and torso forward while the head and neck fall backwards
- This sudden backwards motion forces the neck into an abnormal “S-shape” as the lower part of the spine is extended while the upper part is flexed
- After a short delay, the head and neck fall forward into a flexed position
- The spine returns to its normal curve.
The soft tissue injuries to the muscles, ligaments, discs and joints in the neck are caused by the abnormal S-shape which occurs just milliseconds after impact in a car accident. “Whiplash” refers to the injuries to these structures while “Whiplash-Associated Disorder” (or WAD) refers to chronic neck pain after a whiplash injury that does not resolve despite appropriate treatment and is usually associated with psychological distress, such as depression and anger.
What are the symptoms of whiplash?
Common symptoms of whiplash include: neck pain and stiffness, headaches, jaw pain, shoulder pain, arm pain and weakness, ringing in the ears, visual disturbances, dizziness, numbness, tingling and back pain.
Common symptoms of WAD include the symptoms described for whiplash but also include: depression, anxiety, anger, frustration, sleep disturbances, stress, social isolation and post-traumatic stress.
How is whiplash diagnosed?
After a motor vehicle or sports accident, a patient may be seen and examined by either an emergency room physician or a primary care physician and evaluated for any evidence of whiplash injury. If bony injury to the spine is suspected, standard front and side-view X-rays may be ordered to rule out fracture or dislocation. Dynamic X-rays with views of the cervical spine in both flexion and extension may also be done to rule out a serious ligament injury which can cause instability of the spine. A CT-scan or MRI may also be performed if there is any reason to suspect damage to the spinal cord or nerve roots.
Imaging studies such as X-ray and MRI are often normal in whiplash injuries. Normal results, however, do not rule out the soft-tissue injuries to discs, ligaments, muscles and facet joints which are typical of whiplash.
There is also a possibility that you may be told that your MRI study shows degenerative changes such as a “disc bulge” or “arthritis.” It is important to correlate the MRI findings with your physical signs and symptoms and not to attribute the whiplash, or soft tissue, pain to the degenerative changes noted on your MRI study. It is essential that you do not worry excessively about degenerative changes to the discs and joints because they are very common and are found just as often in people without pain as in those with whiplash injuries. These changes were more than likely present before your accident when you did not have any pain and are unlikely to be the source of your whiplash pain.
How can my X-rays be normal when I have pain?
Injuries to the discs and facet joints in the spine have consistently been found in studies done on victims of fatal motor vehicle accidents. Injuries include: tears and contusions of the outer rings of the discs, tears of the joint capsules, contusions of the joint meniscus, hemorrhage in the joint, and fractures of the joint cartilage.
These injuries are often present but are not seen on X-rays or CT scans and may not even be seen on MRI studies. We know that small fractures and joint hemorrhage are the source of pain in other joints, so it is reasonable to deduce that they are also painful when found in the joints of the neck.
How is whiplash treated?
After a whiplash injury, patients are frequently treated initially with anti-inflammatory medications and referred to physical therapy for treatment of their neck pain and stiffness. Therapy programs which focus on active exercises and range of motion exercises lead to better patient outcomes and more complete recovery than passive therapy programs in which ultrasound, massage, and heat are the primary treatment modalities.
Soft collars may be prescribed to help alleviate neck pain related to whiplash. However, wearing a soft collar for pain relief after a whiplash injury prolongs rather than hastens recovery time. Patients with whiplash who avoid use of a soft cervical collar have improved outcomes and speedier recoveries.
Patients who are encouraged to resume their normal activities and are told that they can act as they normally would also have improved outcomes following whiplash injuries.
Education is extremely important for a patient with an acute whiplash injury. Understanding that the pain and stiffness associated with whiplash are due to soft tissue injuries of the neck and that these symptoms are very normal following an acute injury is beneficial. Knowing that the vast majority of patients do not have any long-term problems or chronic pain related to their injury and that most patients recover within 6 weeks is encouraging for patients with an acute whiplash injury.
What can I do to speed up my recovery?
- Do your normal activities to the best of your ability. Although it may be uncomfortable at first, remember that normal activities will not cause any further damage but will actually speed up your recovery.
- Resume exercising early after injury even though it may be uncomfortable. Patients who exercise as tolerated do better than those who avoid exercise. Remember that active exercises rather than passive exercises speed recovery.
- Although wearing a soft collar may seem to help initially, it is important to avoid wearing one if possible as it can prolong recovery time.
- When used in the acute phase after injury, medications may allow you to be a more active participant in an early exercise program; however, they do not accelerate recovery from whiplash injuries. It is important not to rely solely on medications for complete pain relief.
- Try to avoid focusing too much on your pain as it can make your pain more severe.
- It is normal to be more acutely aware of your body’s various aches and pains after an injury. Remember that aches and pains are common, especially in settings of stress, and attributing all aches, pains and headaches that you experience in the months following your accident to the whiplash injury may prevent a full recovery.
Are there any other treatment options if I continue to have pain?
While many patients will have resolution of their symptoms in a matter of weeks, there are patients that may continue to have pain despite appropriate treatment and exercise. Up to 60% of whiplash patients with chronic neck pain have facet joint-related pain. These patients may benefit from diagnostic medial branch blocks of the facet joints under X-ray guidance.
Medial branch nerves are tiny nerves that carry the pain signal from the inflamed, damaged facet joints. A medial branch nerve block serves several purposes. First, by placing numbing medicine around the nerve, the amount of pain relief you experience will help either confirm or deny the joint as a source of your pain. Also, the pain relief that you experience may allow you to better tolerate exercise or therapy.
If the block is successful in alleviating your pain and we have confirmed the joint as the source of your pain, then we may be able to treat that joint with more permanent procedures, such as radiofrequency ablation.
Used with permission by AANEM
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