Whiplash

Neck pain is a common symptom of whiplash.

• Whiplash is a relatively common injury that is often ignored or mistreated due to lack of understanding of the condition.
• Whiplash is usually the result of a rear impact while in a stationary position.
• Early range of motion and exercises lead to a more rapid recovery than prolonged immobilization or use of a cervical collar.
• Failure to properly educate and treat patients with whiplash can lead to chronic psychosocial symptoms including depression and anxiety.

Whiplash is a relatively common injury that occurs to a person's neck following a sudden acceleration-deceleration force that causes unrestrained, rapid forward and backward movement of the head and neck, most commonly from motor vehicle accidents. The term "whiplash" was first used in 1928. The term "railway spine" was used to describe a similar condition that was common in persons involved in train accidents prior to 1928. The term "whiplash injury" describes damage to both the bone structures and soft tissues, while "whiplash associated disorders" describes a more severe and chronic condition.

Fortunately, whiplash is typically not a life threatening injury, but it can lead to a prolonged period of partial disability. There are significant economic expenses related to whiplash that can reach 30 billion dollars a year in the United States, including:

• medical care,
• disability,
• sick leave,
• lost productivity, and
• litigation.

While most people involved in minor motor vehicle accidents recover quickly without any chronic symptoms, some continue to experience symptoms for years after the injury. This wide variation in symptoms after relatively minor injuries has led some to suggest that, in many cases, whiplash is not so much a real physiologic injury, but that symptoms are more created as a result of potential economic gain. Many clinical studies have investigated this issue. Unfortunately, while there will always be people willing to attempt to mislead the system for personal gain, whiplash is a real condition with real symptoms.

Whiplash is most commonly caused by a motor vehicle accident in which the person is in a car that is not moving, and is struck by another vehicle from behind. It is commonly thought the rear impact causes the head and neck to be forced into hyperextended (backward) position as the seat pushes the person's torso forward - and the unrestrained head and neck fall backwards. After a short delay the head and neck then recover and are thrown into a hyperflexed (forward) position.

More recent studies investigating high-speed cameras and sophisticated crash dummies have determined that after the rear impact the lower cervical vertebrae (lower bones in the neck) are forced into a position of hyperextension while the upper cervical vertebrae (upper bones in the neck) are in a hyperflexed position. This leads to an abnormal S-shape in the cervical spine after the rear impact that is different from the normal motion. It is thought that this abnormal motion causes damage to the soft tissues that hold the cervical vertebrae together (ligaments, facet capsules, muscles).

Common symptoms related to whiplash may include:

• neck pain and stiffness,
• headache,
• shoulder pain and stiffness,
• dizziness,
• fatigue,
• jaw pain (temporomandibular joint symptoms),
• arm pain,
• arm weakness,
• visual disturbances,
• ringing in the ears (tinnitus), and
• back pain.

In a more severe and chronic case of "whiplash associated disorder" symptoms may include:

• depression,
• anger,
• frustration,
• anxiety,
• stress,
• drug dependency,
• post-traumatic stress syndrome,
• sleep disturbance (insomnia),

Patients with whiplash injuries may enter into litigation and social isolation may occur as a result of their symptoms.

After an accident the patient may be taken to the hospital or a doctor's office to be examined. The doctor will examine the patient to determine if they have any injuries that require treatment. Based on the symptoms and examination findings the doctor may place a collar on the neck for additional support. The doctor may also obtain X-rays of the neck to check for more serious injury. The most important first step is to make sure there is no major injury to the neck, head or the rest of the body requiring immediate treatment.

If the X-rays are normal but the patient continues to have neck pain, the doctor may keep the cervical collar in place and see the patient back in the office in about a week for an additional examination. At that time, the doctor may obtain new X-rays to see if there have been any changes. If the doctor is still concerned about soft tissue injuries, he or she may obtain either X-rays with the head leaning forward and backward (dynamic X-rays) or obtain an MRI (magnetic resonance imaging study). These dynamic X-rays or MRI scans are better able to detect injuries to the soft tissues of the neck, especially instability, that may not been seen with normal X-rays of the neck.

Treatment of whiplash depends on the wide variety of symptoms present. Unfortunately, most treatments of whiplash have not been well tested to determine their effectiveness.

The most important issue in the management of whiplash is optimal education of the patient about their injury. This includes information on the cause, potential treatments, and likely outcomes. Patients should understand that this is a real injury, but that nearly all patients have the ability to fully recover. Patients that do not receive this information are much more likely to develop the more chronic "whiplash associated disorder."

In the past, the initial treatment for whiplash was often a soft cervical collar for several weeks. The goal of the collar was intended to reduce the range of motion of the neck and to prevent any additional injuries. More recent studies have shown that this prolonged immobilization actually slows the healing process. If there is no evidence of abnormal spinal alignment, early range of motion is advised.

Patients involved in early range of motion exercises have been shown to have a more reliable and rapid improvement in their symptoms. This treatment typically involves rotational exercises performed 10 times per hour as soon as symptoms allow within the first four days of the accident.

It seems that excessive rest and immobilization have been shown to have greater chances of chronic symptoms. This is explained by loss of range of motion leading to increased pain and stiffness. Immobilization also causes muscle atrophy (muscle wasting), decreased blood flow to the injured soft tissues, and healing of damaged muscles in shortened position that renders them less flexible.

Physical therapy can be useful in helping to wean a patient from a cervical collar as well as to help strengthen muscles and reduce painful motions. Occupational therapy can be used to help return the patient to the work environment.

If the patient begins to develop psychological symptoms including anger, anxiety or depression following an injury, prompt treatment of the emotional condition is recommended. This can help the patient better understand the good chances for successful recovery and reduce the chances of chronic symptoms.

While it is not always possible to prevent accidents, advances in automobile safety have attempted to reduce the associated risks. Many advances in seat belts and head restraints have been able to reduce the risk of whiplash injury. The proper use of these devices is crucial to their success in preventing injury. Head restraints are designed to prevent the head from moving into hyperextension when struck from behind. In order for this to work properly, the head restraint should be optimally positioned directly behind the head. If the head restraint is lowered below the level of the head it could actually force the head into further hyperextension after an impact. Many automobiles have additional safety equipment including air bags and air curtains to further protect drivers and passengers from injury.