Archive for the ‘Whiplash’ Category

Whiplash (or the rapid acceleration forwards followed by deceleration or sudden stopping of the moving head during the whiplash event) occurs at a speed that is so fast, we can’t prepare for it. In other words, by the time it takes us to voluntarily contract a muscle to guard ourselves against injury, that rapid forward/backwards “whipping” of the head and neck is already over! When considering the details of the injury event, sometimes we lose focus on what REALLY matters. Is there a way to reduce the chances for a long-term chronic, disabling, neck pain / headache result? Last month, we found out that the long-term use of a cervical collar is NOT a good idea. What are some other ways to prevent long-term disability?

A very interesting study investigated the first 14 days of treatment during the acute stage of whiplash neck sprain injuries following a car accident. The researchers wanted to determine what long-term consequences resulted from two different treatment approaches. In one group (201 patients, 47% of the total group), the patients were encouraged to, “…act as usual,” and continue in their normal daily, pre-injury activities. The patients in the second group were given time off from work and were immobilized in a soft cervical collar during the first 14 days after the car crash. At the end of the 14 days, there was a significant reduction of symptoms between the first visit to the fifteenth day (24 hours after the 14 day initial treatment time frame in both groups). However, when evaluated at the six-month point, the group that continued their normal daily routine, did not take time off work, and did not wear a collar had, “…a significantly better outcome,” compared to the other group. This study supports that over-treatment with a collar and time off from work “sets people up” for adopting a “sick role” where the patient is overly-focused on their problem. This study parallels what we discussed last month and embraces the chiropractic philosophy to staying active, exercise, don’t use a collar, and the use of manipulation which exercises joints and keeps them from stiffening up, thus reducing pain and the fear of doing activity!

Another study looked at different presenting physical factors that might be involved in the development of long-term handicaps after an acute whiplash injury in a group of 688 patients. They measured these physical factors at three, six, and twelve month intervals and found the relative risk for a disability a year after injury increased with the following: 1) A 3.5 times disability increase with initial high pain intensity of neck pain and headaches; 2) A 4.6 times increase with initial reduced neck movement or ranges of motion; and 3) A 4 times greater chance with initial multiple non-painful complaints (such as balance disturbance, dizziness, concentration loss, etc.). In yet another study, both physical and psychological factors were found to predict long-term disability. These included initial high levels of reported pain and poor activity tolerance, older age, cold sensitivity, altered circulation, and moderate post-traumatic stress.

The “bottom line” is that as chiropractors, we are in the BEST position to treat and manage whiplash injured patients based on the type of care we perform and offer. We promote exercise of muscles and joints, encourage activity not rest, and minimize dependence on medication, collars, and other negative treatment approaches.

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Whiplash – Rest or Treatment?

Posted: November 1, 2013 in Whiplash

Whiplash, or WAD (whiplash associated disorders) results from the rapid movement of the neck and head resulting in injury. This is the net result of the “classic” motor vehicle collision, though other injury models (like slips and falls) can result in similar injuries. Last month, we listed basic facts, of which one was better results (less long-term pain and disability) occurred from initial active treatment of the neck with mobilization/manipulation, exercise, and encouraging movement vs. placing a collar on the patient and “resting” the injured neck. Though there are a few studies that suggest there is no difference in results, the majority state that it is BEST to actively treat the patient and encourage movement (of course, assuming no unstable fractures have occurred) rather than to place the patient into a collar and limit activities. The first question that we’ll address this month is, why is this important?

The simple answer is that you, as an advocate for an injured friend, family member or as a patient yourself, may NOT be offered “the best” treatment approach by the ER or primary care physician. In fact, one study cited a survey regarding the management of whiplash injuries in an ER and reported that between 23-47% of physicians prescribed a soft cervical collar for acute whiplash rather than promoting immediate active treatment. By knowing this information, the knowledgeable patient can refuse the collar method of care and seek care that emphasizes the use of early mobilization and manipulation, like chiropractic! Though referrals to chiropractors are increasing as more research becomes available, chiropractic care is still significantly ignored or not considered by many practicing ER and primary care physicians. As always, you need to be your own “best advocate,” and the only way to do that is to be informed, hence the intention of this Health Update! Some studies even report that the use of a collar may have deleterious or “bad” side effects and can actually make you WORSE (this was reported by the Quebec Task Force)! The majority of studies on the subject of whiplash report that encouraging “normal activity,” as opposed to immobilization, IS the best approach. We will certainly help steer you in the right direction!

Next, let’s talk about WHY does this method works better? The research supports that soft tissues injuries heal better and with less scar tissue formation when patients receive active treatment/early activity types of care (like manipulation / chiropractic). In general, any treatment approach that reduces patient suffering sooner, encourages one to return to “normal activities” faster, and promotes independence and self-care methods earlier is the best approach!

Whiplash “Basics”

Posted: October 4, 2013 in Whiplash

Whiplash is a non-medical term typically describing what happens to the head and neck when a person is struck from behind in a motor vehicle collision. Let’s look at some basic facts about whiplash:

 

  • Before cars, trains were the main source of whiplash and was called “railroad spine.”
  • Better terms for whiplash injuries include “cervical acceleration-deceleration” (CAD) which describes the mechanism of the injury, and/or the term “whiplash associated disorders” (WAD), which describes the residual injury symptoms.
  • Whiplash is one of the most common non-fatal injuries involved in car crashes.
  • There are over one million whiplash injuries per year due to car crashes alone.
  • An estimated 3.8 per 1,000 people per year have a whiplash injury.
  • In the United States alone, 6.2% of the population has “late whiplash syndrome” (symptoms that do not resolve at one year).
  • 1 in 5 cases (20%) remain symptomatic at one year post-injury of which only 11.5% returned to work and only 35.4% of that number returned to the same level of work after 20 years.
  • The majority of whiplash cases occur in the fourth decade of life, females>males.
  • Whiplash can occur from slips, falls, and brawls, as well as from horse-riding, cycling injuries, and contact sports.
  • Injury from whiplash can occur at speeds of 15 mph or less.
  • In the “classic” rear end collision, there are four phases of injury (time: 300msec)
    • Initial (0msec) – before the collision (the neck is stable)
    • Retraction (1-150msec) – “whiplash” starts where the head/neck stay in the original position but the trunk is moving forwards by the car seat. This is where the “S” shaped curve occurs (viewing the spine from the side).
    • Extension (150-200msec) – the whole neck bends backwards (hopefully stopped by a properly placed head rest).
    • Rebound (200-300msec) – the tight, stretched muscles in the front of the neck propels the head forward immediately after the extension phase.
  • We simply cannot voluntarily contract our neck muscles fast enough to avoid injury, as injury to the neck occurs within 500msec. and voluntary contraction or bracing takes 800msec or longer.
  • Injury is worse when the seat is reclined as our body can “ramp” up and over the seat and headrest. Also, a springy seat back increases the rebound affect.
  • Prompt treatment is better than waiting for a long time. Manipulation is a highly effective (i.e., COME SEE US!) treatment option.

Whiplash Diagnosis

Posted: September 16, 2013 in Whiplash

Whiplash is, by definition, the rapid acceleration followed by deceleration of the head causing the neck to “crack like a whip” forwards and backwards at a rate so fast that the muscles cannot react quickly enough to control the motion. As reported last month, if a collision occurs in an automobile and the head rests are too low and/or seat backs too reclined and the head moves beyond the allowable tissue boundaries, “whiplash” injury occurs.

When gathering information from the patient, this portion of the history is called “mechanism of injury” and it is VERY IMPORTANT, as it helps us piece together what happened at the time of impact. For example, was the head turned upon impact? Was the impact anticipated? What were the weather conditions (visual, road conditions)? What was the direction of the strike (front, rear, side, angular, or combinations of several)? Did a roll over occur? Was a seat belt used (lap and chest) and were there any seat belt related injuries (to the low back/pelvis, breasts/chest, shoulder, neck)? Any head impact injuries with or without loss of consciousness (if so, how long)? Any short-term memory loss and residual communication challenges (post-concussive syndrome)? All of the answers to these questions are very important when determining the examination path, establishing the diagnoses, and determining the treatment plan.

We also discussed last month the WAD classification or, Whiplash Associated Disorders, which was coined in 1995 by the Quebec Task Force. Types I, II, and III are defined by the type of tissues injured and the history and examination findings. In 2001, the Quebec Task Force found that WAD II (loss of range of motion or ROM/negative neurological findings) and WAD III (both ROM loss and neurological loss) carried progressively greater risk of prolonged recovery compared to WAD I injuries (those with pain but no loss of motion or neurological findings).

Establishing a strong diagnosis allows for accuracy in prognosis and treatment plan recommendations. For example, in WAD II & III injuries, flexion/extension x-rays are needed to determine the extent of ligament damage as normally, the individual vertebrae should not translate or shift forwards or backwards by more than 3.5mm. Similarly, the angle created between each vertebra in flexion & extension should be within 11 degrees of the adjacent angles, and if that’s exceeded, ligament damage is likely to have occurred. So often, ER records describe little to no information about the historical elements reviewed in the 1st paragraph and if x-rays were taken, they rarely include flexion/extension stress x-rays.

Headaches are another component of WAD. Here, the first three sets of nerves that exit the uppermost levels of the spine (C1, C2, and C3) innervate the head. When a patient describes headaches that start in the upper part of the neck and radiate up into the head, the distribution of the pain by history can tell us which nerve(s) are most affected. In the examination, applying manual pressure to the base of the skull can reproduce pain when a nerve is injured. Tracking these findings on a regular basis can tell us how the condition is healing. Chiropractic is at the forefront of diagnosis for WAD!

Whiplash “Fun Facts”

Posted: August 14, 2013 in Whiplash

Whiplash is a slang term for cervical acceleration, deceleration syndrome, or CAD. There are facts and myths surrounding the subject of whiplash. Let’s look at some of the facts.

1. The origin of CAD. The history of CAD dates back to a time prior to the invention of the car. The first case of severe neck pain arose from a train collision around the time of 1919 and was originally called “railroad spine.” The number of whiplash injuries sharply rose after the invention of cars due to rear-end crashes.

2. Whiplash synonyms. As stated previously, the term “cervical acceleration-deceleration disorder, or CAD, is a popular title as it explains the mechanism of injury, where in the classic rear-end collision, the neck is initially extended back as the car is propelled forward, leaving the head hanging in space. Once the tissues stretch enough in the front of the neck, the head and neck flex forward very rapidly, forcing the chin towards the chest. This over stretches the soft tissues in the back of the neck. Another term for whiplash is WAD or, Whiplash Associated Disorders. In 1995, the Quebec Task Force categorized injuries associated with whiplash by the type of tissues that were found to be injured. Here, WAD Type I represents patients with symptoms/pain but normal range of motion and no real objective findings like muscle spasm. Type II includes injuries to the soft tissues that limit neck motion with muscle spasm but no neurological loss (sensation or muscle strength). WAD Type III includes the Type II findings plus neurological loss, and type IV involves fractures of the cervical spine.

3. Head rest facts: Prior to the invention of head rests, whiplash injuries were much more common and more serious because the head was propelled in a “crack-the-whip” like fashion. However, headrests are frequently not adjusted correctly; they are either too low and/or too far away from the head. If the seat back is reclined, this further separates the head from the headrest. The proper position of the head rest should be near the center of gravity of the head, or about 9 cm (3.5”) below the top of the head, or at minimum, at the top of the ears. Equally important is that it should be as close as possible to the back of the head. When the distance reaches 4” away from the head, there is an increased risk of injury, especially if it’s also set too low. When the headrest is properly positioned, the chances of head injury are decreased by up to 35% during a rear-end collision.

4. Seat back angle. The degree of incline of the seat back can also contribute to injury of the cervical spine. As stated above, as the seat is reclined, the head to headrest distance increases, furthering the chance for injury. A second negative effect is called “ramping.” Here, the body slides up the seat back resulting in the head being positioned over the top of the head rest. Also, the degree of “spring” of the seatback contributes to the rebound of the torso during the CAD process.

5. Concussion: The notion that the head has to hit something to develop a concussion is not true. Also, the idea that a loss of consciousness is needed to develop a concussion is also false. Simply, the rapid forward/backward movement of the head is enough force for the brain (which is suspended by ligaments) to literally slam into the inner walls of the skull and can result in concussion. The symptoms associated with concussion are referred to as post-concussive syndrome or, mild traumatic brain injury.

Whiplash “101” (Part 2)

Posted: July 23, 2013 in Whiplash

Our current Whiplash topic continues from last month when we reviewed the “mechanism of injury,” the “type of injury,” and “prognosis.” This month, we will review the “nuts and bolts” of the whiplash injury or, whiplash associated disorders (WAD).

Whiplash diagnosis: The diagnosis of whiplash first and foremost requires a thorough history. Here, we discuss the factors leading up to the MVC (motor vehicle collision), the angle or direction of impact (front end, angular, side or T-bone, rear end), whether the head was pointed straight or rotated, whether the head hit anything inside the car, airbag deployment and any related injury, seat belt location and effectiveness, the conditions of the day (weather, road, lighting, etc.), the onset of each injured area including neck, upper/lower back, headache, memory loss, and radiating symptoms (time lapse to symptom onset), ER/ambulance involvement, the initial 24-48 hours, the point of maximum pain intensity, job and non-vocational capabilities, prior test results (x-ray, CT, MRI, lab, etc.), prior treatment effectiveness, and more! The physical examination centers on observation (posture, patient distress, mood); palpation or touching the injured areas; orthopedic tests (looking for positions that either relieve or increase symptoms); range of motion (how far forward, back, sideways, and in rotation can the head be voluntarily moved and its related level of comfort, speed/quality of motion); neurological exam (sensory, motor, cranial nerves, etc.); and special tests (x-ray, CT, MRI, lab, etc.) if not previously done.

Course of care: The type and length of treatment will vary based on the degree of injury (see last month’s “prognosis” discussion), the initial response to care (improvement vs. worsening), the compliance of the patient in modifying their activities, performing home-based care (ice, rest, exercise, etc.), and the patient’s motivation to get better. The latter may be partially dependent on factors like whether there is litigation planned or occurring, their belief that they will “get better,” and how the health care provider manages the care (the use of passive approaches where the patient must go and see the doctor vs. active approaches where the patient is taught how to self-manage through diet, exercise, activity modifications, education, etc.)

Treatment options: The patient has the choice of following a traditional medical model of initial anti-inflammatory medication, patient education, wait and watch, and/or a physical therapy referral. The chiropractic approach includes patient education, anti-inflammatory approaches (ice – NOT HEAT, anti-inflammatory herbs), exercise training and manual therapies including spinal adjustments. The latter, when applied properly, has been found to return patients to work faster than other approaches with a shorter recovery time and is less costly and more satisfying. When comparing treatment options beyond 6 or 12 months, the differences are more subtle. Other treatment options include acupuncture, massage therapy, and various forms of exercise. When necessary, injections, narcotics, and other pharmaceutical options exist but are not recommended as initial care approaches. Behavioral and cognitive therapy can help people cope with chronic, permanent pain related problems. There are many approaches to the management of whiplash and the patient needs a “quarterback” or someone to help them with these decisions. This is perhaps the most important role of the chiropractor!

Whiplash “Syndrome”

Posted: May 23, 2013 in Whiplash

The term “whiplash” is a slang term for a neck injury most accurately called a cervical acceleration-deceleration (CAD) injury. Now you know why we call it “whiplash”! It suggests that the head was forced through a range of motion that exceeds the barriers of our normal tissue, resulting in injury to the neck.

Though a slip and fall, or even a bar-room brawl, can cause whiplash, whiplash is usually associated with injuries that occur from a car accident or “motor vehicle collision” (MVC). The term “syndrome” refers to a cluster of symptoms that can include neck pain, headache, light-headedness, ringing in the ears, visual disturbances, memory loss, nausea/vomiting, noise and/or light sensitivity (usually associated with mild traumatic brain injury or, post-concussive syndrome), TMJ (jaw) pain, radiating pain, numbness, and/or weakness in the arm, limited neck movements, and more. Even the low back can be injured in a whiplash injury! In other words, a whiplash injury can affect MANY different parts of the body, and the clinical picture can vary widely from case to case.

Whiplash is diagnosed through a thorough history, paying particular attention to the mechanism of injury – that is, how fast were you and the opposing vehicle traveling, in what direction did you get hit (front, side, rear, angular, or combinations), what size was your vs. the opposing vehicle, was your head turned or pointed straight at the time of impact and did you hit your head? Also, we will ask, what were your immediate symptoms compared to 30 min., 60 min., 3 hrs, 6 hrs later, the next morning, and when did your symptoms peak? What activities (including work) have been affected, and to what degree? What self-management approaches have you tried, and how have they worked? The more we can learn about the accident and your immediate symptoms, or delay in symptom onset, the better we can address your problems. The physical examination is also very important as we will observe your movement quality, posture, pain expression, palpate for muscle guarding, trigger points, and swelling of the injured joints. We will also evaluate your neck and back range of motion, assess your neurological functions, and assess extremity issues that might be present. X-rays will more than likely be done and may include “stress views” where you bend the neck forwards and backwards to assess the stability of your spine. Comparison to older x-rays can be very helpful, if they exist. Depending on the degree and type of the injury, special tests will be considered such as MRI, EMG/NCV, laboratory tests, and perhaps others.

Treatment will consist of: addressing the acute inflammatory painful symptoms by the use of gentle massage, mobilization and/or manipulation, electrical stim or a different anti-inflammatory modality, review how to apply ice and/or heat, how to bend/lift/pull & push properly to avoid irritation. We’ll teach you exercises, proper sleep positions, and other home applied, self-help techniques. The goals of pain management, functional restoration, and prevention will be applied. If needed, coordinating care between our office and primary care, orthopedic, neurology, or others will be smoothly managed as the need arises.