Resolving Whiplash Injuries
Whiplash injuries are commonly misunderstood. Many insurance companies would like you to believe that whiplash injuries don’t even exist. Of course, that perspective is complete nonsense!
Whiplash injuries are well-documented and have considerable scientific support. There is a mountain of research about the biomechanics of whiplash injuries (whether or not insurance companies like it). Unfortunately most physicians are not familiar with this data, and many insurance companies would prefer this information be kept hidden.
When we think of a whiplash injury, we normally visualize a person’s head being thrown back-and-forth or side-to-side.
In reality there’s much more to this injury than initially meets the eye. The biomechanics of whiplash injuries are quite unique, with injury often occurring at very low speeds and with almost a little or no damage to both vehicles.
Unfortunately, whiplash injuries do not always manifest immediately after an accident. In some cases, it takes several years to manifest, often long after insurance claims are settled.
It is not hard to see why a comprehensive understanding of the physics and biomechanics of whiplash injury is essential for proper treatment and recovery.
Without a complete understanding of these unique circumstances, and the supporting body of evidence, physicians often make mistakes that prevent a complete resolution of this injury. In fact, it is very common for physicians to misdiagnose a whiplash injury, or to recommend ineffective treatments or exercise protocols. Even worse, many physicians do not believe their patients are truly injured. In such cases, insurance companies are more than happy to accept this opinion and reject the patient’s claim.
Whiplash injuries are complex, involving much more than just one set of structures. This type of injury often involves; joints, muscles, ligaments, tendons, connective tissue, and a wide array of neurological structures. Besides the immediate pain and suffering felt from the initial incident, this type of injury can often lead to degenerative osteoarthritis ten or twenty years later. This is extremely well-documented in the scientific literature.
The first factor to consider is that hyper-extension, hyper-flexion injuries occur in an extremely short period of time. Most of these injuries occur in about one-quarter of a second. This means that the occupants of a vehicle which is struck from behind do not have time to react to the accident. Keep this time-frame in mind as we cover some of the actions that occur.
Vehicle Impact Phase
Let us start with the onset of a standard rear-end collision. Let us consider what happens from the perspective of the driver of the vehicle that was hit from behind. On initial impact where the vehicle in the rear hits the car in front; The force of impact begins to move the front vehicle forward. Since the seat of the car is attached to its frame, the driver’s seat moves forward with the car. But the driver is not attached to the frame of the car, and he/she continues to remain in a fixed position; this is due to inertia. Physics defines inertia as “the tendency of a body to resist acceleration.” Keep in mind, all of this is occurring within milliseconds.
Then, within a faction of a second, the car seat is pushed into the driver’s lower and mid back. This rapid forward acceleration also pushes the lower part of the drivers neck forward (lower cervical spine). This has the effect of straightening out the normal curve in the driver’s neck (the lordotic curve) and the curve in the driver’s mid back (the kyphotic curve). This creates an abnormal S shaped curve in their cervical spine (neck).
A considerable amount of damage can be done during this phase.
Normally, neck motion is the result of multiple vertebral joints, each of which contribute only a few degrees of motion to an action. Therefore movements like neck extension are made up of the summation of multiple vertebra each adding small degrees of motion to produce the total action.
When the neck is in this abnormal S-shaped position, the joints of the neck (facet joints) are forced past what is consider their normal physiological range-of-motion limit. This excessive motion causes damage to the area around the spinal joints (facet joints). This damage can include: facet capsule ligament tearing, bony impingements, and intra-articular (within the joint) hemorrhages. The degree of joint damage depends on the severity of collision.
This next, high-speed, forward motion, jerks the driver’s head back. In many cases the head moves right back over the headrest. This often occurs since most people keep their headrest too low to be effective, or it can occur due to poor head rest design. If the impact of the accident is severe enough, a considerable amount of soft-tissue and joint damage can occur in the front of the neck as the head is thrown back.
Common areas of damage as the head is thrown back:
- Facet joints are the most commonly injured joints in the neck.
- ALL (Anterior Longitudinal Ligament) – This ligament runs down the front of the vertebral bodies and prevents excessive extension. Damage to this ligament causes instability in the neck (cervical spine), and can be a cause of chronic neck pain after a whiplash injury.
- Facet capsules – The facet capsules in the neck are often injured due to the severity of muscle contractions and vertebra motions during whiplash accidents.
An anatomical investigation of the human cervical facet capsule, quantifying muscle insertion area J. Anat. (2001) 198, pp. 455–461
Anterior Muscles and Nerves Injured During Hyper-Extension
- Longus Colli muscle
- Platysma muscle
- Scalene muscles
- SCM (Sternocleidomastoid) muscle
The most predominant symptoms after a whiplash accident are:
- Arm pain – This can be due to nerve compression or referred pain from the facet joint or disc
- Facial pain (either direct or referred pain)
- Headaches – The second most common symptom, headache is usually on one side of the head and begins at the base of the skull (occiput). This pain often radiates to the top of the head and frontal regions.
- Jaw Pain – TMJ problems are common
- Neck pain – The most common symptom
- Nerve entrapment syndromes
- Shoulder blade pain (interscapular pain)
- Shoulder pain (rotator cuff)
Whiplash injuries also cause:
- Balance problems (often upper cervical related)
- Difficulty sleeping
- Dizziness (often upper cervical related)
- Fatigue (this can be severe)
- Low back pain
- Poor concentration, loss of memory
- Psychological changes, such as depression
- Tinnitus (ringing, buzzing, whistling, or other noises heard in one or both ears)
- Visual disturbances (sensitivity to light – this can be stress induced, adrenal stress)
After major injuries such as fractures have been ruled out, treatment can begin. For the first 72 hours ice should be used to reduce pain, inflammation, and swelling. See our section on the correct procedures for icing. After this initial acute stage, implementation of ART procedures should begin as soon as possible.
Early implementation of treatment procedures can prevent acute injuries from becoming chronic problems. In the case of whiplash injuries research has show that 15 to 40% of individuals who have had these injuries develop chronic neck pain. Early intervention can help you avoid becoming one of these statistics.
Chronic whiplash and whiplash-associated disorders: An evidence-based approach Journal of the American Academy of Orthopedic Surgeons October 2007;15(10):596-606 Schofferman J, Bogduk N, Slosar P.
Scar Tissue Forms Fast
Also considering how quickly fibrotic tissue (scar tissue) forms in damaged tissue (7 days), early intervention becomes essential. For example, research has shown that after a hyper-extension hyper-flexion injury a muscle called the anterior scalene often becomes fibrotic.
The anterior scalene extends from the vertebra of the neck to the second rib (TP’s C3-C6 to scalene tubercle first rib, anterior surface second rib).
When this muscle becomes fibrotic it can cause compression on a network of nerves called the brachial plexus. This can create a syndrome called neurogenic thoracic outlet syndrome (NTOS) which creates neck pain, headaches, altered sensation (paresthesias), and weakness in the shoulders, arms, wrists, and hands.
It is interesting to note that brachial plexus compression injuries often do not show up for 7 to 37 days after the injury. If manual therapy procedures, such as Active Release Techniques are implemented soon enough scar tissue formation in areas such as the anterior scalene can often be avoided, along with all the consequences of syndromes such as NTOS.
Although early intervention is important, it is equally important to have the the practitioner consider all the areas that could be, or are, damaged in a hyper-extension, hyper-flexion injury. The practitioner must look for damage in more than just the neck, and review possible injuries to the patient’s jaw, shoulders, arms, wrists, upper-back, lower-back, hips, and some times even the lower extremities. Areas that have been injured often do not show symptoms for several weeks.
This is often the case with jaw problems caused by whiplash injuries. With whiplash injuries, one in three people who have been in a hyper-extension hyper-flexion accident will develop delayed TMJ problems.
Delayed temporomandibular joint pain and dysfunction induced by whiplash trauma: a controlled prospective study Journal of the American Dental Association August 2007;138(8):pp. 1084-91 Salé H, Isberg A.
From a kinetic chain perspective, jaw motion and neck motion are directly linked to each other. Activation of neck and jaw muscles occurs simultaneously, which synchronized movements of the TMJ, cervical spine, and the atlanto-occipital joints. (The Atlanto-occipital joint lies between the base of the skull (occiput) and the C1 vertebra (atlas)).
Deranged jaw–neck motor control in whiplash-associated disorders European Journal of Oral Sciences, February, 2004; 112: 25–32. Per-Olof Eriksson, Hamayun Zafar, Birgitta Haggman-Henrikson
Thus any injury to neck muscles can directly affect jaw function. When Active Release practitioners consider this type of kinetic chain relationship, it becomes much easier to resolve whiplash injuries.
Exercise is a critical component in rehabilitating whiplash injuries. Initially, exercises should be performed within as much of a pain free range-of-motion as possible. This will help to insure that no abnormal neurological motor responses are created, and tissue repair is fully completed. It is very important to remember that injured tissue needs time to remodel, without the right exercise the possibility of re-injury is very high. See our Page on “Exercise and Tissue Remodeling”
If you are looking for a series of exercise specifically designed to rehab the neck after a whiplash injury check out our kinetic chain series of exercise books. We have achieved great results with the “Jaw to Shoulder” book in the treatment of whiplash injury patients. This book covers several of the main areas commonly injured in a hyper-extension hyper-flexion injury.