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Whiplash Injury

Whiplash Injuries

Whiplash injury results from a rapid back-and-forth movement of the neck that is provoked by external forces, such as those exerted during a car accident. Whiplash injury is accompanied by neck pain and stiffness as well as headaches. While chronic neck pain persists in some cases, most patients fully recover after an appropriate therapy.


Presentation

Because WI is caused by trauma, WI patients are usually involved in some type of accident a few hours before presentation. Symptoms do not generally take more than 24 hours to develop.

The most common symptoms in WI patients are neck pain, stiffness and headaches, often originating from the base of the skull. Pain may also radiate to shoulders, arms and upper back and usually worsens with movement. Dizziness and vertigo are not uncommon and paresthesias, particularly in the arms, as well as cognitive disorders, may also be present [19][20]. Those cognitive disorders may encompass blurred vision and tinnitus. Psychological symptoms such as irritability, problems with concentration and memory and sleep disturbances may also occur and even result in depression.

Initially, the exact tissue damage causing these symptoms is usually not obvious [21]. Vertebrae, vertebral joints with ligaments and intervertebral discs and neck muscles may be involved as well as vessels and nervous tissue, particularly dorsal root ganglia.

To date, the origin of pain in chronic whiplash is not fully understood. While tissue damage may persist in some cases [22], many people suffering from chronic whiplash presumably adopt poor postures in order to avoid pain. Such pain may initially have been caused by tissue damage but is later probably sustained by the poor posture itself [23].

Infectious Mononucleosis
  • Early diagnosis of the cervical infection was masked by the simultaneous presence of infectious mononucleosis. Aggressive surgical management including bilateral thoracotomy was required to resolve the septic course.[ncbi.nlm.nih.gov]
Neck Pain
  • Only 0.4% of respondents reported posterior neck pain only.[ncbi.nlm.nih.gov]
  • At 12 months follow-up, 49 (44.1%) reported disability (NDI 8) and 23 (20.7%) neck pain (NRS-11 4). Grades 2-3 ligament changes in the acute phase were not related to disability or neck pain at 12 months.[ncbi.nlm.nih.gov]
  • Thirty-seven subjects reporting neck pain following a motor vehicle accident were examined within five weeks post-injury.[ncbi.nlm.nih.gov]
  • Abstract The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed.[ncbi.nlm.nih.gov]
Shoulder Pain
  • We report the case of a collegiate swimmer who developed left-sided neck and shoulder pain secondary to a spinal accessory nerve palsy (SANP) after a "whiplash injury," which we believe to be the first such reported case in the English language literature[ncbi.nlm.nih.gov]
  • In addition, there was no association between the change in CSA and clinical symptoms such as neck and shoulder pain.[ncbi.nlm.nih.gov]
  • Upper back and shoulder pain can also occur. Most whiplash injuries heal within weeks, but if left untreated they can linger and turn into chronic conditions that last for years and lead to pain and sometimes disability.[verywellhealth.com]
  • Some other Whiplash symptoms are: Blurred Vision Dizziness Headaches Shoulder Pain Neck Pain Arm Pain Neck Stiffness Low Back Pain Reduced Range of Motion in the Neck The Consequences of Avoiding Orthopedic Treatment Ignoring your symptoms and delaying[aicaorthospine.com]
Upper Back Pain
  • Risk factors for a less favorable recovery include older age, the presence of interscapular or upper back pain, occipital headache, multiple symptoms or paresthesias at presentation, reduced range of movement of the cervical spine, the presence of an[ncbi.nlm.nih.gov]
  • Symptoms may include: Neck pain or stiffness Headache Shoulder pain , arm pain or upper back pain .[physioworks.com.au]
  • Symptoms may include: Neck pain or stiffness Headache Shoulder pain, arm pain or upper back pain.[physioworks.com.au]
  • The primary symptom of whiplash is neck or upper back pain. Photo Source: 123RF.com. #2. Symptoms of Whiplash The primary symptom of whiplash is neck or upper back pain.[spineuniverse.com]
  • Other symptoms can include neck stiffness or reduced range of motion, neck instability, shoulder and/or upper back pain, or headache. There could also be tingling, weakness, or numbness that radiates into the shoulder and/or down the arm.[spine-health.com]
Spine Pain
  • By realigning the spine, pain and other symptoms from the injuries can be alleviated. It is important to seek chiropractic care immediately following a car accident.[cristchiropractic.com]
Tinnitus
  • Once it is manageable, I start with amplification and change the sound therapy regimen for tinnitus retraining.[journals.lww.com]
  • CASE REPORT: A 70-year-old man with acquired hearing loss suffered a whiplash injury in a low-speed road traffic accident, and subsequently presented with bilateral 'tinnitus.' On closer questioning, he described hearing orchestral music.[ncbi.nlm.nih.gov]
  • Tinnitus, where the patient hears nonexistent noises. Tinnitus usually sounds like ringing in your ears, but can also cause the patient to perceive hissing, static, or humming noises.[oklahomalawyer.com]
  • Other symptoms of whiplash include: Headaches Dizziness Jaw Pain Tinnitus Neck, shoulder, and back pain Trouble sleeping Vision problems Concentration issues Decreased range of motion Brain injury OUR PERSONAL APPROACH Many of these symptoms are easy[etehadlaw.com]
Benign Paroxysmal Positional Vertigo
  • OBJECTIVE: The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness[ncbi.nlm.nih.gov]
  • In another piece of research, 60 percent of subjects tested within 15 days of whiplash injury had ongoing complaints of vestibulopathy, including cervical vertigo, benign paroxysmal positional vertigo, or ocular motor system abnormalities, especially[journals.lww.com]
Auditory Hallucination
  • INTRODUCTION: A musical hallucination is defined as a form of auditory hallucination characterised by the perception of music in the absence of external acoustic stimuli.[ncbi.nlm.nih.gov]
Dizziness
  • Vertigo and dizziness are also reported in 25-50% of the cases. In otoneurologic studies, magnetic resonance angiography (MRA) is used for the evaluation of vertebrobasilar hemodynamics in patients who complain of dizziness and vertigo.[ncbi.nlm.nih.gov]
  • A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated.[ncbi.nlm.nih.gov]
  • Symptoms of dizziness, headaches, fatigue and sleep disturbances improved, as well as the quality of life (QOL) and the Fibromyalgia Impact Questionnaire (FIQ) scores. Insurance claims continued to be more prevalent in the control group.[ncbi.nlm.nih.gov]
  • Subjects were 20 healthy volunteers who were tested under standing condition (normal group), consciously swaying the body under standing condition like malingerers (pseudomalingering group) and 32 patients who complained of neck pain with vertigo or dizziness[ncbi.nlm.nih.gov]
Vertigo
  • Vertigo and dizziness are also reported in 25-50% of the cases. In otoneurologic studies, magnetic resonance angiography (MRA) is used for the evaluation of vertebrobasilar hemodynamics in patients who complain of dizziness and vertigo.[ncbi.nlm.nih.gov]
  • […] lumbar proprioceptors) is a cause of vertigo due to whiplash injury.[ncbi.nlm.nih.gov]
  • OBJECTIVE: The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness[ncbi.nlm.nih.gov]
  • STUDY DESIGN: Cross-sectional study of whiplash injury patients with vertigo and healthy volunteers consciously pretending to have postural sway as in malingering.[ncbi.nlm.nih.gov]
  • This postulate is applicable to the explanation of aural vertigo following whiplash injury.[ncbi.nlm.nih.gov]
Neck Stiffness
  • Symptoms may include: Neck pain Neck stiffness Dizziness Ringing in ears Blurred vision Concentration or memory problems Irritability Sleeplessness Tiredness The symptoms of whiplash may resemble other conditions and medical problems.[cumc.columbia.edu]
  • Some other Whiplash symptoms are: Blurred Vision Dizziness Headaches Shoulder Pain Neck Pain Arm Pain Neck Stiffness Low Back Pain Reduced Range of Motion in the Neck The Consequences of Avoiding Orthopedic Treatment Ignoring your symptoms and delaying[aicaorthospine.com]
  • Whiplash destabilizes the spine and causes severe pain, as well as these other indicators: Blurred vision Neck pain Headaches Dizziness Shoulder pain Reduced range of motion in the neck Arm pain Neck stiffness Low back pain The tricky part about diagnosing[albertachiro.com]
  • First Symptons of Whiplash or a Neck Sprain Pain, stiffness and restricted movement in your neck Stiffness or soreness in your shoulders and upper back Headaches, nausea or dizziness Lethargy It is important to seek medical advice as soon as you suspect[spencerssolicitors.com]
  • These are the most common symptoms of whiplash: Neck pain Neck stiffness Shoulder pain Low back pain Dizziness Pain in your arm or hand Numbness in your arm or hand Ringing in your ears Blurred vision Concentration or memory problems Irritability Sleeplessness[hopkinsmedicine.org]
Meningism
  • Other possible causes of acute neck pain and stiffness include vertebral fractures, cervical disc herniation, subarachnoid hemorrhage, meningitis.[boneandspine.com]

Workup

A medical history involving a car accident or other traumatic experiences, as well as indications to physical abuse generally lead to the suspected diagnosis of WI.

A thorough clinical examination focusing on the patient's head and neck may reveal further evidence of a traumatic neck lesion. The skin may exhibit bruises, cuts and abrasions, while head and neck movement may be painful. In order to anatomically localize possible damage, cautious, controlled head movements up, down and to both sides have to be evaluated. Nerve damage may lead to numbness, tingling or other pathological sensations in different parts of the body and the patient should be asked if they experience such sensations.

Radiographic imaging is generally applied to check for fractures. If additional serious injuries are suspected, the corresponding imaging techniques (computerized tomography and magnetic resonance imaging) may help to detect them.

As long as no definitive conclusion regarding the severity of WI and possible involvement of the cervical spine or nervous tissue is made, the patient should wear a neck-stabilizing collar and a backboard.

Treatment

WI therapy aims at pain control and restoration of head and neck mobility. Here, the latter is strongly associated with the former since painful movements may prompt the patient to adapt to poor postures and to avoid certain movements. This, in turn, may cause additional pain and eventually lead to chronic whiplash.

While rest may be necessary to avoid additional damage in severe cases of WI, the aim should be to restore full mobility as soon as possible. Therefore, pharmacological therapy should be complemented with the appropriate exercises.

In detail, therapy usually consists of:

  • Analgesics. Generally, paracetamol and non-steroidal anti-inflammatory drugs are applied to control pain.
  • Muscle relaxants. May be necessary to further control pain and allow for greater mobility and restful sleep.
  • Local anesthetics. If analgesics and muscle relaxants do not suffice to alleviate muscle pain, an injection of local anesthetics may be considered.
  • Stabilizing collars. Collars may be initially helpful to stabilize the neck and avoid additional tissue damage. They should, however, not be used for longer periods of time since they impair recovery due to muscle loss.
  • Physiotherapy. The physiotherapist has the patient perform certain movements to strengthen muscles and regain mobility. The physiotherapist may also assist in correcting poor postures.
  • Home exercises. In addition to supervised exercises in physiotherapy, the patient should carry out some simple movements and stretching exercises at home. These may include neck rotation, head tilting and shoulder rolling, as long as the overall condition of the patient allows these movements.

Prognosis

Prognosis of WI strongly depends on the severity of the initial injury. While patients suffering from minor WI usually recover within a few weeks, moderate injuries involving  ligament strains and muscle stiffness may require a few months to heal. Severe WI involves damage to the cervical spine, the vertebral joints or to nervous tissue. Their prognosis is doubtful. In some cases, chronic whiplash may develop and permanent neck pain or even disability may ensue.

If a car accident leads to WI, the severity of the reported accident does not necessarily affect the patient's prognosis in a significant way. Allegedly minor accidents happening at low speed may even expose the car's occupants to greater acceleration and deceleration forces since the crumple zone does not deform and thus, the metal does not absorb physical forces [17][18].

Etiology

WI results from traumatic experiences, most commonly from car accidents. Indeed, this type of neck injury is one of the most frequent injuries sustained in motor vehicle accidents and it is therefore often seen in emergency departments [2]. Car accidents involving considerable rear-end, front or side impacts provoke a sudden acceleration and subsequent deceleration that neck muscles and bones fail to withstand. The head moves rapidly forward and backward, muscles, ligaments and tendons are overstretched, and the bones forming the cervical spine may be damaged as well as intervertebral discs, vessels and nerves.

Other situations exposing the neck to similar physical forces, e.g. sports accidents and physical abuse, may cause similar tissue damage and trigger WI.

The very same event may cause WI of different severity to different individuals, depending on the affected person's posture at impact, their overall condition and gender. One of the most important factors that determine the severity of the injury is the patient's awareness of the upcoming impact. Those factors influence neck stability at the time of the impact.

A healthy nervous system is a prerequisite for an effective stabilization response. Furthermore, women generally suffer more severe WI than men, a fact that may be due to less muscling and more fragile bones. Awareness is especially important to withstand minor to moderate physical forces whereas the patient's strength may not suffice to resist a strong impact even when they are aware of it. Previous studies have shown that the driver of a car involved in an accident often suffers less severe WI than the passenger, because the driver may have important split seconds to prepare themselves for the impact after seeing the other vehicle in the rear mirror.

Epidemiology

Due to the high number of car accidents, WI is very common. The number of WI has considerably increased during the last decades, presumably due to the increase in traffic volume. Of note, the growing incidence of WI is one of several factors contributing to rising insurance premiums. In order to prevent insurance frauds, a standardized system for WI diagnosis should be developed. At the same time, the automotive industry is working on new interior designs to reduce the number of WI victims.

Incidence rates of up to almost 1 per 100 persons have been reported, whereby this high incidence corresponds to women aged 20 to 24 in the United States [3]. The mean incidence, independent of age and gender, seems to range between 1 and 3 per 1,000 people. Such rates have been reported from Canada [1], Australia [4] and the Netherlands [5]. Whereas somewhat higher rates have been reported for Western Europe [6], low incidences have been calculated for Northern Europe [7].

Chronic whiplash is diagnosed when symptoms persist for more than six months. Although some studies report that the vast majority of cases achieves full recovery and only 6% of all patients suffer from residual neck pain for long periods of time, other studies estimate this number to be as high as 66%.

Sex distribution
Age distribution

Pathophysiology

Due to the high number of anatomical structures possibly damaged during WI, the pathophysiology behind that traumatic injury is complex. No two WI happen under exactly the same circumstances, which is why experiments with dead bodies or animals are of little value.

The physical forces observed during a car accident or similar traumatic experiences may damage the cervical spine, its vertebral joints and capsular ligaments [8][9] and the craniovertebral junction [10], in addition to cervical muscles [11], vertebral arteries and dorsal root ganglia [12][13]. While muscle injuries are certainly responsible for a significant share of neck pain and stiffness [14], only damage to vertebral joints could be linked to chronic whiplash [15].

Because full recovery is the overall aim of any WI treatment, scientific studies nowadays focus on joint involvement in WI. In this context, it has been found that neuromuscular patterns are altered in patients suffering from chronic whiplash. However, as of yet it is not known whether alterations in muscle activity result from pathological neuronal input or if they are  part of an intended, protective strategy to avoid pain. Such protective measures are not unlikely, since different types of adaptive responses have been observed in WI patients [16].

Prevention

Whiplash injury can be prevented by avoiding situations causing it.

With regards to car accidents, that means seatbelts should always be used, cars with airbags should be preferred and the seat headrest should be properly adapted to the respective passenger in each journey. The seat headrest is of particular importance in avoiding WI because the headrest stops the head when snapping backwards after an impact. These safety instructions basically apply to all kinds of vehicles, i.e. for cars, buses but also roller coasters.

Since contact sports such as football and rugby may also lead to WI, these sports should be carried out with the proper safety equipment.

Physical abuse should not only be avoided due to ethical and legal reasons, but also be reported to the authorities when suspected.

Chronic whiplash may be prevented by compliance with the treatment regimen. Patients should be consulted towards a certain behavior that may help to prevent the pain from becoming chronic [24].

Summary

Whiplash injury (WI) affects both hard and soft tissues of the neck that are exposed to considerable acceleration and deceleration forces, e.g. during rear-end car accidents. Due to the sudden exertion of strong external forces, the affected person is not able to maintain his or her head upright. The head is rapidly thrown forward, backward or even sideways. Tendons and ligaments are stretched beyond their limits and this provokes tissue damage that results in a variety of symptoms called whiplash-associated disorders [1]. 

Although rear-end car accidents are the most common cause for WI, other traumatic experiences may also lead to WI. Collisions from the front or from the side may also cause WI. Of note, for an accident to provoke WI, it does not necessarily need to happen at high speed. Furthermore, WI has been associated with sports accidents, particularly those happening in contact sports such as football or rugby, physical abuse, punching and shaking (such as shaken baby syndrome), domestic and other types of accidents.

Anamnesis usually leads to the suspected diagnosis of WI. Tissue damage may then be confirmed with diagnostic imaging. Radiographic imaging and computerised tomography are the techniques of choice in order to detect fractures and other damages to the skeleton, whereas magnetic resonance imaging may be applied to reveal soft tissue damage.

Pharmacological therapy is generally based on analgesics, e.g. on paracetamol and non-steroidal anti-inflammatory drugs. Appropiate exercises may help patients to regain mobility. However, chronic whiplash may develop if symptoms last for more than six months.

Patient Information

WI results from car accidents, sport accidents, abuse and other traumatic experiences that involve a sudden forceful back-and-forth movement of the head. This movement causes damage to tissue structures of the neck, e.g. to the cervical spine, its vertebrae, muscles, ligaments, vessels and nerves. The medical terms for injuries like this are cervical sprain and cervical strain and they are associated with neck and shoulder pain and stiffness, headaches, dizziness and possibly with cognitive disorders.

If WI is diagnosed due to preliminary report and clinical examination, imaging techniques such as X-rays are likely performed, to check if any anatomical structure suffered serious damage.

Therapy consists of pharmacological treatment with analgesics and muscle relaxants with additional physiotherapy and home exercises.

While mild and moderate cases of WI usually achieve full recovery after a few weeks or months, severe cases involving considerable damage to the cervical spine or nerves may take a long time to heal. In these cases, the prognosis for full recovery is worse.

Some patients do still experience neck pain years after the accident and are thus suffering from chronic whiplash. While there is a certain correlation between severity of the initial lesion and probability of chronic whiplash, it is not possible to give a certain prognosis.

References

Article

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  2. Quinlan KP, Annest JL, Myers B, Ryan G, Hill H. Neck strains and sprains among motor vehicle occupants – United States, 2000. Accid Anal Prev. 2004; 36:21–27.
  3. Quinlan KP, Annest JL, Myers B, Ryan G, Hill H. Neck strains and sprains among motor vehicle occupants-United States, 2000. Accid Anal Prev. 2004;36(1):21-27.
  4. Miles KA, Maimaris C, Finlay D, Barnes MR. The incidence and prognostic significance of radiological abnormalities in soft tissue injuries to the cervical spine. Skeletal Radiol. 1988; 17:493–496.
  5. Wismans KSHM, Huijkens CG. Incidentie en prevalentie van het ‘whiplash’-trauma. TNO report. Delft: TNO Road-Vehicle Research Institute; 1994.
  6. Holm LW, Carroll LJ, Cassidy JD, et al. The burden and determinants of neck pain in Whiplash associated disorders after traffi c collisions, results of the Bone and Joint Decade 2000–2010 Task Force on Neck pain and its Associated Disorders. Spine. 2008; 33(4 Suppl): S52–S59
  7. Jansen GB, Edlund C, Grane P, et al. The Swedish Society of Medicine and the Whiplash Commission Medical Task Force. Whiplash injuries: diagnosis and early management. Eur Spine. 2008; J 17(Suppl 3): S359–S418
  8. Bogduk N. The anatomy and pathophysiology of whiplash. Clin Biomech. 1986;1:92-101.
  9. Winkelstein A, McLendon RE, Barbir A, et al. An anatomic investigation of the cervical facet capsule quantifying muscle insertion area. J Anat 2001;198:455-461. 
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  13. Örtengren T, Hansson HA, Lövsund P, et al. Membrane leakage in spinal ganglion nerve cells induced by experimental whiplash extension motion: A study of pigs. J Neurotrauma. 1996;13:171-179. 
  14. Brault JB, Wheeler JB, Siegmund GP, et al. Clinical response of human subjects to rear-end automobile impacts. Arch Phys Med Rehab. 1998;79:72-80. 
  15. Lord SM, Barnsley L, Wallis BJ, et al. Chronic cervical zygapophysial joint pain after whiplash, A placebo-controlled prevalence study. Spine. 1996;21:1737-1745. 
  16. Falla D, Bilenkij G, Jull G. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine. 2004; 29, 1436-1440
  17. Nederhand MJ, Hermens JH, IJzerman MJ, et al. Chronic neck pain disability due to an acute whiplash injury. Pain. 2003; 102, 63-71.
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Last updated: 2018-06-22 09:15