AUTHOR: SAMANTHA PANOS (PHYSIOTHERAPY STUDENT- UNIVERSITY OF SYDNEY)
CO-AUTHOR: MATTHEW CRAIG, PHYSIOTHERAPIST AT BOUNCEREHAB
To enhance your blog reading experience: ♫ “Whip it” – Devo ♫
WHAT IS WHIPLASH?
Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. I.e. the result of a rapid force applied to the neck. It’s often a result of motor vehicle accidents, but can also occur after other mishaps such as diving into a shallow pool, falling, or in sport such as receiving a direct blow to the head by an opponent.
The rapid, excessive force transferred to the neck can result in bony or soft tissue damage (referred to as “whiplash injury”- the structures affected may include bones, nerves, muscles, joints, ligaments & discs). The symptoms that are caused from this are collectively called “whiplash associated disorders”.
Whiplash injury → Acute (short term) Whiplash Associated Disorders (WAD) → Chronic (long term) WAD
Often without proper medical management, acute WAD can develop to become a chronic condition, where symptoms are prolonged beyond the time that it takes for the bony/soft tissue injury to heal.
→ Whiplash injuries causing symptoms occur in 106 per 100,000 people in Australia! The more you know! ←
WHIPLASH ASSOCIATED DISORDERS (WAD)… TELL ME MORE!
WAD refers to the collection of symptoms that are triggered from an initial acceleration-deceleration (whiplash) injury to the neck.
The 3 most common symptoms are:
- Neck pain
- Decreased cervical spine (neck) movement
Other symptoms that can occur in WAD include:
- Tinnitus (ringing in the ears)
- Pins & needles/numbness
- Pain referring down the arm
- Visual disturbances
- Memory loss or concentration problems
- Dysphagia (difficulty swallowing)
- Temporomandibular joint pain/dysfunction
- Psychological distress
Medical professionals use a grading system to identify the seriousness of the complications of a whiplash injury. This is based on the patient’s symptoms and physical signs.
SO..WHAT ACTUALLY HAPPENS TO THE NECK WHEN WHIPLASH OCCURS?
Basically, the neck is forced out of its normal range of movement, which results in abnormal loading and subsequent strain of the bony, neural and soft tissues in the neck.
Whiplash injury is most commonly seen as a result of a rear end or side on motor vehicle crash, and can even occur at low speeds. In rear-end collisions, the forces acting on the head and neck force the lower cervical and upper thoracic spine into extension, and the upper cervical spine into flexion. This forces the neck into an abnormal “S” shape. (Phase 2: “during impact” seen in above image)
This abnormal, non-physiological alignment of the neck can cause:
- Compression and damage to the facet joints (primarily the C2-3 and C5-6 joints)
- Stretching and tearing of the ligamentum flavum/interspinous ligaments/ligaments surrounding the facet joint capsules
- Disruption to the intervertebral disc
- Rupture of the anterior longitudinal ligament
- Stretching of the temporomandibular (jaw) joint capsule
- Straining of cervical muscles
- Vertebral fractures/dislocation in severe cases
Muscles in the neck (e.g. sternocleidomastoid) are unable to reflexively activate quickly enough to prevent this abnormal S-shaped posture from occurring, even if you were aware that the collision was about to occur. Once these muscles do have time to contract in response to the impact, the movement of the spine into the S-shape causes lengthening of these muscles at the front of the neck. These muscles try to slow down the backwards movement of the neck, and shorten to pull the head forward at the same time as they are being forced into a stretched position. A similar scenario then happens for the muscles at the back of the neck (e.g. trapezius, semispinalis capitis) when the head is forced forward. Clearly, these muscles come under incredible strain and can undergo significant damage- they are forced into a position that doesn’t allow optimal force generation (ie. they are forced into lengthened positions) and have to work against an abnormally large load.
After the head moves into an S-shape, it is forced into extension (Phase 3: hyperextension) and then the entire neck moves into flexion (Phase 4: hyperflexion) as seen below.
WALKING INTO YOUR FIRST PHYSIO SESSION AFTER A WHIPLASH INJURY – WHAT SHOULD YOU EXPECT?
A physiotherapy session would involve:
- A detailed history-taking of the incident along with any other relevant details that could help with your management
- Physical examination of your neck and surrounding structures
- Determining if you need an x-ray (ruling out fracture/dislocation)
- Pain and disability assessments
- Defining the grade of your injury
- Applying an appropriate treatment and monitoring its effect
WILL YOU NEED A SCAN AFTER A WHIPLASH INJURY?
Diagnosis for whiplash is clinical- this means that there are no specific scans needed and an accurate diagnosis can be made by a trained healthcare professional (such as a physiotherapist) based on the history of the injury and the signs/symptoms that you experience.
If the physiotherapist suspects that you may have a fracture or dislocation, you’ll be referred onto the emergency department or a specialist, and will likely need a scan (e.g. x-rays) and further investigations performed. If fracture/dislocation isn’t suspected, sometimes a referral for scanning would be required if you experience symptoms such as pins and needles/numbness that are felt in the arm and don’t resolve with conservative treatment.
It’s important to remember that even if your scan shows some changes in the structures of your neck, these changes DON’T correlate with how long you may experience pain/disability rising after your initial whiplash injury.
PHYSIOTHERAPY TREATMENT OPTIONS FOR ACUTE WHIPLASH ASSOCIATED DISORDERS (timeframe: within 12 weeks of the injury occurring):
The appropriate physio treatments differ between patients, depending on the severity of injury and types of symptoms.
Approximately 40% of patients with whiplash recover completely from their symptoms within the first 12 weeks of their injury (Motor Accident Authority, 2014).
There is strong evidence in the research that recommends the following management options for acute whiplash associated disorders (i.e. Weeks 1-12 post injury) to decrease pain and disability. There is a strong emphasis to learn how to take on an active role in recovery and self-manage symptoms.
- Education & advice to stay active!
Early physical activity is key to reducing pain, improving how much you can move your neck, and is also shown to reduce the amount of time spent on sick leave! Remember that symptoms are a normal part of being injured, and it’s important to focus on improvements in your symptoms and function.
2. Return to usual activities
In most cases of whiplash, it’s best to “act as usual” as much as possible, especially in the early stages.
There is good evidence to suggest that active exercise is the MOST effective treatment choice for acute whiplash associated disorders. Exercises should incorporate:
– Range of motion
– Low load isometrics
– Postural endurance
– Strengthening (neck & scapular)
Starting exercise EARLY after whiplash injury (i.e. within the first 96 hours) has a greater positive effect on pain and functioning than starting exercise later.
4. Advice on medication
Paracetamol for first line of treatment (low grade disorder), NSAIDs if paracetamol isn’t effective at reducing pain, or oral opioids if pain is very severe (high grade disorder). You will need to consult your GP or chemist on use of medications.
* Note: exercise programs should be tailored to each individual’s needs for safety and optimal recovery, so it’s important to have these prescribed by a trained professional (such as a BounceRehab physiotherapist!).
Some examples of exercises used to manage whiplash associated disorders:
If the symptoms from the initial whiplash injury don’t subside within 4-6 weeks, physiotherapists are able to choose from a toolbox of different treatment options that can be tailored to individual patient needs. Multiple treatment modes are often combined and include:
- Manual therapy (e.g. joint/neural tissue mobilisations & thoracic manipulations to loosen stiffened joints. Research shows that manual therapy combined with exercise can help with short term pain relief in acute cases of whiplash)
- KT taping
- Trigger point needling
- Postural & stabilisation exercises (particularly targeting the neck and scapula)
- Relaxation techniques
*Lack of research evidence but may be helpful for management of some whiplash cases.
Is there anything that SHOULDN’T be used in management for whiplash?
The 3 big NOPEs for treating whiplash according to research (in the majority of cases):
- NO reducing participation in your usual activities for > 4 days
- NO collars for immobilising the neck (this has been shown to potentially impede recovery.. not good!)
- NO anticonvulsants, antidepressants, muscle relaxants, botulinum toxin type A (botox injections), steroid injections (depending on grade of injury) or pulsed electromagnetic treatment (PEMT)
Will I need injections or surgery for whiplash?
In some cases where symptoms persist in acute cases, an intravenous injection of methylprednisone by a sports physician may be an effective treatment choice.
Surgery isn’t recommended for most cases of whiplash that are managed with physiotherapy. In rare cases, surgery may be considered if someone sustains a high grade injury and experiences symptoms that are consistent with a “cervical radiculopathy” (i.e. a compromise to spinal nerve roots in the neck), and that don’t clear up over time/get worse rapidly. The symptoms may include:
- Pain felt in the arms
- Muscle weakness
- Changes in skin sensation (e.g. pins & needles or numbness)
- Reduced or absent tendon reflexes
So we’ve discussed managing acute whiplash.. what about CHRONIC whiplash?
Approximately 30-50% of patients who have had a whiplash injury will go on to have chronic (long term) and potentially more widespread complications (Stace & Gwilym, 2015).
According to research, you may be at risk of developing chronic whiplash associated disorders if you experience the following:
- Higher intensity of neck pain
- Higher perceived disability (e.g. inability to perform daily activities) from the neck injury
- Poor expectations of recovery from the injury
- Post traumatic stress
- Reduced neck range of motion
- Cold hyperalgesia (cold temperature increases pain)
- Higher self-rated perceived collision severity (lower quality of research evidence for this risk factor)
Pain doesn’t just come from the amount of structural damage that has occurred to our bodies. Our pain experience is also affected by the interaction of other body systems (such as the immune and endocrine system), as well as by psychosocial factors- such as our beliefs and previous experiences of pain. For example, you may have noticed that you tend to have a heightened pain experience if you’re stressed, unwell or tired.
After an injury, you might still experience painful symptoms even after the physical damage to your body has healed. This prolonged pain experience can arise from a process known as “central sensitisation”, which is essentially when your nerve cells send disproportionally more pain signals in response to little or no pain stimulus.
ALERT! INTERESTING FACT –> Trigger points in chronic whiplash:
A common feature of chronic neck pain due to whiplash injury is the presence of “trigger points” in the neck muscles. Trigger points (or “knots”) are areas of contracted muscle that can be extremely tender when pressed on by a therapist. Researchers theorise that the increased sensitivity of these areas of muscle to touch is due to the central sensitisation process. Amazing!
How can we tackle chronic whiplash?
Whiplash is considered chronic when the symptoms/disability persist 12-24 weeks after the initial whiplash injury. Managing chronic whiplash associated disorders is tailored to each patient and involves a team of trained health professionals such as pain specialists, psychologists and physiotherapists to address the physical AND psychosocial factors involved in the ongoing symptoms.
Physiotherapy management can involve:
1. Pain education & advice on self management:
- Including ergonomic advice
- Learning how to manage symptoms independently
2. Manual Therapy
- Activation, coordination, strength & endurance focused exercise therapy (i.e. deep neck flexors and extensors) required for neck stability
- Postural exercises, including axioscapular muscle retraining
- Addressing decreased proprioception of the neck (sense of position in space)
Research has shown that changes occur in the way that whiplash patients activate their neck muscles, and may use compensatory muscles which can cause further pain. This can be retrained with specific neuromuscular exercises.
Research in 2015 found that female patients who had persistent, moderate to severe whiplash associated disorder showed degeneration of the deep neck muscles involved in neck stability (i.e. cervical multifidus, longus capitis & longus colli). Individualised resistance strengthening exercises designed to target these muscles were found to have an effect on reducing neck disability.
^The above image shows how to correctly activate the deep stabilising muscles of the neck during cranio-cervical flexion (chin tucks)
FYI 2.0! Research shows that there’s a link between a person’s expectations about their recovery and how well they actually recover from chronic whiplash associated disorders (Ferrari, 2014). That’s why it’s so important for health professionals to provide excellent education about a person’s pain and what they can expect during the course of their recovery- something that the staff at BounceRehab are very well trained to do!
In some cases where the symptoms of chronic whiplash associated disorders persist despite non-surgical interventions such as physiotherapy, research suggests that a “radio frequency neurotomy” (i.e. an injection which involves delivering radio waves that generate heat to specific nerves, which interferes with their ability to transmit pain signals) may be the most appropriate treatment option.
Whether it’s a day or two years after a whiplash injury, BounceRehab has the resources to help put you on the road to recovery with…
- To help restore functioning and reduce pain/disability
- Manual therapy techniques
- Exercise prescription & techniques for self management
- Pain education
- Dry needling, trigger point therapy & soft tissue therapy
- KT taping
- Hot/cold therapy
- Pressure biofeedback to help with the correct activation of neck stabilising muscles
- Performing strengthening, range of motion and stabilising exercises under the supervision of a qualified physiotherapist
Advice by our resident nutritionist Caroline Zanelli & Bioceutical supplementation:
- Chondroplex: provides key nutrients including glucosamine, chondroitin & MSM to support joints and relieve inflammation
- Theractive: contains curcumin which has anti-inflammatory and pain relieving properties
- Omega Trienol: contains fish oil to help relieve inflammation
- Probiotics: have anti-inflammatory properties
- Sleep Complex: promotes sleep (poor sleep quality may be a factor associated with chronic WAD)
Massage therapy to relieve muscular tension
Psychology for pain/stress management
Whiplash can be a pain in the neck, but the right management
will ensure you achieve an optimal outcome. You’ll return to whipping it on the dance-floor in no time! ♫ “Whip It!- LunchMoney Lewis” ♫
- Stace, R. M., & Gwilym, S.E. (2015). Whiplash associated disorders: a review of current pain concepts. Bone & Joint. 4(1) 37-39. Doi: 10.1302/2048-0105.41.360315
- Motor Accidents Authority. (2014). Guidelines for the management of acute whiplash associated disorders for health professionals 2014, Third Edition. Accessed September 1 2016. http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/The%20APA/StatePAGES/TAS/TAS_Final-Guidelines-for-the-management-of-a~d-WAD-disorders-for-health-professionals-3rd-edition-2014-MAA32-0914-28-11-14a.pdf
- Ferrari, R. (2014). Predicting recovery from whiplash injury in the primary care setting. Australian Family Physician. 43(8): 559-62. Accessed September 1 2016. http://www.racgp.org.au/afp/2014/august/predicting-recovery-from-whiplash-injury/ .
- Sefariadis, A., Rosenfeld, M., & Gunnarsson, R. (2004). A review of treatment interventions in whiplash-associated disorders. European Spine Journal. 13(5); 387-397. Doi: 10.1007/s00586-004-0709-1
- Drescher, K., Hardy, S., Maclean, J., Schindler, M., Scott, K., & Harris, S.R. (2008). Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Physiotherapy Canada. 60(3): 215-23. Doi: 10.3138/physio.60.3.215
- Miller, J., Gross, A., D’Sylva, J., Burnie, S.J., … & Hoving, JL. (2010). Manual therapy and exercise for neck pain: a systematic review. Manual Therapy. 15(4): 334-354. DOI: http://dx.doi.org/10.1016/j.math.2010.02.007
- Pastakia, K., & Kumar, S. (2011). Acute whiplash associated disorders (WAD). Open Access Emergency Medicine. 27(3): 29-32. doi: 10.2147/OAEM.S17853.
- Walton, D.M., Macdermid, J.C., Giorgianni, A.A., Mascarenhas, J.C., West, S.C., & Zammit, C.A. (2013). Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. 43(2): 31-43. doi: 10.2519/jospt.2013.4507.
- Mayo Clinic Staff. Accessed 1 September 2016. http://www.mayoclinic.org/tests-procedures/radiofrequency-neurotomy/basics/definition/prc-20013452
- Teasell, R.W., McClure, J.A., Walton, D…. Death, B. (2010). A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 – overview and summary. 15(5): 287-94. Accessed 1 September 2016. http://www.ncbi.nlm.nih.gov/pubmed/21038007
- Teasell, R.W., McClure, J.A., Walton, D…. Death, B. (2010). A research synthesis of therapeutic interventions for whiplash-associated disorder: part 2 – overview and summary. 15(5): 295-304 Accessed 1 September 2016. http://www.ncbi.nlm.nih.gov/pubmed/21038008
- Peloso, P.M., Gross, A.R., Haines, T.A…..Aker, P. (2006). Medicinal and injection therapies for mechanical neck disorders: a Cochrane systematic review. 33(5); 957-67. Accessed 1 September 2016. http://www.ncbi.nlm.nih.gov/pubmed/16652427
- Brukner P., Khan K. Clinical Sports Medicine. 3rd. McGraw-Hill Professional; 2006.
- O’leary, S., Jull, G., Van Wyk, L., Pedler, A. and Elliott, J. (2015). Morphological changes in the cervical muscles of women with chronic whiplash can be modified with exercise—A pilot study. Muscle Nerve, 52: 772–779. doi:10.1002/mus.24612
- Jull, G.A. (2010). Deep Cervical Flexor Muscle Dysfunction in Whiplash. Journal of Musculoskeletal Pain, 8(1-2): 143-154. Doi: 10.1300/J094v08n01_12
- Rodriquez, A. A., Barr, K. P. and Burns, S. P. (2004). Whiplash: Pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve. 29: 768–781. doi:10.1002/mus.20060
- Brault, J.R., Siegmund, G. P., and Wheeler, J.B. (2000). Cervical muscle response during whiplash: evidence of a lengthening muscle contraction. Clinical Biomechanics. 15(6): 426-435. doi: 10.1016/S0268-0033(99)00097-2