Injuries seen with whiplash.

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Welcome back to the Forensic Chiropractor podcast.

Today I want to cover one of my favorite research articles discussing whiplash associated disorders.  The emphasis should probably be on the word associated.  Whiplash has been around almost as long as vehicles.  In 1928 Harold Crowe who was a physician in the United States saw patterns of injuries with people in motor vehicle collisions and came up with the word Whiplash.  The pattern of injury he saw was neck pain after a torso was pushed forward by the seat and the head lagged behind and then snaps backward and forward rapidly.  Almost 100 years later the term whiplash is still being used.  Today’s study covers whiplash with all of its associated problems. 

Today’s study is Characterization of acute and chronic whiplash-associated disorder published by James Elliott et at in the Journal of Orthopedic and sports physical therapy May of 2009.  They started the study by stating that most whiplash injuries recover in 2-3 weeks.  Although no reference was given to support that statement.  They do go on to show that 42% of whiplash injuries will become chronic injuries.  This statistic was based on a study from 1994 in the Pain journal.  42% is a high percentage of people that fail to make a full and quick recovery from a whiplash injury.  I feel like my own clinical experience would be similar to the 42%.  Some patients make a quick recovery and do not seem to have residual symptoms, but a lot just never make a full recovery regardless of utilizing multiple providers and treatments.  Don’t get me wrong with treatment we can make drastic improvements and with ongoing care manage the symptoms, but not a full recovery. 

Today’s study reported that we will see a lot of common symptoms after a whiplash injury that are associated with a failed recovery.  They reported seeing the following symptoms with chronic whiplash injured patients:  pain, dizziness, visual and auditory disturbances, temporomandibular joint dysfunction, photophobia, dysphonia, dysphagia, fatigue, cognitive difficulties such as concentration and memory loss, anxiety, insomnia and depression.  They say that this makes whiplash injuries one of the more controversial and confusing musculoskeletal conditions.  This is such a complex condition that we are spending $29 billion in the US per year treatment whiplash. 

They state that whiplash injuries can by damage to the bones, intervertebral discs, facet joints, ligaments, muscles and nerve tissue.  I would add that brain injuries should be part of anatomy that whiplash injuries can damage.  They reported that evidence suggest that treatment should focus on identifying the damaged anatomy and this is  what makes an injury become a chronic injury. 

The study started by breaking down the 4 types of whiplash associated disorders according to the Quebec taskforce review.  The first is neck complaints with stiffness or tenderness in the neck with no physical signs of injury.  The second is neck complaints with stiffness or tenderness and some physical signs of injury such as point tenderness or trouble turning the head.  The third is neck complaints with stiffness, tenderness and neurological sings of injury such as changes to reflexes or weakness in the arms.   The 4^th is neck complaints with fracture or dislocation of the neck. 

They reported that one problem with the classification system is that different anatomy can be damaged in the same grouping and treating each group the same has not lessened the frequency of whiplash injuries turning into chronic injuries.   Assuming what anatomy was injured is not effective especially since there can be so much anatomy damaged in a whiplash injury.  It helps to consider the mechanism of injury in a typical whiplash case. 

Assuming a rear end collision the vehicle will be pushed forward.  Since the occupant of the vehicle is not part of the vehicle they will not move forward.  The seat will eventually push the patient forward which causes an upward movement of the patient as the spine straightens the lower part of the spine moves forward as the head and neck lag behind.  Depending on how well the head rest is positioned often the head will stay where it was and the rest of the body will move forward.  This extends the neck.  Then the neck is abruptly flexed forward creating the whipping motion.  These quick movements include upward, backward and forward motions of the neck/head.  If the impact was not directly in the middle there will be rotational forces as well.  This study reported that muscle that support the spine offer little if any support since the collision happens so fast that the reflexive activation doesn’t respond quick enough. 

This reminds me of a couple aspects of prior podcasts.  One this reflexive control of muscles is mediated by the ligaments.  Once the ligaments are damaged, we no longer get the reflexive control at all.  The second concept is that ligaments can have tearing even if the stretch is not longer that the ligaments limit if the stretch is fast.  

As seen in this study the best clinical options are to treat the specific anatomical injuries.  This study reported that the quote “energy release could potentially impact and injure any number of anatomical tissues in the cervical spine like intervertebral discs, joint capsules, ligaments, facet joints, muscles and nerve tissues” end quote.  As I mentioned before I strongly feel that brain injuries should be added to this list. 

Today’s study goes through the different anatomy that can be damaged in a whiplash injury.  They start with facet joints.  They reviewed studies that show there can be direct damage to facet joint with tears in the joint capsules and cartilage damage including fractures.   They showed studies that showed facets can have sub failures in the capsular ligaments.   Facet joints have lots of nerves that can be one of the largest structures to experience and create pain after a whiplash injury.  The best test we have to assess facet joint damage is diagnostic injections.  Facet joint pain has been shown to predispose people to pain from central sensitization.  This was discussed in podcast 35.  This is when the nervous system is altered in a way that patients feel more pain in healthy tissues. 

The second anatomical structure they covered is the nerve roots.  The nerve roots are vulnerable to excessive stretching and injury during the rapid acceleration and deceleration movements.  The nerve root are also vulnerable to lateral bending.  Disc herniations are another method of damaging the nerve roots.  Nerve root damage can be seen with an EMG/NCV test as well as some damage seen on an MRI. 

The third anatomical structure they covered in ligaments.   I have spend a lot of podcast talking about ligament damage.  We have talked about catastrophic ligament damage and sub catastrophic ligament damage.  Today’s study talks about sub failure of ligaments or microscopic ligament damage.  This sub failure ligament damage was shown to damage mechanoreceptors and nociceptive nerve endings leading to pain and inflammation that can become chronic.   This ligament damage was shown to be seen a lot in the upper cervical spine.  The next question is how to assess for ligament damage.  They reported that MRIs can be used to see high signals in ligaments on T2 or STIR views.  These high signals would indicated ligament damage.  My second podcast covered the study published by White et al showing how to assess for catastrophic ligament damage.   Podcast 13 showed ways to assess for sub catastrophic ligament damage.   Podcast 27 covered multiple ways to assess for ligament damage with x-rays.  There are lots of ways to assess the cervical spine to see if this is the type of injury we are dealing with. 

The fourth anatomical structure they covered is intervertebral discs.  They reported that studies have shown that 20-25% of whiplash injured patients have disc damage.  C5-6 was the most common level of disc damage.  MRI is the gold standard for assessing disc pathology. 

The fifth anatomical structure they covered is muscle injuries.   They reported that studies have shown that whiplash injuries occur often in the superficial neck muscles which leads to morphological alterations and loss of muscular force capabilities.   They do not mention any diagnostic testing to assess for muscle injuries.  This is often done with an examination.  Palpation and resisted movements is often a great way to assess for muscle damage. 

Today’s study reported that due to the lack of gold-standard testing we often do not know the specific anatomy injured.  Today’s study came out in 2009 and I would argue that we do have better testing for anatomical injuries after a whiplash injury now.  The problem I see is expense.  If we do diagnostic testing for facet damage, EMG/NCV testing for nerve root damage, multiple x-rays and MRIs for ligament and disc injuries and an examination for muscle damage we could be spending a lot of time and money.  Not to mention that we are often dealing with damage to a lot of different anatomical structure in a whiplash injury and not just one of them. 

The next section in today’s study addresses factors that increase the risk of whiplash injuries becoming chronic.  They found 2 factors were seen in the literature regarding potential for whiplash to become chronic and they are pain and functional disability levels.  They showed that high pain and disability levels seen with physical and psychological factors including loss of movement, hyperalgesia, and posttraumatic stress are indicators of poor outcomes with symptoms 2-3 years after the whiplash injury.  

The next section in today’s study addresses the clinical presentation of whiplash.  They state that patient will often have a loss of cervical range of motion, altered muscle patterns, alteration in postural control, balance and eye movement control problems. 

They stressed that range of motion testing is one of the most common clinical characteristics of whiplash.  Range of motion testing has been shown to accurately assess patients with and patients without history of neck complaints.  All whiplash patients had a range of motion deficit within 1 month of the whiplash injury.  Range of motion deficits persisted for 2-3 in only those with moderate or severe symptoms.  Altered muscle patterns persistent for patient with chronic symptoms as well as those without chronic symptoms.  I’d like to repeat that again both patients with chronic symptoms and those that reported a full recovery had altered motor patterns.  They reported that these patients with altered muscle control may be quote “more vulnerable to future episodes of neck pain” end quote.  That means that all whiplash patients with or without a full recovery will have altered muscle function and are more vulnerable to future neck pain.   

This reminds me of podcast 6 where I talked about Wolff’s law.  The altered function of muscle in all whiplash patients will alter the biomechanics of the spine.  This will lead to degenerative osseous changes or bone spurs.  These changes take time to be seen on imaging and clearly are not seen to the same extent with all patients.  This is evidence that all whiplash injuries are permanent injuries and will never make a full recovery. 

Loss of balance and eye movement control issues are seen with chronic whiplash.  This could be from a brain injury or damage to the neck.  This is more common in patients with dizziness.  Today’s study doesn’t go into more detail about this, but I would assume it has a lot to do with brain injuries. 

Todays study did report that there is growing evidence to show that whiplash injuries do lead to central sensitization.  That is when the nervous system gets pain signals and becomes sensitized and created pain in areas that there are no anatomical injuries.   Listen to podcast 35 for more info on that. 

Today’s study said quote “There is no doubt that chronic whiplash pain is associated with psychological distress” end quote.  Chronic whiplash is seen with affective disturbances, anxiety, depression and behavioral abnormalities such as fear of movement.  These psychological symptoms were not seen in acute whiplash patients and only chronic patients.  This suggests that persistent symptoms are a trigger for psychological distress.  They reported that psychological distress can decrease recovery time.  They also showed that smoking or drinking was associated with longer symptoms after whiplash.  They reported that a lot of the psychological distress may be related to posttraumatic stress due to the traumatic event that typically brings on whiplash. 

It is clear that persistent whiplash injuries lead to different psychological distress and this distress leads to longer pain.  This is one reason that we need to do our best to determine the exact anatomy injured and do our best to get the symptoms resolved quick.  The longer the symptoms last the more likely we are to have central sensitization and psychological distress all of which has been shown to lead to chronic pain. 

Injured spines from whiplash will have altered function.  The altered movement of the spine will lead to degenerative changes.  We talked about degenerative osseous changes.  Today’s study brought up the degenerative changes seen in the muscles.  Today’s study showed that whiplash pain over 3 months showed fatty infiltration of the cervical muscles.  This is easily seen on an MRI.  These degenerative muscles changes were shown to be associated with nonrecovery.  This is evidence of another type of permanent injury seen with whiplash.  Permanent degenerative changes to the muscles in the cervical spine after a whiplash injury is no small thing.  This is a very serious permanent injury.  This muscle degeneration was not from direct trauma to the muscles and affected the deeper cervical muscles that are not typically seen with whiplash injuries.  Today’s study showed that a possible cause for the muscle degeneration is generalized disuse.  This is not always disuse from pain, but due to ligament damage we lose the ligament mediated reflexive control of muscles and the muscles do not function normally.  Another possible cause for muscle changes after whiplash is from the inflammatory response.  Patients with insidious onset of neck pain did not have degenerative muscle findings.  This suggests that the muscle atrophy comes from trauma.   

This study then addressed the clinical implications.  We have seen that if whiplash symptoms become chronic there are a lot of complications.  The clinical implications showed that if we can do our best to figure out the damaged anatomy whiplash patients have we can do a better job of treating the damage and help prevent chronic pain.  They stressed that posttraumatic stress can play an important role in recovery and appropriate referrals or treatment should be considered.    

They stated that early management and a multidisciplinary approach is best to treat whiplash injuries.  Treatment should be started right away and not quote “waiting to determine whether the symptoms are not resolving” end quote.  

To summarize today’s article 42% of whiplash patients will have chronic pain.  Common symptoms associated with whiplash are pain, dizziness, visual and auditory disturbances, TMJ dysfunction, photophobia, dysphonia, dysphagia, fatigue, cognitive difficulties, concentration and memory loss, anxiety, insomnia, depression and PTSD.   Best practice is to find the specific anatomy injured in a whiplash injury which typically includes bones, discs, facet joints, ligaments, muscles, nerve tissue and I add brain. 

Best clinical practice is to accurately diagnose specrrific anatomy injured which is done with a good physical exam, diagnostic injections, EMG/NCV, X-rays, motion x-rays, and MRIs.  This study showed an urgency to find the diagnosis and accurate treatment with multiple providers as soon as possible to prevent chronic pain.  Regardless of symptom recovery all whiplash patients have altered mechanics of their cervical spine.  These altered mechanics lead to degenerative osseous changes and degenerative muscles changes. 

As I covered in podcast 35 pain that persists will cause a sensitization of the central nervous system and this can perpetuate the pain and cause pain in areas with no tissue damage.  We can help these patients with an accurate diagnosis and proper treatment if we act fast.  The problem is that it would cost a lot of money to accurately diagnosis all patients.  It would be cost limiting to have diagnostic injections, MRI, x-rays, and EMG/NCV tests on all patients.  Clinicians should focus on clinical judgment, but order and refer sooner vs later. 

Real world

For today’s real world example will be given from more of the legal side of things.  If a new client comes to a law firm after a MVC the law firm has lots of things to worry about.  I would assume one of the biggest concerns a lawyer would have is related to the budget.  After a MVC there is almost always a budget.  The budget can be a commercial policy with over a million dollars available.  Or in the state of Utah the minimum policy is I believe $30,000.   The typical fee for the attorney is 1/3 of the settlement.  If a patient has $30,000 in benefits and the attorney is able to get the full $30,000 that means that there is only $20,000 available for the patient and the medical bills.  Today’s study showed the urgency to accurately diagnosis and treat with a multidisciplinary approach.   Diagnostic injections, x-rays, EMG/NCV and MRIs would often utilize a lot of this theoretical $20,000.  Then treatments to manage the different anatomical injuries seen with whiplash would take a lot more of this budget.  Not to mention that a lot of patients went to the ED and already spent $10,000 and if they went by ambulance there can be a lot less money available.  There are always other options to pay for care and diagnostic treatments.  There can be underinsured or uninsured coverage and possible health insurance. 

I bring this up because the literature showed us to prevent chronic symptoms after a whiplash injury we need to move fast, but doctors also need to be aware of what the patient can afford to do.  It will not help the patient to order $50,000 worth of care and diagnostic exams in the first month if they have no ability to get this done.  I think the statistic of 42% of whiplash patients will become chronic suffers will not go down until we do more and do more right away.  Unfortunately I see a lot of care that I refer and testing that I refer out not getting done due to the inability to pay for care.  This is a real world problem. 

Neither should an insurance company be responsible for every treatment and diagnostic test known to man.  This comes down to clinical evaluation and judgement.  Best practice does seem to be move quick to avoid chronic symptoms.  Let me know if you have any questions or any topics you would like me to cover.

Thanks.