Whiplash Injury; Causes, Symptoms, Diagnosis, Treatment

Whiplash injury








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Whiplash injury is a hyperextension and flexion injury to the neck or sudden thrusting forwards due to forceful, rapid back-and-forth movement of the neck, like the cracking of a whip. Whiplash most often occurs during a rear-end auto accident, but the injury can also result from a sports accident, physical abuse or other trauma.

Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.

Whiplash is commonly associated with motor vehicle accidents, usually, when the vehicle has been hit in the rear;[Rx] however, the injury can be sustained in many other ways, including headbanging,[Rx] bungee jumping and falls.[Rx] It is one of the most frequently claimed injuries on vehicle insurance policies in certain countries; for example, in the UnitedKingdom 430,000 people made an insurance claim for whiplash in 2007, accounting for 14% of every driver’s premium.[Rx]

  • Trauma and sports injuries are more common in young adults.
  • Rates of whiplash are higher in persons using a seatbelt with shoulder restraint than with no restraint but seatbelts often prevent more serious injuries.
  • Poor posture.
  • Poorly-fitted head restraints.
  • Women sustain higher rates of whiplash, probably because their neck muscles are less well developed than men’s.
  • Narrowing of the cervical spinal canal due to acquired or congenital disorders predisposes to spinal cord damage with these types of injuries.

Types of Whiplash Injury

There are two types of injury

  • Typical cervical hyperextension injuries – occur in drivers/passengers of a stationary or slow-moving vehicle that is struck from behind. The person’s body is thrown forward but the head lags, resulting in hyperextension of the neck. When the head and neck have reached maximum extension, the neck then snaps into flexion.
  • A rapid deceleration injury throws – the head forwards and flexes the cervical spine. The chin limits forward flexion but the forward movement may be sufficient to cause longitudinal distraction and neurological damage. Hyperextension may occur in the subsequent recoil.

Whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms

  • Grade 0 – no complaints or physical signs.
  • Grade 1 –  indicates neck complaints but no physical signs.
  • Grade 2 –  indicates neck complaints and musculoskeletal signs.
  • Grade 3 –  neck complaints and neurological signs.
  • Grade 4 –  neck complaints and fracture/dislocation

or

QTF classification of whiplash-associated disorders

Grade Classification
0 No complaint about the neck. No physical signs
I Neck complain of pain, stiffness or tenderness only. No physical signs
II Neck complain and musculoskeletal signs. Musculoskeletal signs include decreased range of motion and point tenderness
III Neck complain and neurological signs. Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits
IV Neck complain and fracture or dislocation

The Position of spine vertebra Affected most

  • Most cervical spine fractures occur predominantly at two levels – at the level of C2 or at C6 or C7.
  • Most fatal cervical spine injuries occur in upper cervical levels, either at the cranio-cervical junction C1 or at C2.

The Canadian cervical spine rule for risk of skeletal injury:

  • The Canadian cervical spine rule applies to trauma patients who are alert (Glasgow Coma Scale of 15) and stable.
  • It has been shown to be safe and reliable, missing only one unstable injury in a series of over 16,000 cases.

High-risk factors

  • Age 65 years or over.
  • Paraesthesia in extremities.

Dangerous mechanism of injury, which is considered to be

  • A fall from a height of at least a meter or five stairs.
  • An axial load to the head – eg, during diving.
  • A motor vehicle collision at high speed (>100 km/h) or with rollover or ejection.
  • A collision involving a motorized recreational vehicle.
  • A bicycle collision.
 Low-risk factors
  • Simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle).
  • Able to sit rather than lie down in the emergency department.
  • Ambulatory at any time.
  • The delayed (not immediate) onset of neck pain.
  • The absence of midline cervical spine tenderness

Causes of whiplash injuries

  • A whiplash injury may occur if the head is moved violently away from the body because of a sudden and powerful jerk or jolt. The neck moves beyond its normal range of movement, resulting in overstretched ligaments, muscles and tendons. The injury is often exacerbated because the muscles, in order to compensate for the sudden movement, pull the head back into position too hard, causing another overstretching in the opposite direction.
  • The jolt (or blow to the head) can come from behind, in front, and from the side. A slow-speed collision may also cause a whiplash injury.

Possible causes of whiplash

  • Automobile accidents
  • A sudden blow to the head from a contact sport, such as rugby, boxing, karate, or American football.
  • A horse riding or a cycling accident
  • Any fall which causes the head to violently jolt backward
  • Being hit on the head with a heavy object
  • Shaking a child/baby violently (possible child abuse)
  • Punching a child/baby (possible child abuse).

Symptoms of Whiplash Injury

Common symptoms related to whiplash may include

In a more severe and chronic case of “whiplash associated disorder,” symptoms may include

It is essential to consider serious injury in the immediate period following injury. Other possible causes of acute neck pain and stiffness include:

  • Spinal Fracture.
  • Cervical disc herniation.
  • Subarachnoid hemorrhage (may precede or occur at the time of a road traffic accident).
  • Meningitis or meningism due to systemic infection.
  • If the neck symptoms persist then it is also very important to consider other causes of chronic neck pain, even though soft tissue ‘whiplash’ injuries may cause long-term symptoms.
  • Other possible causes of persistent neck pain and stiffness include
  • Cervical spondylosis – this results from the narrowing of the canal around the spinal cord, with or without the formation of bony osteophytes.
  • Tumors –  brain tumors, bone tumors.

The National Institute for Health and Care Excellence (NICE) recommends using an adapted version of the Canadian cervical spine rules that incorporates some aspects of the rule to identify patients who need imaging of the cervical spine.

Cervical spine X-rays

  • A standard series of X-rays of the cervical spine consists of three views: anteroposterior, lateral and anteroposterior odontoid peg views.
  • The lateral view must show the top of the T1 vertebral body; the odontoid peg view should show the lateral masses of the atlantoaxial articulation.
  • In children aged <10, use anterior/posterior and lateral radiographs without an anterior/posterior peg view; use CT imaging to clarify abnormalities or uncertainties.

The following patients should have plain radiography (three views) of the cervical spine

  • Patients with neck pain or midline tenderness if aged ≥65 years, or any age if there was a dangerous mechanism of injury.
  • Any patients where it is considered unsafe to assess movement. Safe assessment can be carried out if the patient:
  • Was involved in a simple rear-end motor vehicle collision.
  • Is comfortable in a sitting position in the emergency department.
  • Has been ambulatory at any time since the injury with no midline cervical spine tenderness.
  • Has delayed onset of neck pain.
  • Patients initially considered safe to have neck movement assessment still need cervical spine X-rays if on the assessment they cannot actively rotate the neck 45° to the left and right.

The Cervical spine CT scanning

CT scan is indicated immediately if

  • The patient had a Glasgow Coma Scale <13 on initial assessment.
  • The patient has been intubated or is being scanned for multi-region trauma.
  • A definitive diagnosis of cervical spine injury is needed urgently for a patient (eg, before surgery)

CT is also indicated

  • If plain films are deemed inadequate, suspicious, or definitely abnormal.
  • If clinical suspicion of injury continues despite a normal radiograph.
  • CT is superior to plain radiography, with a reported sensitivity of 100% and specificity of 99%.
 Cervical spine MRI scanning
  • The technique depicts soft tissue structures well, with reported sensitivities for intervertebral disc injury of 93%, posterior longitudinal ligament injury of 93% and interspinous ligament injury of 100%.
  • MRI is indicated for patients with neurological signs, even if plain films are negative.
  • MRI has a role in the assessment of ligamentous and disc injuries suggested by X-ray, CT or clinical findings.
  • MRI can distinguish hematoma from edema, which can have prognostic importance.
  • CT myelography

This is indicated if MRI is not available, the patient cannot tolerate MRI or MRI is contra-indicated.

Treatment of Whiplash Injury

Non-Surgical Management

Here’s the good news: given time, whiplash should heal on its own. To help with recovery, you should:

  • Ice your neck – to reduce pain and swelling as soon as you can after the injury. Do it for 15 minutes every 3-4 hours for 2-3 days. Wrap the ice in a thin towel or cloth to prevent injury to the skin.
  • Use a neck brace or collar – to add support, if your doctor recommends it. However, they are not recommended for long-term use, because they can actually weaken the muscles in your neck.
  • Apply moist heat to your neck but only after 2-3 days of icing it first – Use heat on your neck only after the initial swelling has gone down. You could use warm, wet towels or take a warm bath.
  • Other treatments – like ultrasound and massage, may also help.
  • Recovery and return – to full function are best aided by sympathy and encouraging the patient to take an active role in dealing with the symptoms.
  • Provision of adequate analgesia.
  • There is now good evidence that the use of collars in whiplash injury prolongs the recovery of the patient. Patients should be advised about neck mobilization and encouraged to remain as active as possible.

Medication

  • Analgesic medications  – are those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Opioids should be used only for a short period of time and under a physician’s supervision. People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect. Opioids can also be addictive. Their side effects can include drowsiness, constipation, decreased reaction time, and impaired judgment. Some specialists are concerned that chronic use of opioids is detrimental to people with back pain because they can aggravate depression, leading to a worsening of the pain.
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) – relieve pain and inflammation and include OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Several others, including a type of NSAID called COX-2 inhibitors, are available only by prescription. Long-term use of NSAIDs has been associated with stomach irritation, ulcers, heartburn, diarrhea, fluid retention, and in rare cases, kidney dysfunction and cardiovascular disease. The longer a person uses NSAIDs the more likely they are to develop side effects. Many other drugs cannot be taken at the same time a person is treated with NSAIDs because they alter the way the body processes or eliminates other medications.
  • Anticonvulsants—drugs primarily used to treat seizures—may be useful in treating people with radiculopathy and radicular pain.
  • Antidepressants – such as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain, but their benefit for nonspecific low back pain is unproven, according to a review of studies assessing their benefit.
  • Muscle Relaxants – If the muscles around the slipped disc experience painful spasms, a muscle relaxant such as Valium may be useful. The drawback to drugs like these is that they do not limit their power to the affected nerve. Instead, they have a generally relaxing effect and will interfere with daily activities. Cyclobenzaprine (Flexeril) – might be prescribed to relieve the discomfort associated with muscle spasms. However, these medicines might cause confusion in older people. Depending on the level of pain, prescription pain medicines might be used in the initial period of treatment.
  • Steroids – If inflammation is severe, a doctor may also prescribe a steroid. Steroids, such as cortisone, reduce swelling quickly. A cortisone shot directly in the affected area will have an immediate effect on the displaced disc.
  • Counter-irritants – such as creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Topical analgesics reduce inflammation and stimulate blood flow.
  • Nerve Relaxant — Pregabalin or gabapentin and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).
  • Calcium & vitamin D3 – to improve bones health and healing fracture.
  • Glucosamine & Diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
  • Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
  • Dietary supplement -to remove general weakness & improved health.
  • Spinal manipulation and spinal mobilization  – Are approaches in which professionally licensed specialists (doctors of chiropractic care) use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. The techniques have been shown to provide small to moderate short-term benefits in people with chronic low back pain. Evidence supporting their use for acute or subacute low back pain is generally of low quality. Neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.
  • Traction  – Involves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released the back pain tends to return. There is no evidence that traction provides any long-term benefits for people with low back pain.

Exercises

  • Patients should receive instruction about exercises. However, no high-quality evidence has been found for the benefit of neck exercises for mechanical neck disorders, indicating that there is still uncertainty about the effectiveness of exercise for neck pain.
  • Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial.

Provide the following advice and reassurance for the majority of patients who have not suffered a severe injury

  • Reassurance that whiplash-associated disorder is usually benign and self-limiting.
  • Encouragement of early return to usual activities and early mobilization. Explain that usual activities may initially be painful but this is not harmful and not indicative of ongoing damage.
  • Discouragement of rest, immobilization and the use of soft collars.

Manipulation and mobilization

  • Manipulation and mobilization have been shown to have benefits for MND with or without a headache.
  • Although support can be found for use of thoracic manipulation versus control for neck pain, function and quality of life results for cervical manipulation and mobilization versus control are few and diverse.
  • Findings suggest that manipulation and mobilization present similar results for every outcome at immediate/short/intermediate-term follow-up.
  • Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up.
  • There is a risk of very rare but serious adverse events for manipulation –  eg, arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma.

Physical therapy

  • A study comparing education by GPs compared to physiotherapists found no significant differences in the overall outcome; treatments by GPs and physiotherapists were of similar effectiveness:
  • The long-term effects of GP care seemed to be better compared to physiotherapy – for functional recovery, coping and physical functioning.
  • Physiotherapy was found to be more effective than GP care on a cervical range of motion at short-term follow-up.
  • Patients with particularly severe symptoms or symptoms that are not resolving may benefit from referral to physiotherapy but physiotherapy treatment is most effective if started soon after the injury occurs. There is some evidence that acupuncture treatment for patients with chronic neck pain is associated with an improvement in neck pain and a reduction of associated disability.
  • For patients with acute whiplash, there has been a trend towards active treatments to reduce pain and stiffness but the evidence remains conflicting. There is insufficient evidence to indicate the most effective treatments for patients with whiplash-related problems that have lasted for longer than six months.

Take painkillers or other drugs

  • if recommended by your doctor. Non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, will help with pain and swelling. However, these medicines can have side effects. Never use them regularly unless your doctor specifically says you should. Check with your doctor before taking them if you take other medicines or have any medical problems. If over the counter medications do not work, prescription painkillers and muscle relaxants may be necessary.

Injections

  • Corticosteroid or lidocaine injections may help relieve muscle spasms.

 Muscle relaxants

  • These may help ease muscle spasms. As muscle relaxants may cause drowsiness, most doctors advise their patients to take them at bedtime.
  • Intramuscular injection of lidocaine for chronic mechanical neck disorders (MNDs) and intravenous injection of methylprednisolone for acute whiplash are effective treatments.
  • There is limited evidence of the effectiveness of epidural injection of methylprednisolone and lidocaine for chronic MND with radicular findings.
  • Other medications, including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, have contradictory or limited evidence of effectiveness.
  • There is moderate evidence that botulinum toxin type A intramuscular injections for chronic MND are not better than saline.
  • When ‘yellow flags’ (indicators of psychosocial barriers to recovery) are identified, early intervention is important and may include
  • Simple education and reassurance to correct erroneous beliefs.
  • Referral for a short course of cognitive behavioral therapy.
  • Referral to a psychologist or pain clinic.

Surgery may be required for a fracture or spinal cord injury

Home Remedies For whiplash injury

  • Use Cow’s ghee in your food. It is a best natural “Vata” reliever and gives nourishment to the nerves and other body parts.
  • 1 tablespoonful of Turmeric should be consumed once everyday, after boiling it in milk for half an hour. It is a very useful herbal treatment for cervical Spondylosis.
  • Constipation must be avoided at all costs. Constipation may increase pain in Cervical Spondylosis.
  • Herbs have divine healing powers and they have the ability to cure any disease from the root. They were gifted to us by God when he created life. So believe in God if you want to get rid of your problems !
  • Ayurvedic herbs are unique natural remedies for Cervical Spondylosis. Ayurvedic principles are different in many ways from modern medicine for example – Drinking water from a copper pan after keeping it overnight is also very useful in Rheumatoid arthritis and Cervical Spondylosis.
  • Consuming castor oil at night with milk or alone is a very useful herbal remedy for arthritis, especially rheumatoid arthritis and Cervical Spondylosis.
  • Improve your nutrition as the first step. It plays an important role to fight diseases. When nothing works, nutrition works a lot.
  • Use herbal juices like Aloe vera juice and Amla Juice in routine. Amla is the richest source of natural Vitamin C. Vitamin C improves the natural immunity of the body. 100 gm of Amla juice contains 30 times more vitamin C than 100 gm of oranges.

Homeopathy for whiplash injury

  • Shallaki (Boswellia serrata) – Boswellia serrata is a very popular natural anti-inflammatory herb used by Ayurveda physicians all over the world. It is commonly known in India as ‘Salai Guggul’. The resin obtained from the tree is purified and then used for pain and inflammation. It relieves cervical Spondylosis and other arthritis pains naturally without causing any side effects.
  • Guggul (Commiphora Mukul) – Commiphora Mukul is a known anti-inflammatory agent used by Ayurveda physicians worldwide. The analgesic and anti-inflammatory action are almost immediate. Guggul is also used in weight loss formulas and is effective in reducing weight, thus it also helps osteoarthritis patients as well as cervical Spondylosis pains.
  • South (Zingiber officinale) –  It is commonly known as dry ginger. Dry Ginger is another useful anti-inflammatory herb. It also improves appetite and good for the digestive and respiratory system and helps to control data element.
  • Ashwagandha (Withania somnifera) –  Ashwagandha is popularly known as Indian ginseng in the west. It has known anti-inflammatory, anti-cancer, and anti-stress activities.
  • Ashwagandha (Withania somnifera) – The herb also possesses anti-inflammatory, antitumor, antistress, antioxidant, immunomodulatory, hemopoietic, and rejuvenating properties. It is especially useful in diabetics and blood pressure people as it also controls diabetes and blood pressure. It relieves stress, anxiety and enhances physical and mental performance naturally.
  • Tagar (Valeriana wallichii) – It is commonly known as ‘Valerian’ and is a very popular herb in the west. It is used in India for its benefits in calming down the nervous system. It relieves stress and anxiety and also fights depression. It also relaxes muscles and is very useful among natural herbal remedies for Cervical Spondylosis.
  • Brahmi (Bacopa monnieri) – The herb ‘Brahmi’ is used in Ayurveda since ages for loss in memory, lack of concentration, forgetfulness. It increases the retention power as well as recollection. It is very useful in many mental illnesses also. Regular use also helps in stress, anxiety, blood pressure, hallucinations, and epilepsy. Regular use of this herb improves mental ability and cognition.

Dos and Don’ts of

  • Avoid Acid-Forming Foods – Foods that make your body more acidic increase your body’s rate of inflammation and keep you from healing as fast as you would like. Sugar, fried food, refined flour, alcohol, and tobacco should all be avoided as much possible or at least limited if you wish to manage the pain that comes with cervical spondylosis.
  • Sunlight – Sunlight in moderation is good for anything that ails you. It lightens your mood and releases feel-good endorphins in your body which makes it easier to handle any uncomfortable muscle pains.
  • Work on Your Posture – A lifetime of slouching and bad posture will cause your spinal cord to grow in incorrect angles which cause the vertebrae to push against each other. By standing tall, you stretch out your spinal cord and give the vertebrae a chance to set correctly.
  • Wear a Neck Brace – If the neck ache is both chronic and severe, where even small movements result in waves of pain, then invest in a neck brace. The brace will help support your neck and let the muscles heal unimpeded.
  • Sleep on Your Back – Lying flat down at night without a pillow will allow your spine to set into its natural position.
  • Don’t Overexert Yourself – Your spinal cord will be especially prone to serious injuries if you have this condition. Therefore, you should avoid very strenuous exercise to prevent further damage.
  • Massages – Regular massaging can loosen the stiff vertebra in your neck allowing for less painful and freer movement

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