Diagnosis, treatment and prevention of whiplash
Winter really is here to stay for a while and with it comes snow and ice, leading to an increase in car accidents. Chiropractic offices are inundated with car accident cases involving whiplash, headaches, and lower back pain. Whiplash is the most common injury sustained in a rear-end collision due to the forces exerted on the cervical spine at the point of impact and in the seconds following. Whiplash describes a cervical sprain/strain that occurs when the head and neck are forced to rapidly extend from the initial rear impact, followed by rapid recoil into flexion. This rapid back and forth movement causes stretching and tearing of the muscles and ligaments of the cervical spine. Chiropractic care incorporates hot/cold therapy, spinal manipulation, stretching, soft tissue work, and physical therapy modalities such as ultrasound, electrical muscle stimulation, and traction to treat whiplash injuries. Chiropractors stretch tight muscles in spasm and strengthen weak muscles to bring balance back to the cervical spine. They use gentle spinal manipulations to restore normal range of motion and relieve pain. Chiropractors use physical therapy modalities such as ultrasound and electrical muscle stimulation to reduce muscle spasms and decrease pain. Special stretches and exercises done at home will help speed recovery and reduce pain levels. To understand whiplash injuries, it is important to understand the anatomy and physiology of the neck and the pathophysiology behind muscle strain injuries. This article will cover these topics in detail to better explain whiplash injuries.
The primary muscles of the cervical spine involved in this case are the trapezius, suboccipitals, longus coli, longus capitis, and levator scapulae. The trapezius is a large superficial muscle that covers the back of the neck. The muscle extends from the nuchal line of the skull, the external occipital protuberance, the ligamentum nuchae, and the spinous processes of C7-T12 to the lateral third of the clavicle, the acromion, and the spine of the scapula. Elevates, retracts, and rotates the scapula when firing and works to stabilize the head in a neutral position. The suboccipital region on the posterosuperior aspect of the neck is composed of 4 groups of muscles. The rectus capitus posterior major travels from the spinous process of C2 to the lateral part of the inferior nuchal line. Rectus capitus posterior minor travels from the posterior tubercle of C1 to the medial portion of the inferior nuchal line. The inferior oblique originates from the spinous process of C2 and inserts on the transverse process of C1.
The superior obliques arise from the transverse process of C1 and insert on the occipital bone. These muscles are classified as postural muscles and assist in the movement of the atlanto-occipital and atlanto-axial regions. The longus coli and longus capitus are classified as deep neck flexors and are very important stabilizers of the cervical spine. They lie posterior to the deep prevertebral fascia and are considered anterior vertebral muscles. The longus coli muscles arise from the anterior tubercle of C1, the bodies of C1-C3, and the transverse processes of C3-C6 and insert on the bodies of C5-T3 and the transverse processes of C3-C5. Working bilaterally causes neck flexion. If fired unilaterally, it causes neck flexion and contralateral rotation. The longus capitus muscles arise from the basilar portion of the occipital bone and insert on the anterior tubercles of C3-C6 and the transverse processes. The main action is to flex the head. The levator scapulae is a thick, strap-like muscle that arises from the posterior tubercles of the transverse processes of C1-C4 and inserts on the superior portion of the medial border of the scapula. When fired, it elevates the scapula and tilts the glenoid downward by rotating the scapula.
Upon rear impact, the head is forced to extend causing stretching and tearing of the anterior neck ligaments and muscles and impaction of the posterior neck joints including the facets. The posterior elements of the spine, especially the spinous processes, get stuck and can cause fractures in severe impacts. As the head snaps back into hyperflexion, the posterior spinal muscles are stretched and torn and the anterior spinal tissues, including the spinal discs, are compressed. As a result of this rapid stretching, the muscles of the cervical spine go into reflex spasm to stabilize the area. The extent of the muscle strain and/or ligament sprain varies depending on the severity of the crash and the amount of force exerted on the neck. A cervical strain describes the diagnosis of a soft tissue injury to a muscle surrounding the cervical spine and a cervical sprain describes the same type of injury to a ligament. Sprains and strains are classified as grade I, II, or III depending on the extent of the injury. A simple grade I strain involves minimal damage to the adjacent muscle and ligamentous fibers (1-10%).
It usually presents with minimal pain, splinting and tenderness. Trigger points may be present and there is a loss in range of motion of the joint. Fixation may occur and joint play may decrease. A grade II strain involves partial tearing of the muscle or ligament (11-50%), often accompanied by bleeding and severe splinting. Trigger points and fixation can occur and can present with more severe pain. Grade III strains involve a severe tear of the muscle or ligament (51-100%) and may involve complete rupture of the muscle. It presents with severe pain, bleeding, and ecchymosis, resulting in extensive impairment of function. In most cases, whiplash patients experience mild grade I strain of the cervical musculature resulting in hypertonicity and myospasm.
In more serious rear-end collisions, a Grade II-II sprain/strain can occur and typically requires immediate medical attention and x-rays to rule out fracture and dislocation of the cervical spine. In the case of a grade I sprain/strain, without initial treatment, the myospasm will worsen and cause the patient to be wary of any movement. This reduces the active range of motion in the cervical spine and can affect flexion, extension, rotation, and lateral flexion. Short-term effects may be a reflex increase in tone, fixation, and decreased range of motion. If left untreated, long-term effects include adhesion formation and degeneration. The etiology of a cervical sprain/strain can be due to several causes, including automobile accidents, falls, sports injuries, overuse, sustained postural positions, and trauma. Safety measures can be taken in the car to reduce the chances of serious injuries from whiplash. Seat belts should always be worn correctly with lap and shoulder restraints in the proper position.
When available, the steering wheel and door airbags should be activated. The car seat should be in a normal resting position. If the seat is too close to the steering wheel, it can cause serious injury from airbag deployment and increases the risk of head injury from hitting the windshield. It also increases the chance of knee and hip injuries from impacting the knee against the backboard. This can cause a fracture of the femur, hip, and most commonly the acetabulum within the joint. If the seat is tilted too far back, it can cause an increase in whiplash injuries because the seat belt will not fit properly and can cause a throwing effect of the body. The head piece on the car seat should be elevated so that the back of the skull hits the middle of the padding. If the headpiece is too low, the head can hyperextend over the top of the headrest in the initial rear-end collision and cause increased injury and even dislocation.