You get whiplash from a car accident, right? Yes, but whiplash is not restricted to car accidents. Whiplash is a colloquial term used for a cervical acceleration/deceleration (CAD) injury to the neck and head. Whiplash labels the injury you sustain and the symptoms you are left with. A Whiplash injury is a collection of problems that we can expect to find when dealing with a forwards & backwards or sideways jerk of your neck.
There are a lot of structures in your neck. During a quick, uncontrolled movement any of these structures can be damaged. Lets look at some of the structures to understand how each of these may be injured in a whiplash injury.
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What is your neck made up of?
Your neck joins your head to your body. It enables you to move your head and eyes to see and avoid obstacles when you walk or drive. This movement is generated by muscles pulling on the joints of your neck.
You have seven cervical vertebrae, stacked from the bottom of the skull down to the first thoracic vertebra. The cervical vertebrae naturally form a curve, called the cervical lordosis. The vertebrae are named and counted from the top down. C1 (atlas, named after the Titan warrior condemned to carry the heavens on his shoulders by Zeus) and C2 (axis) are unique in the pivot joint they form to enable rotation, which comes in handy when following the ball during a tennis match. C3 to C7 look fairly similar, they predominantly move the neck to look up and down or bend your ear to your shoulder. All the joints need to work in harmony to allow full, pain free movement.
Between each cervical vertebra is a disc (except for C1 and C2). The disc has a fibrous outer layer, the annulus fibrosus, that encloses the gel like inner part, the nucleus pulposus. Almost like a few layers of onion surrounding a jelly like substance inside. The discs act as shock absorbers in your neck. Too much force may force these disc to pop and cause a slipped disc in your neck.
The cervical vertebrae and neighbouring discs are connected to each other with different ligaments to aid in stability and keep them in position. The most important ligaments are the alar and transverse ligaments. These three ligaments (1x transverse + 2x alar) keep the bony axis of C2 (dens) in contact with C1. If the dens is not securely positioned it can move and cause damage to the spinal cord. You also have ligaments between the spinous processes (the bony bits you can touch from the back of your neck) and the transverse processes (pointing sideways). These ligaments can be torn or ripped from its anchor point during a whiplash injury.
Seen from above the vertebrae have a fairly round shaped hole in which the spinal cord runs from the brain down to the lower back. From the spinal cord nerve roots exits above each vertebra, forming nerve roots C1 – C7, with the C8 nerve root exiting the spinal cord below the 7th cervical vertebra. The nerve roots then merge and divert into the brachial plexus, that supply the arm to allow movement and relay messages of sensation to the brain. Nerves can become irritated or compressed during a whiplash injury.
Neck Blood Supply (Arteries & Veins)
Alongside the vertebrae important blood vessels run to supply the brain of oxygen from the heart and lungs. The most superficial being the external carotid where you can feel your pulse if you press your index finger just below the jaw bone.
Muscles attach in different layers to the vertebrae and skull to generate force on the bones to allow you to move your neck. Some muscles keep the neck still while others move your neck. Muscles also guard the other structures and are the first to get injured, torn or ripped apart during a Whiplash injury to your neck. Muscles spasm in your neck that are there for a reason.
How does a Whiplash injury happen?
Whiplash (acceleration/deceleration) happens most frequently in a car accident. Let’s say you were driving along the highway and suddenly had to slow down for the backed up traffic. The guy behind you doesn’t brake fast enough and hits your car from behind.
On impact your head bends backwards rapidly to counter the force you got from behind, reaches end range (the complete movement your neck is able to make) and then snaps forward again. If you were looking directly to the front, in a split second your head moves from a relaxed forward facing position to bent all the way back, to bent all the way forward. Like a Whip that is cracked, the tail of the whip gets lashed forward then jerked backwards creating a swift snap. In the same way your neck snaps abruptly without warning.
Totally a different story if your head was turned sideways reading the add you were driving past. Any of the structures explained above can be damaged. The amount of damage will be different depending on the direction and force of impact.
What gets injured in a Whiplash
Any of the structures can get injured with this uncontrolled, forceful end range movement. Worse case scenario is a fracture to one or more of the cervical vertebrae. This will be ruled out by on X ray. In most cases immediately after the accident if you were admitted to hospital. Mainly the neck joints gets crushed on the side of the most impact (Primary impact). Overstretch of the joint capsules, muscles & ligaments on the opposite side (Secondary side of impact) are our biggest concern. Both sides will be affected, some more than other.
The impact may cause tears to the annulus fibrosus (outer layer of the disc), which can lead to a disc prolapse or bulge. Ligaments can be torn. This will lead to instability of the vertebrae. Instability of the C1/C2 joint can be dangerous if the dens moves into the space of the spinal cord or nerves. Nerves get irritated or pinched from swelling that sets in after the injury. Membranes in the spinal cord can get inflamed and cause headaches. Arteries and veins running between the vertebrae get stretched or may even get small tears, which may lead to blood clots. Muscles rapidly contract to protect the neck joints, tearing some muscle fibers. Tendon anchors (where the muscle attaches to the bone) can sustain tears at the areas where they attach and rip out a piece of bone.
Causes of Whiplash
You can sustain a whiplash injury from any form of rocking your head on your neck in a rapid, uncontrolled manner, the most obvious ones include:
- car accident
- a fall (where your head makes contact with the floor)
- tackle (rugby/wrestle)
- fight (boxing)
- diving into the bottom of a pool
As we discussed above the neck is a sophisticated combination of joints, muscles, ligaments and nerves; which can all be affected with a whiplash injury.
The seriousness of the accident does not correlate with the severity of the symptoms.
The injury to the joints, ligaments and muscles will not be visible to the naked eye, therefore “if you can’t see it its not that bad”. This is a fallacy. There will not be bleeding or any other sign of injury. This does not mean you’re “Ok”.
Remember that an accident is also an emotional experience. Circulating Adrenaline will be high, masking your pain initially, but when it wears off, be prepared for the cascade of pain to come…
Inflammation will only set in later. The injury may seem harmless, but the network of structures that must control and move your neck &head takes a heavy beating. Your head weighs on average 8% of your body mass, about 5 kg. Have you ever held your arm out to catch a 5kg weight in mid air… That’s heavy, your elbow won’t come off unscaved.
The excessive load placed on the musculotendinous junction tears(where the muscle attaches to the bone). This leads to hemorrhage (bleeding) and inflammation. Inflammation is the bodies normal way to send a lot of cell to a injured area, this leads to swelling which causes an increase in pressure in the confined space in your neck. In order to protect your neck, the muscles react to try and provide some stability. Severe muscle spasm will follow.
Whiplash injury has a high risk of becoming chronic, if not diagnosed and treated well. See how Acute injuries become chronic and how they’re distinctly different.
Symptoms of Whiplash
Symptoms after a whiplash may linger to slowly get worse as time goes by.
- Immediately following the injury you won’t feel pain. You may interpret this as nothing serious.
- The swelling occurs, inflammation builds up, pressure increases, intramuscular spasm sets in and you are in pain.
- Because of the pain, you don’t move your neck, then stiffness sets in, and then you cannot move your neck. Awful cycle to be in.
How bad is it?
Each whiplash injury will be specific to each individual. Because the direction of impact and speed of impact will differ in each case.
The Quebec Task Force has divided whiplash associated disorders into five different grades.
Grade 0: no neck pain, no stiffness or any physical signs
Grade 1: neck pain, stiffness and tenderness, no physical signs on examination
Grade 2: neck pain and stiffness, with decreased range of motion and point tenderness
Grade 3: neck pain with neurological signs, weakness and sensory deficits
Grade 4: neck pain and fracture, dislocation or injury to the spinal cord
Experiencing minor symptoms (slight pain and stiffness) is normal after a whiplash injury, while the inflammation settles. It is still worthwhile to get a thorough evaluation after a whiplash injury to rule out any damage to the delicate structures in the neck. The sooner the better. The secondary muscle spasms around the neck becomes a problem. We find it difficult to assess the deeper damage if the muscle guarding is preventing any and all neck movements, that makes it tricky to assess the underlying cervical joints.
Speed makes all the difference. The faster impact injury the forces carried through the neck will be much greater. You may even hit your head on the dashboard. This may lead to a concussion injury too. In this type of scenario, the concussion takes priority.
If you experience severe symptoms listed above, it is definitely advised that you get a thorough examination. Rather be safe than sorry.
Fractures are possible & very dangerous
Neck fractures are top priority, that’s why we start our investigation taking X-rays. Grade 4 injuries are the most severe and will be diagnosed by X-ray to visualise the fracture. You will be hospitalised, placed on traction and may need surgery to stabilise the fracture.
How is Whiplash diagnosed?
On the scene of an accident all passengers will be treated as though they have sustained a cervical fracture, until X-rays can be taken to rule out the possibility.
X-rays show us the bones of the cervical spine, and only that. X-rays however may be useful to see any broken pieces of bone, shift out of its normal position or crush to the facet joints.
Magnetic Resonance Imaging show us the entire bony spine and soft tissue, including the muscles, ligaments, joint capsules, blood vessels and nerves. This will show the damage to all the structures involved. This is a detailed and much more expensive test that must be ordered by a specialist.
How we test it
We are able to assess all the different structures in your neck. This allows us to make a diagnosis based on your individual injury. An evaluation can rule out any injury to your nerves and ligaments. It will include range of motion, quality of movement, sensory conduction, deep tendon reflexes and muscle power testing.
Then we will custom your treatment, according to what we find to be injured.
Why is my whiplash pain not going away?
We find in a lot of cases that after a X-ray is clear, that is no fractures are diagnosed, patients are treated only with some medication, usually analgesics, anti-inflammatories and if you are lucky muscle relaxants.
Sure the medication will decrease the spasm and inflammation, but this is only temporary. What happens after that? If your neck joints were injured and not treated, you will most probably develop pain & stiffness later on.
What makes whiplash worse
Left untreated, a whiplash injury can lead to unexplained stiffness, dull aches in the entire neck, headaches, a feeling of your head being too heavy for your neck.
Fear of movement and pain may lead to protective behaviour, without you even realising it. Like turning your entire body when you want to look over your shoulder. That is a normal strategy a few days after your whiplash injury, but not a few weeks later. Fear of movement, leads to less movement, leads to more stiffness, leads to more pain on movement, leads to less movement…. The cycle needs to be broken as soon as possible. Doing the right movement at the right time for your own, specific injury will break the cycle before it becomes a bad habit.
Physio treatment for Whiplash
Each Physio treatment program will be different. As a general guideline our aim is to:
- decrease pain
- gain full, active pain free movement
- Strengthening of the neck muscles
Phases of Rehabilitation & Treatment
1st Phase: Assess the extent injury
We will start treatment after establishing the degree of the injury to the tissues in your neck. Our priority will be to focus our time on your primary problem, while attending to the secondary problems that develop. In the acute phase there is a lot of inflammation and protective muscle spasm. Treatment will be focused on decreasing inflammation and starting range of movement exercises.
2nd Phase: Maintain available range of movement
During the second phase of treatment, as the inflammation settles, our aim is to maintain the movement that you have. At this stage we only move according to what you can do, and work on the surrounding structures to prevent muscle spasms and guarding. We will give you advice what is the best position to sleep and which movements or positions to avoid.
3rd Phase: Progressively regain normal neck movements
After the inflammation has settled, our aim will be to restore your movement. We will try to gain more movement in your neck taking it through all the different motions. At this stage we only move according to what your pain will allow, respecting the pain. It is important to regain good quality of movement and muscle activation in the correct patterns in this phase, to avoid any bad habits from forming.
4th Phase: Restore Neck to normal range of movement
Once the inflammation has settled, your pain will be less and we can aim for full movement of your neck. End of range movement in all directions will be worked towards by means of joint mobilisations and exercise.
5th Phase: Clear all Joint, Muscle, Nerve and Ligaments
During this phase you should have full, pain free range of motion with overpressure. We make sure that all the structures in your neck is back to its normal state and ale to withstand different forces.
6th Phase: Discharge program
This stage involves a strengthening & stretching program, to keep and maintain the normal neck movements. We will explain the warning signs if the pain may return and what to do when this happens.
All whiplash injuries are different, and the healing will be different for each injury. After an evaluation we will be able to give you an indication of how long your treatment is expected to take. Normally we will start off with four treatments spread over two weeks and two treatments in the following two weeks.
After X-ray has been cleared of fractures, your doctor will probably prescribe anti inflammatories and a muscle relaxant to decrease your pain. Even when taking these medications, get your neck evaluated to prevent the risk of chronic neck pain.
You may need a soft neck collar to immobilise your neck, only for a short period of time.
It is not advisable to have your neck manipulated or adjusted at this stage, if a thorough neurological evaluation of not done. This may exacerbate symptoms if a disc was injured.
After pain free movement is achieved it may be necessary to consult a biokineticist. We are able to refer you to the appropriate practitioner.
Surgery for Whiplash
Surgery for a Whiplash injury is only necessary when there are fractures of the vertebrae and will be done in a medical emergency if a fracture dislocation was diagnosed on X-ray. A anterior decompression fusion will be done. This diagnosis will be made immediately after the injury, as it may be life threatening.
If you develop neurological symptoms some time after your injury get your neck checked out. We are able to assess the nerves and refer you to a specialist if necessary.