You get whiplash from a car accident, right? Yes, but whiplash is not something that you can only get from a car accident. Whiplash is only the term used for the type of injury to your neck. It is an acceleration/deceleration injury to your neck and head. Whiplash labels the injury you sustain to your neck and the symptoms you are left with. An injury like this is a collection of problems that we can expect to find when dealing with a forwards and backwards or sideways jerk of your neck.
There are many structures in your neck. With an injury like whiplash, the quick and uncontrolled movements of your neck can cause any of these structures to be injured. Let’s look at some of these structures to understand how each could be injured.
What is your neck made up of?
Your neck joins your head to your body. Therefore it enables you to move your head and eyes to see and avoid obstacles when you walk or drive. Muscles are responsible for moving your neck, by pulling on the joints of your neck.
Neck Vertebrae
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 can be found right at the top of your spine and is called atlas. It is named after the Titan warrior who was condemned by Zeus to carry the heavens on his shoulders. C2 is called axis. C1 and C2 form a unique pivot joint that enables you to rotate your head, which comes in handy when following the ball during a tennis match. C3 to C7 look fairly similar. They help with moving your neck so that you are able to look up and down or bend your ear to your shoulder. All the joints need to work in harmony to allow full and pain-free movement.
Neck Discs
Between each cervical vertebra is a disc (except for C1 and C2). The disc has a fibrous outer layer, named the annulus fibrosus, that encloses a gel-like inner part, named the nucleus pulposus. Almost like a few layers of onion surrounding a substance like jelly on the inside. Most importantly, the discs act as shock absorbers in your neck. Too much force may force these discs to bulge out to the side and cause a slipped disc in your neck.
Neck Ligaments
The cervical vertebrae and discs are connected to each other with different ligaments to aid with stability and to keep the joints in your neck 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.
Neck Nerves
Seen from above, the vertebrae have a fairly round shaped hole through which the spinal cord runs from the brain down to the lower back. From the spinal cord nerve roots exit above each vertebra, forming nerve roots C1 – C7, with the C8 nerve root exiting the spinal cord below the C7 cervical vertebra. The nerve roots then merge and divert into 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 with oxygen from the heart and lungs. The most superficial being the external carotid artery, where you can feel your pulse if you press your index finger just below the jaw bone.
Neck Muscles
Muscles attach in different layers to the vertebrae and skull. They generate force to allow you to move your neck. Some muscles help to stabilize your neck while others move your neck. Muscles also guard the other structures in your neck and are usually the first to get injured, torn or ripped apart during a Whiplash injury to your neck. Therefore, muscle spasms in your neck shouldn’t be ignored. They 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 ahead of you. The guy behind you doesn’t brake fast enough and hits your car from behind.
On impact your head bends backward 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 bending all the way back and then to bending 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 gets whipped abruptly and without warning.
If your head was turned sideways while reading the billboard your were passing, your whiplash injury will be completely different.
Brain injury…
Concussion goes hand in hand with a whiplash injury. A concussion occurs when you get a direct blow to your head. During an accident it is very likely that you could hit your head. The impact during an accident will cause your head to violently move in one direction within a split second. Your brain is suspended in fluid inside your skull and will follow the same route. The inside of your skull will absorb most of the impact, but the brain hits the inside surface of the skull. The brain then rebounds and hits the opposite side as it moves back into position.
The action of sustaining a whiplash injury might be very similar to concussion, but the conditions are different.
- Concussion is a traumatic injury to your head and brain.
- Whiplash is a traumatic injury to your neck.
Both of these are serious injuries. Sustaining a whiplash injury to your neck doesn’t necessarily mean you are definitely going to have a concussion injury as well, and vice versa.
The seriousness of the accident does not correlate with the severity of the symptoms.
As mentioned above, the head and neck is a sophisticated combination of joints, muscles, ligaments and nerves. All of these structures in your neck can be affected by a whiplash injury. The amount of damage will be different, depending on the direction and force of impact. A whiplash injury is not visible to the naked eye like an open wound. Therefore, people tend to believe “if you can’t see it, it’s not that bad”. There will not be bleeding or any other sign of injury, but this does not mean you are “Okay”.
What gets injured in a whiplash injury?
Remember, any accident is also an emotional experience. Initially, your adrenaline levels will be high and it could mask your pain, but when it wears off, be prepared for a wave of pain to come…
Inflammation sets in later. The injury may seem harmless, but the network of structures that controls and moves your head and neck takes a heavy beating with a whiplash injury. On average, your head weighs about 5 kg (8% of your body mass). Have you ever held your arm out to catch a 5 kg weight in mid air? That is extremely heavy! Your elbow won’t come off unscathed.
The excessive load placed on the musculotendinous junctions leads to tears (this is where muscles attach to the bone). This leads to hemorrhage (bleeding) and inflammation. Inflammation is the body’s normal way of starting the healing process. It sends a lot of cells to the injured area. That 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 by trying to provide some stability. You will have severe muscle spasms.
Worse case scenario would be that you fracture one or more of the cervical vertebrae. This will be ruled out by on X ray. In most cases you need an X-ray immediately after the accident. On the side of the most impact (primary impact), mainly the neck joints gets crushed and forced into an end range position. Overstretching of the joint capsules, muscles and ligaments happens on the opposite side (the secondary side of impact). This will be our biggest concern. Both sides will be affected, but usually one more than the other.
There are many other structures that’s involved and – just as important
The impact can cause tears to the annulus fibrosus (outer layer of the discs in your neck), which can lead to a disc prolapse or bulge. Ligaments can be torn and this will lead to instability of the joints in your neck. 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 in between the vertebrae get stretched or may even get small tears, which may lead to bleeding or blood clots. Muscle fibres can get torn. Tendon anchors (where muscles attach to the bone) can sustain tears at the areas where they attach and rip out a piece of bone.
Pain from a whiplash injury, has a high risk of becoming chronic, if it isn’t diagnosed and managed well with the right treatment from the start. See how Acute injuries can become chronic and how they are distinctly different.
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:
- any blow to the back or side of your head
- a car accident
- a fall (where your head hits the floor)
- a tackle (rugby/wrestling)
- a fight
- diving into the bottom of a pool
Symptoms of whiplash
After a whiplash injury you’ll feel pain that may linger and slowly get worse as time goes by.
- Immediately following the injury you won’t feel pain. You may interpret this as nothing serious.
- Then 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, stiffness sets in and then you can’t move your neck. This is an awful cycle to be in.
Self-test: How to know if you have sustained a whiplash injury
Unfortunately there is no standardized grading for diagnosing a whiplash injury as it will depend on which structures got injured. The tests mentioned below are simply a few ways which you can use to test yourself if you think or suspect you might have sustained a whiplash injury.
How bad is it?
Each whiplash injury will be specific to each individual. 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 other 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 points of 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.
With any whiplash injury it’s possible that you could have a fracture of your spine or that you have sustained a concussion.
This is very dangerous!
Experiencing minor symptoms (slight pain and stiffness) is normal after a whiplash injury, while the inflammation settles. However, even a minor whiplash injury is not something you should take lightly. Stiffness and pain with certain movements could be a sign of deeper injury. The muscles in your neck could be guarding other fragile structures that might have been injured.
With a whiplash injury it is highly likely that you sprained one or more of the ligaments in your neck. If a ligament is injured, it cannot provide the stability it’s supposed to. This leads to instability of the joints in your neck and in turn, leads to more muscle spasm and guarding. That is why it is important to get a proper evaluation of your neck especially if you suspect that you may have a whiplash injury. Our physiotherapists will be able to do an in-depth evaluation of your neck.
Speed makes all the difference. Faster impact will mean that the forces carried through your head and neck will be much greater. You may even hit your head on the dashboard. This may lead to a concussion injury too.
Grade 4 injuries are the most severe and neck fractures or concussion will be the top priority to manage and treat.
That is why it is very important to get x-rays taken after your accident. X-rays will show any fractures to your spine. For a concussion however, you will need a brain scan. The severity of your symptoms will determine which condition will be top priority. You will be hospitalised, and your fracture or concussion injury will need to be stabilised, possibly through surgery.
Other structures could be damaged as well and this needs to be taken seriously. Structures like the discs in your neck, nerves running from your spinal cord, arteries running next to your spine and even the cartilage in your neck joints.
Diagnosis of a whiplash injury
On the scene of an accident, all passengers are treated as if they’ve sustained a cervical fracture, until X-rays can be taken. The top priority is to rule out fractures and concussion and after that other structures like muscles, nerves, joint capsules, discs and ligaments can be assessed. A whiplash injury is a collection of symptoms from multiple structures that gets damaged at varying degrees.
X-rays
X-rays show us the bones of the cervical spine, and only that. However, x-rays will be useful to see any broken pieces of bone, bones shifted out of their normal positions or crush fractures to the facet joints. It is recommended that you get x-rays taken directly after your accident.
MRI
Magnetic Resonance Imaging (MRI) show us the entire bony spine and soft tissue, including muscles, ligaments, joint capsules, blood vessels and nerves. This will be a more likely type of scan to use for concussion injuries, as it will show any swelling or bleeding on the brain. This is a detailed and much more expensive test and it must be ordered by a specialist. Your physiotherapist will refer you to a specialist to get an MRI if deemed necessary.
Physiotherapy Evaluation
Our physiotherapists know and understand the intricacy of the anatomy of the head and neck. There are many structures to test and we take into account the complex biomechanics of neck movements. We will accurately diagnose which structures have been involved and to what degree. During your physiotherapy evaluation, we will be stretching and stressing the soft tissue structures like muscles, ligaments, nerves and discs. This way we can diagnose muscle sprains, ligament sprains, disc herniations and nerve irritation/compression. We will look at the range of movement of each joint to be able to diagnose compression type injuries to facet joints. We will also be looking at vascular symptoms that will show us if there has been damage to an artery in your neck. Here are the names of some of the tests which we will be using during your evaluation:
- Alar ligament test
- Sharp purser test
- Passive neck flexion test
- Neural tension tests
- Deep tendon reflexes
- Break test
- Sensory testing
- Cervical artery dissection (CAD) testing
Gaining information through our evaluation allows us to make a diagnosis based on your individual injury. Then we’ll be able to customise the treatment you get for your whiplash injury. This is why our physiotherapists are the best at diagnosing this type of problem.
Why is pain from my whiplash injury not going away?
Often, patients are treated only with medication, if their x-rays show no fractures after an accident. Usually this includes analgesics, anti-inflammatory medication and muscle relaxants. The medication will decrease the inflammation and muscle spasm, but this is only temporary. What happens after that? Pain and stiffness will bother you later on if you injured something in your neck and you didn’t get the right whiplash treatment. An injured joint will stay painful if it has become unstable due to injured ligaments. An injured muscle will continue to cause pain if it can’t manage to carry the load of your neck. A disc will continue to cause pain if your posture or neck movements continuously irritates it. These structures need to be moved and mobilised or given the necessary rest for your whiplash to improve.
Ignoring the pain and hoping that it will simply go away by itself is not the solution. Neglecting your condition and continuing your normal lifestyle could lead to worse pain later on, or pain becoming chronic. Everything might look fine from the outside, but do not simply expect everything on the inside to be fine as well.
What NOT to do when you have a whiplash injury
What you SHOULD do when you have a whiplash injury
Making your whiplash injury worse
A big problem that we see with whiplash injuries
One of the most common problems we encounter, that slows the healing process, is the time it takes for patients to seek treatment after a whiplash injury.
In many cases people tend to think their pain will ‘blow over’ and they continue with their lives. Initially, after a whiplash injury, everything might look fine on an x-ray and you might feel like everything looks fine from the outside. Inflammation will set in soon after your injury. Muscles in the surrounding area will form muscle spasms to guard and protect neck movements. Now these muscle spasms becomes a problem for us. We find it difficult to assess for deeper damage if the muscle spasms are preventing any and all neck movements. The longer you wait to get to your physiotherapist, the harder it gets for us to assess the underlying cervical joints.
It is possible that you sustained a concussion injury too. But, even if your main diagnosis was a concussion, you could have an underlying whiplash injury.
If you manage your concussion injury, but not your whiplash injury it could lead to issues later on. If the pain from your whiplash injury is not managed the right way from the start, it can become chronic. Therefore, not getting an evaluation of your neck means that underlying problems after a whiplash injury can’t be properly diagnosed or get proper treatment.
The use of medication can also be a problem. So if you are managing your pain with only medication, here’s the problem:
A muscle relaxant will reduce the stability that muscles surrounding the neck are responsible for. Take away that stability and the pain will increase significantly. Anti-inflammatory medication will reduce the swelling and inflammation, but when the medication wears off, the pain will return. Using anti-inflammatory medication continuously slows your body’s natural healing process. So medication is a very useful tool to manage your pain and inflammation after an injury, but you should not solely rely on it to heal you tissues or fix your problem.
Someone might recommended that you wear a soft neck brace after sustaining a whiplash injury. Wearing this brace for weeks on end is a big problem.
You should only wear a brace like this for a few days after your whiplash injury. The longer you wear a brace, the weaker your neck muscles will become. Therefore, you will start to rely on the brace more and more and struggle to function or move without it. The only time that you should wear a brace for more than a few days, is when a specialist (usually an orthopedic surgeon) prescribe that you wear it for a longer period. This only happens if you have a fracture or dislocation of one of your neck joints that needs to be kept stable by a neck brace. In this case you will wear a hard neck brace and not a soft neck collar.
It is worthwhile to get a thorough evaluation of your neck after a whiplash injury. This way you will get a proper diagnosis and proper advice from the start as well as treatment for the pain of your whiplash injury. Leaving problems unchecked and untreated can lead to persistent and chronic neck pain. The sooner you seek help, the better.
Physiotherapy treatment for whiplash
We have seen many patients with whiplash injuries and therefore we are confident to provide the best possible treatment that leads to faster recovery. Pain and stiffness after an injury like this will prevent you to move and you might feel afraid to move and afraid to damage anything. This, in turn, will lead to your muscles getting weaker and your joints more stiff. It becomes a vicious cycle. Let us help you break out of this cycle. We will provide guidance and answers every step of the way. Committing to the physiotherapy treatment plan improves your chances of successful long-term recovery from a whiplash injury.
Each physiotherapy whiplash treatment program will be different. As a general guideline our aim is to:
- Determine what is injured
- How bad is it injured?
- Protect it from further injury
- Give it time to heal
- Strengthen surrounding muscles
- Re-evaluate to monitor progress
Your treatment will be specific to your problem and can include:
- Neck joint mobilisation
- Nerve mobilisation
- Myofascial release
- Deep dry needling
- Laser
- Ultrasound
- Exercise and strengthening
- Strapping
- Immobilisation (a soft collar may be needed)
We work with you through all the phases of healing until we can get you back to where you were before your injury.
Phases of rehabilitation and treatment for a whiplash injury
1st Phase: Protection and initial Healing (Week 1-2)
Protect
Protect your neck. Depending on the severity of your injury, we sometimes suggest that you wear a soft neck brace. This is to protect the joints in your neck and to keep the surrounding muscles from having to work too hard. Supportive strapping can help as well.
Rest
Rest as needed. The best form of rest would be to lie down with your head supported on a pillow. Resting will take the load off the muscles in the area.
Ice or Heat
Applying ice to your neck will have a pain relieving effect by making the area feel numb. Applying heat will have a pain relieving effect by easing the discomfort from muscle tightness.
2nd Phase: Maintain available range of movement (Week 2-3)
During the second phase of treatment for whiplash, 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 on the best position to sleep in and which movements to avoid.
3rd Phase: Progressively regain normal neck movements (Week 3-4)
After the inflammation has settled, our aim will be to restore your movement. We will try to gain more movement in your neck by taking it through all the different motions. At this stage we only move according to what your pain will allow, respecting the pain. But 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 normal range of movement to your neck (Week 4-5)
Once the inflammation has settled, your pain will be less and we can aim to get full movement of your neck. During this phase of treatment for whiplash, end of range movement in all directions will be worked towards by means of joint mobilisations and exercise.
5th Phase: Clear all joints, muscles, nerves and ligaments (Week 4-6)
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 able to withstand different forces.
6th Phase: Discharge program (Week 5-7)
This stage of whiplash treatment involves a strengthening & stretching program, to keep and maintain your normal neck movements. We will explain the warning signs and what to do if the pain returns.
Recovery Time
All whiplash injuries are different, therefore the healing will be different for each injury. Your physiotherapist will be able to give you an indication of how long treatment of your whiplash injury is expected to take during your first session and evaluation. Usually, we will start off with four treatments spread over two weeks and two treatments in the following two weeks. It could take 4 – 6 weeks to get back to how you felt before your accident.
Other medical treatments for a whiplash injury
- If your X-rays show no signs of fractures, your doctor will probably prescribe anti inflammatory medication and a muscle relaxant to decrease your pain. Even if you are taking these medications, get an evaluation of your neck by a physiotherapist to prevent the risk of chronic neck pain.
- Cortisone injections might relieve symptoms of inflammation, but this will not be a solution to your problem. But most importantly, long-term use of cortisone has negative effects on the condition of your joints.
- You may need to use a soft neck collar to immobilise your neck, only for a short period of time. You will be able to get a neck collar like this from an orthotist.
- Your doctor or orthopedic surgeon will tell you if you need to wear any other form of neck brace.
- It is not advisable that you get a neck manipulation at this stage. This may exacerbate symptoms if a disc was injured or if a nerve is being irritated.
- It may be necessary to consult a biokineticist. We are able to refer you to the appropriate practitioner.
Surgery for a whiplash injury
You will only need surgery for a whiplash injury if you sustained any fractures or dislocations of the vertebrae in your neck. This is a medical emergency and therefore may be life threatening. Your orthopedic surgeon will do an anterior decompression and neck fusion.
If you develop nerve pain or symptoms like pins and needles, numbness or weakness in your arms and shoulders after your whiplash injury, this could mean that you have injured or damaged nerves that run down from your neck. We are able to help you by testing these nerves through a neurological assessment. This will involve testing the your ability to feel (sensation), to contract muscles in certain areas and to test your reflexes. These are all functions of your nerves and shows out nerve damage.
We’ll do a neurological assessment and refer you to a specialist if necessary. A neurologist will perform a nerve conduction test that confirms and determines the loss of the nerve’s ability to relay messages. Call us sooner rather than later.
What else could cause this pain?
- Cervical disc herniation – pain that spreads into your neck and shoulder blade. It worsens with a sneeze or a cough or bending your head.
- Pinched nerve – nerve root irritation/compression – Sharp electrifying pain with numbness, pins and needles and weakness of the arm.
- Cervical arthritis/degeneration – Neck pain and stiffness (especially in cold weather and in the mornings).
- Concussion – Headaches, nausea, drowsiness and blackouts after a direct hit to the head or neck.
- Neck muscle spasm – Pain in the neck or shoulder blade area that worsens with certain loads or movements.
- Neck muscle strain – Pain and stiffness when doing certain neck movements. Tends to feel better with rest and feel worse with certain loads or movements.
- Wry neck – Neck stuck in a certain position. Very painful or unable to turn head to the side.
