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A Patient's Guide to Auto Accidents, Car Wrecks & Whiplash
Dr. Art Croft
PART 1. About Whiplash, Auto Accidents, Car Wrecks.
Finally, I use the terms doctor and chiropractic physician interchangeably in this booklet. When referring to medical physicians I will mention them using that term or by their specialty (e.g., ophthalmologist).
Dr. Arthur C. Croft
Spine Research Institute of San Diego
PART 1. About Whiplash
Whiplash injuries are not new to our mechanized society. In the last century, not long after the mighty locomotive made its debut, doctors began seeing patients who complained of a number of odd symptoms, such as headaches, neck soreness, back pain, blurred vision, difficulty concentrating, etc. These patients had one thing in common: all had been riding on a train in a passenger car that had been struck abruptly from the rear by another car as it was being coupled. They also had something in common with today’s modern automobile passenger who experiences the same constellation of symptoms after a rear impact collision in a motor vehicle.
Today, we call it whiplash. It’s not the best term, because it really describes only the mechanism of injury not the actual condition. Nevertheless, it’s universally understood and used by doctors and patients alike. It’s often associated with a seemingly bizarre collection of symptoms. So bizarre, in fact, that many physicians who are not trained or experienced in this area often dismiss them as being all in the head. This stigma also was attached to the nineteenth century train injuries, which became known as railway spine. And, just as today, nineteenth century patients fought with insurance companies whose doctors dismissed their complaints as imagined or trivial.
Another special group once suffered from a form of whiplash: military pilots whose planes were launched from the decks of aircraft. In the earliest of these catapult launches, there was no protection for the pilot’s head and neck. As he experienced great acceleration upon launch of his aircraft, his head would be snapped rearward with great force, often resulting in severe injuries. Some pilots even lost consciousness and crashed. Many careers were ended this way until somebody discovered that a head restraint, which limited this rearward motion of the pilot’s head, could prevent such injuries.
Unfortunately, in contrast to those found in today’s multimillion dollar military aircraft, the head restraints in modern passenger cars are poorly designed and frequently inadequate in preventing injury in passengers subjected to rear impact crashes. The Insurance Institute for Highway Safety recently reported that only 3% of the 164 cars tested had head restraints which they rated as “good.” And the fact that they do not generally protect occupants from neck injury is well supported in the medical literature. What’s worse is the fact that only 20% of passengers and drivers actually know how to— or take the time to—adjust those restraints that are actually adjustable. We’ll discuss that subject later.
In the 1950s, researchers began to take a more serious look at whiplash injuries. Investigators at UCLA first conducted actual rear impact crashes at low speeds to simulate real world crashes (real world implying, in this case, the very type of crash that happens every day on the streets of the city or on the highway). The volunteer in those crashes was equipped, as was the car itself, with sensitive instruments which recorded the actual acceleration (usually expressed in the unit g) experienced in the crash. Perhaps the most important discovery in that research was the finding that the human volunteer actually experienced 2½ times more acceleration than the car itself—a finding that goes a long way toward explaining why the car’s occupants can be significantly injured, even when no visible damage to the car is noted. In fact, more than half of all whiplash injuries occur in crashes in which there is little or no damage to the vehicle.
Although this is a very complex area, we can think of the relationship between vehicle damage and the forces the car’s occupants are exposed to as being either elastic in nature or plastic in nature. As simple examples, consider collisions between billiard balls and collisions between empty milk cartons. When one billiard ball strikes another, the struck ball is suddenly accelerated. There is no deformation or crush of either ball, and most of the energy going into the collision is expressed as motion in the struck ball. This is an example of an elastic collision.
Now take the example of two empty milk cartons. If they collide with sufficient force, they crush like accordions. In this plastic collision, much of the energy going into the collision is dissipated or absorbed by the deforming milk cartons. In a similar way, when your car is struck at a speed that is not sufficient to cause structural (crush) damage to the bumper, frame, and sheet metal parts, much of that crash energy is transferred to you directly, resulting in the type of rapid motion (whiplash) that can cause injury. How much energy? A small car (1900 lb) striking at a speed of 12 mph has 9,180 ftlb of energy. A larger car (4200 lb) at that collision speed delivers 20,294 ftlb of energy!
Conversely, when there is damage to the car, it indicates that the energy that it took to cause that damage was used up in the crash and not transferred to the occupants. Although it seems intuitively backward, this inverse relationship is, nevertheless, real and well known by crash researchers. However, despite that, insurance companies commonly leverage the fact that most jurors will not understand this relationship and will instead assume that no damage to the vehicle can only mean that no injury would likely have occurred.
The insurance companies have coined a private and rather cynical little epigram for this: No crash, no cash. It means, essentially, that if there is no structural damage to your car, they will pretend not to believe that you could have been injured. But they do really know about this plastic vs. elastic collision relationship, because, when there is crush damage to the car, they point that out and argue that injuries would not have resulted because the energy of the crash would have been absorbed! In truth, of course, you can be injured whether permanent vehicle damage is visible or not. There is no simple way to equate this damage to the occupant’s injury potential.
In fact, when we try to statistically compare vehicle damage to patient outcomes (that is, how well patients recover from their injuries), we find that there is no correlation. That is also true when we try to determine whether or not the occupant would have been injured, based on the amount of vehicle property damage to his car. This inability to relate property damage to injury potential or outcome has been demonstrated in scientific research in several different studies: it just can’t be done.
This is probably not surprising to most of us, since we’ve all known of someone who was riding in a car which crashed, killing one occupant, while leaving the other with only scratches. Yet both were exposed to the same vehicle crash forces. If we cannot predict who will live and who will die in those severe crashes, it seems sensible that we also cannot predict which occupants will be injured in less severe crashes. Ultimately, only a trained and qualified doctor, such as the one who gave you this booklet, can determine the extent of your injuries. Whether or not it was likely that you would have been injured becomes a subject for academic debate.
Despite the fact that it is not possible to predict who will be injured in these low speed crashes, research has provided some insight into certain risk factors which, when present, do allow us to better predict outcome in the event of an injury. Such risk factors include rear direction impact, prior neck pain or headaches, prior similar injury, advancing age, having your head turned at the time of impact, being unaware that the crash was about to happen, poor position in the car seat (e.g., being turned or bent forward), poor head restraint position or no restraint, crash speed under 10 mph, collision with a vehicle larger than yours, front seat position, second impacts, using the seat belt and shoulder harness, and being slight of build.
The last two might surprise you. There’s no question, however, that, although seat belts and shoulder harnesses definitely help to prevent serious injury or death in higher speed crashes, they also increase your chances for neck and back injury in lower speed rear impact crashes. Nevertheless, you should always wear your safety belts when driving: Many fatal crashes occur at speeds as low as 25 mph. As for being slight of build, the increased risk results from the higher acceleration that those of slight build are subjected to in crashes (nearly two times as much as heavier persons). Don’t be alarmed if some of these risk factors apply to you. Your chances of a good recovery will be enhanced when you take an active role in your therapy.
Risk for Acute Injury
a) Female gender. ,,,,,,,,,,,
b) History of neck injury.
c) Poor head restraint geometry/tall occupant (e.g. > 80th percentile male). ,
d) Rear impact (vs. other impact vectors). ,,,,,,,,,,,,,,,,
e) Use of seat belt shoulder harness (i.e., standard three-point restraints). ,,,,,,,,,,,,,,
f) Body mass index/head neck index (i.e. decreased risk with increasing mass and neck size). ,
g) Out of position occupant (e.g., leaning forward/slumped) ,,,,,,
h) Non-failure of seat back. , ,
i) Having the head turned at impact.
j) Non-awareness of impending impact. ,,
k) Increasing age (i.e. middle age and beyond). ,,,,
l) Impact by vehicle of greater mass (i.e. >25% greater).,,
m) Crash speed under 10mph.
Risk for Late Whiplash Syndrome
a) Female gender.
b) Body mass index in females only.
c) Immediate/early onset of symptoms (i.e., within 12 hours) and/or severe initial symptoms
d) Ligamentous instability.
e) Initial back pain.
f) Greater subjective cognitive impairment.
g) Greater number of initial symptoms.
h) Use of seat belt/shoulder harness. For neck (not back) pain. (non-use has a protective effect.)
i) Initial physical findings of limited range of motion.
j) Initial neurological symptoms.
k) Past history of neck pain or headache.
l) Initial degenerative changes seen on radiographs.
m) A loss of, or reversal of the cervical lordosis (curve).
n) Increasing age (i.e., middle age and beyond)
o) Front seat position
1. Headache. 82.9%
2. Irritability. 66.7%
3. Insomnia. 63.2%
4. Anxiety. 58.1%
5. Memory problems. 57.3%
6. Other pain 56.4%
7. Concentration problems. 52.1%
8. Depression. 52.1%
9. Dizziness. 41.1%
10. Confusion. 41.1%
11. No control of emotions. 36.8%
12. Loss of libido. 35.0%
13. Tinnitus. 29.1%
14. Can't carry out plans. 29.1%
15. Can't plan. 28.4%
16. Flashbacks. 28.2%
17. Don't enjoy sex. 26.5%
18. Nightmares. 26.5%
19. Arithmetic problems. 17.9%
3. Neck pain.
8. Impaired memory.
9. Easy distractibility.
10. Impaired comprehension.
12. Impaired logical thought.
13. Difficulty with new or abstract concepts.
15. Easy fatigability.
17. Outbursts of anger.
18. Mood swings.
20. Loss of libido.
21. Personality change.
22. Intolerance to alcohol.
Cervical Acceleration/Deceleration Syndrome (CAD Syndrome):
This syndrome is characterized by the following symptoms:
a) Neck pain and stiffness.
b) Shoulder pain.
c) Upper back pain.
d) Suboccipital (or frontal) headache.
e) Diffuse pain and/or paresthesiae in upper extremities.
f) Mild and often non-dermatomal sensory abnormalities in the upper and lower extremities.
g) Scapular and interscapular pain.
h) Development of trigger points in neck/upper back.
i) Lower back pain and sciatica.
The Statistics of Whiplash from Auto Accident
The real numbers are staggering, and underscore the magnitude of this huge public health problem. Each year, about three million people experience whiplash neck and back injury. That’s about half of all who are actually exposed to such crashes. Of these three million people, about 1.5 million will eventually fully recover. About 600,000 will continue to have long-term symptoms, and an additional 150,000 will actually become disabled each year as a result of whiplash injury.
To put it another way, a person in a car that is struck from the rear stands about a 50% chance of being injured. If injured, he stands about a 50% chance of having long-term pain or other complaints. And this tragic human wreckage increases every year, so the number of whiplash chronic pain sufferers is always growing. In fact, our research shows that, today, nearly half (45%) of all Americans with chronic neck pain attribute it to car crashes, with whiplash being the most common form. Whiplash truly has reached epidemic proportions.
I report these figures, of course, at the risk of frightening some injured persons and, according to some of my colleagues, at the risk of causing some patients to develop chronic pain merely out of expectation and fear. Nevertheless, I have always been a firm believer that patients have a right to know the truth about their condition. Doctors who paint unrealistically favorable pictures of outcome or candy coat the truth, in my opinion, provide a disservice to their patients. In fact, patients who harbor overly optimistic expectations about outcome rarely follow their doctor’s advice well. As a result, they frequently are disappointed with their outcome and this may also be cause for some resentment. On the other hand, after many years of specializing in this type of trauma, chiropractic physicians have learned how to treat it successfully, and most haven’t found that being honest with patients has hindered them at all.
Having said all of that, there is some light at the end of the tunnel. For one thing, the statistics I mentioned earlier are for patients treated by all health care providers and, in some cases, by none. Your doctor has the special tools and knowledge needed to provide the best chance that you will recover 100% from your injuries. Moreover, he has probably subscribed to the methods of treatment I have taught for years and may even have been trained by me. And, in a recent study, chiropractic care was shown to be able to cure 94% of chronic whiplash cases that were referred from the offices of several orthopaedic surgeons. Therefore, your risk of poor outcome is probably not as grim as that of a general population of whiplash patients who never see a chiropractic physician.
Why Did You Get Hurt In Your Car Wreck?
The entire phenomenon of whiplash is really a series of examples of the so-called Murphy’s Law, which essentially holds that anything that can go wrong, will go wrong, and at the worst possible moment. In the case of whiplash, there are several places where this occurs. The easiest way to discuss the mechanics of whiplash is to break it into a series of four phases. And, by the way, if this doesn’t interest you, feel free to skip to the next section.
When your car is struck from the rear, it suddenly moves forward underneath you. After all, you’re not physically attached to your car, you are simply sitting in it. An analogy would be a paperweight resting on a piece of paper on your desk. When you pull rapidly on the paper, the paperweight tends to remain in its original position and so moves relative to the paper, not necessarily with it in lock step.
As the car moves forward, the back of the seat strikes you first in your lower back and buttock area. This causes the seat back to bend rearward somewhat and, in some cases, to bend permanently or even break. (If that happens, by the way, make sure you mention it to your doctor.)
As the seat back begins to accelerate your torso forward, your head moves rearward, since nothing strikes it directly and prevents this motion. In actuality, it is really moving forward with respect to the earth, but, since the torso moves forward more violently at first, the head moves backward with respect to the torso. If you have well designed and well positioned head restraints (although few of us do), your head may make early contact with the restraint and this will limit the amount of distance your head can move in the rearward direction. However, most of the damage to the neck and spine occurs so quickly that head restraints have been shown to reduce injuries only in 11-20% of the cases.
During this phase the curves of the spine straighten temporarily, high shear strains develop in the neck and brain stem, and high pressure gradients develop in the brain. See Figure 1.
Figure 1. Phase 1 of the whiplash phenomenon. As the car lunges forward, the occupant is forced rearward into the seat back.
When your body loads the seat back initially, it tends to climb up the seat back a few inches. We refer to this phenomenon as ramping. The straightening of the spinal curves contributes to this vertical rise and results in compression of the spine. In recent crash tests, even at crash speeds of under 10 mph, these two effects, combined, resulted in a vertical motion of the head of up to 3 1/2 inches. The volunteers’ heads moved up and over the head restraint, striking it from the top and driving it down as a hammer drives in a nail. As a result, the head restraint failed to prevent rearward head motion and actually acted as a fulcrum, allowing greater bending of the neck and increasing the risk of injury. See Figure 2.
Figure 2. Phase 2 of the whiplash phenomenon. As the car continues to move forward, the head and neck are forced rearward.
Phase 2 is also where the first two elements of Murphy’s Law enter the picture. Usually, these collisions involve a struck vehicle (yours, perhaps) which is stopped. You have your foot on the brake pedal, exerting just enough brake pedal pressure to prevent the car from rolling forward. When a low speed crash occurs, your body will be thrust about 4-6 inches back into the seat. When this occurs, of course, your foot will be drawn temporarily off the brake. The car will then be free to accelerate unimpeded. If you had a choice at that point, you’d want to prevent forward motion of the car.
Imagine, in contrast, that your car was embedded in solid concrete up to the wheel wells so that it could not move at all. When it was struck from the rear, all that would happen would be some crushing of the rear part of the car. It would not move forward, and you would not be accelerated. You would, thus, not experience any whiplash injury.
The second component of Murphy’s Law comes into play when the seat back, which has been bent back by the weight of your torso moving into it, suddenly releases that stored energy, much like a diving board springs upward after you load it with your weight. Unfortunately, this forward seat back recoil occurs at the very moment that your head is moving backward. This results in a shear force that is directed through the neck and is one of the more damaging aspects of this type of crash. It also propels your torso forward with greater force. At this point we are beginning phase 3.
In this phase your body is moving forward in the seat. Your torso is now descending back down the seat back and your head and neck are at their peak acceleration. Meanwhile, the car’s acceleration is tapering off, although it may continue to roll forward.
The elastic recoil of the seat back continues. The risk of forward motion of the car at this point is that it may strike the car in front of it. This will result in a further abrupt deceleration force, increasing the risk of injury. See Figure 3.
As you recall, the early researchers discovered that the occupant’s head would experience acceleration forces greater than those of the vehicle itself. This is due, in large part, to the diving board-like effect, or springiness, of the seat back. In physics we refer to this as the coefficient of restitution. The car also possesses a degree of springiness, because at low speeds our cars are relatively stiff and resist crush. In fact, most passenger cars on the road today can resist crush damage at crash speeds of 10-15 mph when the two crashing cars are perfectly aligned and the bumper contact is near 100%.
Finally, the combined effects of this vehicle springiness, the elasticity of the human neck, and the rebound of the head, in conjunction with muscular contraction, conspire to produce the higher occupant acceleration forces seen in experimental crashes. Of course, higher acceleration forces generally equate to a greater potential for injury.
Figure 3. Phase 3 of the whiplash phenomenon. Now the occupant is thrown forward at a greater acceleration and velocity than the car itself
During phase 3, you are accelerating forward in the car seat. Since the initial motion (phases 1 and 2) was rearward into the seat back, some slack probably developed in the seat belt and shoulder harness webbing. As your body moves forward now in phase 3, this slack will be drawn up. Slack at this time is a disadvantage, however, because the more forward movement is allowed by this slack, the greater speed you will attain relative to the car. Then, when you reach the extent of that webbing slack in phase 4, your deceleration, or stopping force, will be that much greater (i.e., more abrupt). Again, it helps to use an analogy to appreciate this effect.
If you were suspended in air a few inches above a swing seat in a playground, and suddenly dropped into the seat, the forces on your body would be abrupt, but bearable. On the other hand, if you were suspended a couple of feet above the seat and suddenly dropped into it, the forces would be much more abrupt—and painful! In both cases on the swing, you are actually accelerating (downward) at 1 g (the letter g is actually derived from gravity, and is the acceleration exerted by earth’s gravity: 32.2 ft/sec/see). But, since acceleration describes the rate of change of velocity, it means that the longer you accelerate, the faster you get going. So, in the car seat, it would actually be an advantage to have no slack in the restraint webbing.
In this fourth and final phase, your torso comes into contact with the restraint webbing (seat belt and shoulder harness) and your head’s inertia allows it to move forward unimpeded. This then results in a violent forward bending motion of your neck, which is another one of the potentially injurious forces in whiplash injury. Here is yet another instance of Murphy’s Law: As your body moves forward in the seat, your foot, which initially may have been resting on the brake pedal and come off during phase 1 allowing greater acceleration—is now forced back onto the pedal. This results in a further abrupt deceleration just when you need it least. In other words, it would be best at this point to allow the car to roll forward unimpeded, rather than to reapply the brakes. See Figure 4.
To use our swing set analogy, if the swing was suspended by elastic bungee cords, instead of non-yielding chain, when we plopped into the swing seat, our deceleration would be less abrupt. In the same way, if the car could roll forward unimpeded, our deceleration would likewise be less abrupt. In this phase the occupant experiences high spinal tension and shear, as well as high brain stem, spinal cord, and nerve root tension.
Figure 4. Phase 4 of the whiplash phenomenon. The head and neck continue forward as the torso decelerates against the safety belts.
What Happens To the Head and Spine?
The human brain is a very soft structure, suspended in a fluid called cerebrospinal fluid. When the head is subjected to rapid acceleration, followed by a rapid deceleration (i.e., the quick back and forth movement of the head), pressure gradients develop within the brain which reverse rapidly when the direction of the head reverses. This results in significant mechanical deformation of brain tissue and frequently results in a form of brain injury referred to as mild traumatic brain injury (MTBI). In some cases, patients temporarily lose consciousness and have symptoms of a mild concussion. More often, there is no loss of consciousness, but patients complain of mild confusion or disorientation just after the crash.
Due to the high degree of shear experienced in many cases, the brain stem (the part connecting the brain with the spinal cord) may be injured. See Figure 5.
Figure 5. High pressure gradients develop within the brain during the violent and rapid back and forth motion of the head during whiplash. The brain stem is labeled bs.
The structures of the spine are also frequently injured during the four phases of whiplash. These include the spinal joints (known as facet joints), the discs, ligaments, tendons, and muscles. Spinal cord injury may also occur, as can injury to spinal nerves as they exit from the spine. See Figure 6. We’ll discuss these injuries in more detail later.
In addition to neck pain, about 4000of all whiplash victims will experience back pain following whiplash injury. In fact, our research found that of all Americans with low back pain, 17% of males, and 29% of females attributed it to motor vehicle crashes. While the precise mechanism of this form of injury is less clear, it is likely that it results from the initial loading of the seat back and the subsequent forward bending around the seat belt. Just about all of the typical symptoms experienced by patients after whiplash can be explained by the injury mechanisms mentioned in this section.
Figure 6. This is an illustration of part of the cervical spine (black portion of inset). Part is cut in half for better viewing. This illustrates all of the injuries that have been reported to occur in whiplash trauma. (Naturally, it is unlikely that all will be present in any one person.)
Injuries That Result From Auto Accidents & Whiplash Trauma
There are many reasons why whiplash injuries have gained an ill-deserved reputation in some circles. Perhaps foremost among these is the inability of many physicians to comprehend the nature of the trauma and the resulting soft tissue injuries that result. Another is the adversarial relationship that frequently develops between responsible parties and injured victims. These contentious relationships have, unfortunately, spawned a growing collection of junk science and misleading editorial literature which has served only to confuse the issues further, while providing unjustified fuel for the ongoing controversy.
At the same time, there exists a much larger body of scientific literature which has better defined the true nature and range of these injuries. In fact, I have written entire textbooks on the subject, and they are comprehensively referenced with scientific work. Thus, the controversy is entirely manufactured, and at the expense of the injured victims of whiplash. You can be confident that the facts discussed in this booklet are very well grounded in science.
Brain injury From Auto Accidents/Car Wrecks
Believe it or not, brain injury, usually a minor variety, is rather common following whiplash injury, due to the mechanical deformation of the brain during the four phases mentioned earlier. After the initial injury, a cascade of biochemical reactions continue to injure the brain for up to 96 hours. These involve the formation of oxygen free radicals and other toxic biochemical reactions that are well beyond the scope of this booklet. The result, however, is commonly experienced as mild confusion, difficulty in concentration, sleep disturbances, irritability, forgetfulness, outbursts of anger, mood disorders, loss of libido (sex drive), and other psychological effects which have commonly been used to suggest that the hapless victim is, instead, mentally or psychologically unstable and, therefore, fabricating or imagining most or all of his other symptoms. Unfortunately, this is a common ploy by the defense in cases that are brought to trial.
Studies have also shown that significant pain itself can have a temporary adverse effect on a patient’s psychological and cognitive (i.e., mental) status. There is also a well known association between depression and chronic pain: Persons with chronic pain are much more likely to become depressed.
Cranial nerve injury In addition to the type of brain injury that causes cognitive difficulties, cranial nerves can sometimes be injured. These are nerves that exit directly from the brain. Some are sensory only, such as the 1st cranial nerve which provides the sense of smell. Others are motor, such as the ones that control eye movements. Still others have both sensory and motor function. Together these nerves sense or control vision, taste, hearing, movements of the jaw and tongue, sensation on the head, muscles of facial expression, and certain movements of the shoulders and neck, in addition to the other faculties mentioned. Many complaints are related to injuries to these nerves. Some patients, for example, complain of blurred vision after a whiplash injury. This results from an accommodation error in the eye, which adversely affects pupillary dilation and is manifested as mild visual acuity problems (blurred vision). Many eye doctors do not realize that such problems occur after whiplash and will attempt, instead, to refract these patients i.e., test their vision using conventional ophthalmology/optometry procedures. However, most types of vision impairment that are amenable to refractive correction (near- and farsightedness; astigmatism) are due to actual abnormalities in the shape of the outer portion (cornea) of the eye. Corrective lenses will help these conditions. Accommodation is dependent upon the ability to change the size of the pupil. This takes place inside the eye. Abnormalities in this function are the result of trauma to the nerves controlling the iris. As a result, corrective lenses cannot remedy this type of blurred vision.
Other visual problems are the result of a loss of normal motor control of the eyes. These are usually the result of injury to one of the three cranial nerves controlling eye motion. These injuries can also manifest themselves as blurred vision.
Another type of complaint that is fairly common is dizziness. It is a sense of balance loss and must be distinguished from vertigo, which is a rather more severe motion disorder, although the latter is occasionally seen following whiplash trauma. Usually vertigo is the result of an injury to the inner ear and goes by the name of benign paroxysmal positional vertigo (BPPV). This condition is precipitated by certain motions of the head and generally lasts only 15-20 seconds. There is a simple treatment for this condition which your chiropractic physician can help you with. There are a few other causes of vertigo. Most also involve the inner ear.
Dizziness, on the other hand, often results from injury to the joints of the cervical spine. It may also be the result of brain stem injury or injury to the brain itself. Usually it is short lived and is frequently also amenable to chiropractic treatment. Much work has been done recently in the area of balance disorders resulting from whiplash. These may also be effectively treated by chiropractic care.
The endocrine (hormonal) system may be affected by whiplash injury because the part of the brain that controls part of this system (the hypothalamus and the pituitary gland) may be injured during the rapid acceleration and deceleration of the brain. A colleague and I published some research a few years ago in which we found evidence for an as yet undescribed form of hypothyroidism that is commonly found to develop in the months following whiplash. Since the thyroid gland normally stores enough thyroid hormone to maintain normal endocrine function for about four months, these conditions do not typically show themselves until several months after an injury. As a result, they are not usually attributed to the whiplash injury and are, instead, considered coincidental. And this hypothesis is usually easy to accept because hypothyroidism is a fairly common disorder.
Symptoms include slowness in cognition (mental activity), weight gain, fatigue, intolerance to cold, thickening and edema of skin, puffiness of the hands and face, constipation, drowsiness, personality changes, loss of hair from the eyebrows and scalp, and musculoskeletal pain. Changes in menstrual flow are also common. Menstrual disorders are often seen following whiplash trauma, and appear to have a similar endocrine connection, although the exact mechanism is unclear. Your chiropractic or family physician with a simple blood test can confirm hypothyroidism.
After neck pain, headaches are the most prevalent complaint among those suffering from whiplash injury. While some headaches are actually the result of direct brain injury, most are related to injury of the cervical spine (the part of the spine that runs through the neck) and its connecting structures. Many of the structures that are injured in this part of the spine can cause pain to be referred into the head—a fact that has been confirmed in several experimental studies over the years. As a result, your doctor will treat headaches primarily by treating your neck and back.
While we are still in the head, a less common, but troublesome, disorder that results from whiplash is temporomandibular joint disorder (TMD). It too may cause headaches, and is also associated with pain in and around the jaw joint, just in front of the ear. Clicking and popping noises in this joint are found in about 40-50% of the normal population and, by themselves, are not cause for alarm. However, new noises that arise after whiplash and are associated with jaw joint pain should be evaluated immediately. Many chiropractic physicians are specially trained to treat TMD.
It is the single most common complaint in whiplash trauma, being reported by over 90% of patients. Studies have shown that most of the structures in and around the spine are vulnerable to injury (see Figure 6), and nearly all of them can cause neck pain. Often this pain radiates out across the shoulders, up into the head, and down between the shoulder blades. And, because the nerves that provide motor power (i.e., those that make the muscles move) and convey sensory information (i.e., the sensations of touch, vibration, position sense, and pain) exit from the spine, they may become inflamed, irritated, or compressed by spinal injuries. When this happens, you may experience weakness, clumsiness, tingling or numbness, or pain in your arms, forearms, hands, or fingers.
Low back pain
This is another poorly understood result of whiplash trauma. Many doctors—especially those working on behalf of insurance companies—dismiss it as coincidental to whiplash because they fail to comprehend the causal mechanism. Nevertheless, even the Insurance Research Council reports that it is seen in 39% of cases of whiplash. Most other studies of whiplash patients also report incidences of low back pain of 35-50% or more following whiplash trauma. A colleague and I studied a variety of car crash types and found low back pain in 57% of the rear impact collisions in which injury was reported, and 71% of the side impact crashes. Of interest was the fact that we found fewer neck injuries in the side impact crashes, possibly because these people were more often aware of the impending crash than those in rear impact crashes. Another likely reason for this finding is that, in side impacts, your body will move in a side-to-side direction. This allows the motion of the spine to be more evenly distributed throughout the neck and torso portions of the spine. In rear impact crashes, in contrast, the torso’s motion is limited by the seat back and the shoulder harness, so most of the motion becomes concentrated in the neck portion of the spine.
There are other conditions and symptoms that sometimes result from whiplash injury. We’ve merely discussed the most common of the constellation of symptoms here. You should never assume that any condition is not related to the crash, merely because it develops days, or even weeks later. Always report your new symptoms to your doctor so that he can make the proper assessment of your condition.
What If Your Symptoms Are Delayed?
Actually, we more commonly see delays in the onset of symptoms than an immediate onset of symptoms. This is very well supported in the clinical literature, although the reason for it is not well understood. With most everyday minor bumps and bruises, we expect to have pain as soon as we injure ourselves. When we sprain an ankle, for example, it hurts right away. Why is it then that most victims of whiplash injury experience no immediate pain? The most likely explanation is that it takes the body 24-72 hours to develop inflammation. And, while inflammation has four parts-swelling, redness, heat, and pain for the structures located deep in the neck, pain is usually the only outward sign of inflammation.
Yet, delayed pain is not really so foreign to us. We are all familiar with the delayed inflammation of muscle which results from a bout of strenuous exercise, such as beginning a new workout program at the gym. On the day of the exercise, about the only effect we feel is fatigue after the workout. The next day we might start to feel a little stiffness. By the third day, our muscles are so sore it hurts to move them.
The question of just how long a delay is reasonable is a difficult one. In the case of inflammation secondary to injured tissues in the neck, three days is the most common. On the other hand, disc injuries may be quite occult and may smolder for weeks or months before becoming symptomatic. And subtle joint injuries can gradually alter the normal biomechanics (motion) of the spine over several weeks’, or even months’ time. This too can be a source of neck pain or back pain.