Whiplash is a modern problem. Whiplash is also a very misunderstood problem. It comes in many forms and becomes a long-term condition if not treated correctly. After being evaluated by a physician, massage and bodywork is one of the most recruited modalities to help this soft tissue injury heal. When applied carefully and skillfully, massage therapy for whiplash can help clients find relief and prevent or begin reversing chronic pain. The information below will hopefully clear up some long-held confusion about living with whiplash and how to treat it.

Understanding Whiplash

Whiplash injuries are basically simple. During a collision (vehicle, contact sport, a bad fall), the head and torso are thrust in opposite directions in a very short period of time. The neck itself makes a whip-like motion bending first towards and then away from the point of impact. An S-shaped curve forms during the early phase of impact where the upper cervical spine flexes as the lower cervical spine extends. The most abnormal motion happens at the C4-C6 spinal segments and damages the longus colli and sternocleidomastoid muscles (muscles used to tilt the head or turn from side-to-side). Therefore, it is not surprising that most of the symptoms of whiplash center in that part of the body between the head and the torso – the neck – but can radiate into other areas forming long-lasting and highly uncomfortable issues if left untreated.

Aside from nasty spills and participating in contact sports, most people experiencing whiplash do so during motor vehicle accidents. Nearly one-third of accidents are rear-end collisions, and it is this type that is responsible for most whiplash injuries. The pain may or may not be felt immediately after impact and could take up to two or three days. Researchers show a 97% rate of neck pain after whiplash injury in chronic patients, onset of neck pain occurring in 65% of patients within six hours, within 24 hours in an additional 28%, and within 72 hours in the remaining 7%. Ben Benjamin, Ph.D., a massage therapist who holds a doctorate in education and sports medicine, explains that this delayed onset is because it takes time for scar tissue to manifest in the sprained or strained muscles and ligaments. And because scar tissue is more adhesive than regular tissue, people experience it as stiffness in the injured areas.

Symptoms of Whiplash

The number one symptom of whiplash, of course, is neck pain. Headaches are the second most common symptom and result from slowed circulation to the head caused by the swelling in the injury. The head generally possesses about 10 lbs of inertial mass. Compressive G forces can range from 1.0g to 1.5g in collisions at just 4-5 mph. When adding the weight of the head already exerting a 10 lb. force, this very low-speed collision could result in possible loads of 20-25 lbs. Additionally, many patients with whiplash injury are taking medications for pain. Ironically, overuse of analgesics for pain are a well-documented source of headaches. Chronic headaches, if left untreated, are unlikely to go away on their own, as some patients still have symptoms many years after the injury. Massage therapy (soft tissue manipulation and trigger point work) for whiplash can immediately work to reverse and unlock this pain pattern in muscles.

Additional symptoms of whiplash can include the following:

• Tightness, stiffness and soreness in your neck
• Swelling, bruising, redness and/or tenderness
• Pain in the shoulder or between the shoulder blades (sometimes called “coat hanger pain”)
• Low back pain
• Pain or numbness in the arms or extremities
• Discomfort or stiffness in the chest
• Dizziness and pain when moving your head
• Hoarseness and difficulty swallowing and/or chewing
• Paresthesia
• Headache, ringing in the ears, blurry eyesight
• Trouble sleeping, concentrating, or carrying out everyday activities

The Québec Task Force came up with a classification for whiplash, used as a tool for determining the severity of acute or chronic symptoms:

GRADE 0: No whiplash. No complaints about neck, no physical signs.

GRADE 1: Neck complaint of pain, stiffness and tenderness only, no physical (musculoskeletal or neurological) signs.

GRADE 2: Neck complaint of pain, stiffness, tenderness. Musculoskeletal signs of decreased ROM and point tenderness. Injury to muscles, tendons, ligaments and joint capsule serious enough to cause muscles spasm.

GRADE 3: Neck complaint of pain, spasm, stiffness and tenderness. Neurological signs including decrease deep tendon reflexes, weakness, sensory defect. Injury to Nervous system is due to mechanical injury or secondary to inflammation.

GRADE 4: Neck complaint with fracture and dislocation.

Other symptoms that can appear in any of the above grades:
Deafness, dizziness, dysphagia, headache, memory loss, TMJ pain, tinnitus

General Stages of Whiplash (Does not apply to some clients):

Acute: 1-2 weeks
Early sub-acute: 3-4 weeks
Late sub-acute: 4-5 weeks
Chronic: 6+ weeks

A Pattern of Chronic Whiplash

Experiencing the trauma of any accident or impact creating a whiplash injury is a frustrating process usually creating unnecessary stress from the following sequence of events:

1. A whiplash accident occurs with soft-tissue injury.
2. Patient is thrust into confrontations with the insurance company.
3. Physicians, relying on x-rays and MRI’s that do not point out myofascial injuries, discharge the patient as “normal”.
4. Stress from interactions with the insurance company exacerbates the pain symptoms,
5. Resulting in chronic physical and psychological symptoms.
6. Friends, co-workers, or relatives may have a difficult time understanding why the pain hasn’t “gone away on its own” and think the patient is “making it up.”

As an aside, recent studies now show that it is very difficult for an ingenuine person to fake a profile typical of a whiplash patient and that financial compensation does not effect a cure and that despite settlement, a substantial proportion of patients suffers persistent pain and distress.

So Why Doesn’t Whiplash Go Away On Its Own?

Many people walk around every day with whiplash symptoms and don’t realize it. They may simply associate their pain with “that’s just life” or “my bed is getting old”. Middle-aged adults who played contact sports in high school fall into this category. Some people experienced bad accidents in their youth but shrugged it off, not realizing that some of the chronic pain experienced into adulthood stems from these experiences. Whiplash injuries can have both a short and long-term impact on the accident victim. The first concerns involve the mechanical injury to the muscle, bone, ligament, nerve, and tendon tissue and the resulting pain, inflammation, and muscle guarding. Management of inflammation and pain is the main focus for mainstream medicine. Most attending physicians will prescribe anti-inflammatory, pain-killer, and muscle relaxant medications and send the patient on their way. The long-term concern is the effect of the neuromuscular guarding that can become neurologically habitual, causing health and postural problems years after the date of injury.

An example often used to illustrate these kinds of neurological habits is the act of “grocery getting.” Have you ever walked around with an arm load of heavy groceries for 20 minutes or so, and after you set it down you can not quite straighten your arm out? This phenomenon is known as temporary sensory-motor amnesia (coined by Thomas Hanna). The cerebellum temporarily recalibrates the range of motion (ROM) based upon the range used while loaded. If you do nothing you will regain your normal range of motion after a few moments because it is temporary. If you contract muscles for hours a day in a limited ROM the cerebellum will eventually recalibrate and make this the new default ROM leading to permanent limitations.

It is necessary to extend this understanding to severe spinal pain centered in the neck. Head forward posture due to muscle guarding after sustaining a whiplash injury is extremely common, if not the rule. It has an immediate negative effect on posture and the efficiency of musculoskeletal balance. If the guarding muscles are not addressed in treatment the effect of the neurological habits may well be life-long establishing permanent sensory-motor amnesia.

The longer one ignores the dysfunctional neurological habits, the more pervasive they become. Over time the compromised structures involved can actually change the shape of bones and discs. Most conditions involving disc degeneration, and arthritis, are sites of earlier trauma. The effect of the permanent increase in muscle tension from unrelenting muscle guarding reduces the range of motion and tissue health over time eventually leading to degenerative disc disease, stenosis, and even spinal fusion.

Untreated whiplash injuries can lead to: Cervical Spondylosis and premature Degenerative Disc Disease (even five years post injury), disc herniation (primarily C4-C6), Thoracic Outlet Syndrome (happening 67% of the time on the same side as the seatbelt shoulder strap), TMJ Disorder, Carpal Tunnel Syndrome (from gripping the steering wheel, bracing the hands on the dashboard during the collision, or injury during airbag deployment), Horner’s Syndrome (blurred vision or other visceral disturbances), dysphagia (difficulty swallowing), dizziness and vertigo, insomnia, and chronic headaches.

Ironically, research consistently shows that women are at a higher risk of developing chronic whiplash pain than men, possibly due to differences in anatomy or seating position.

The Anatomy of a Motor Vehicle Accident

According to researchers, the less a car is damaged or crushed in a collision, the higher the acceleration of the struck vehicle and the greater the risk of injury. Engineering tests show that an occupant in a low-speed collision with no damage to the vehicle may be at a significantly higher risk of injury than an occupant in a collision with a damaged vehicle. The collision scenario posing the highest risk of whiplash injury is when the vehicle is hit at an angle and the occupant is unaware as the collision takes place.

Anatomy of a Car

Many improvements have been made to cars within our lifetime and since nothing is “perfect”, let’s look at the key areas of injury within a car.

1. 90% of head restraints are adjusted improperly. Head restraints are mistakenly thought of as “head rests.” The restraint should be positioned so that the back of the head touches it. Another common problem is that seats in cars are set back at an angle and many people drive leaning forward. In this situation, the head can fully hyperextend, even with a head restraint. But, the question is: If all modern passenger cars are required to have head restraints, and head restraints protect occupants from whiplash injuries, why do we still have so many whiplash cases? The answer is simple: head restraints are not designed to offer the best protection. Volvo researchers are working on this problem, and focusing on the entire seat/head restraint/shoulder belt structure itself to reduce the risk of injury.
2. We all know the law: Buckle Up! Literature is quite clear that seatbelts lower serious injuries and fatalities from high-speed, frontal collisions. It is also clear that seatbelts increase the risk of cervical spine injury in rear-end collisions. A dirty little secret nobody wants to talk about. Injured areas include: breast area and fat necrosis, heart and sternal injuries, thyroid injury, laryngeal trauma, carotid artery injury. An advanced massage therapist treating whiplash will assess the myofascial areas involved to provide a complete and thorough recovery process, along with the neck muscles.
3. Airbags were developed to save lives, and, like seatbelts, in serious head-on collisions they do so. The types of injuries that can be caused by airbags become obvious when we look at the force with which the airbags open. The velocity of deployment averages 144 mph with maximum velocities of 211 mph reported (velocities of the airbag itself, irrespective of the severity of the collision). Injuries sustained include: from the module cover itself, occurring primarily in shorter drivers sitting closer to the steering wheel; injuries from the force of the airbag itself including eye injuries, broken arms, and facial injuries; and lastly, a link has been found between airbag deployment and TMJ injuries and pain.
4. Anti-Lock Brakes are significantly less likely to rear-end another car. However, cars with ABS are 30% more likely to be rear-ended themselves.

Treating Whiplash: Speed Up the Healing Time

Healthcare professionals now say the best way to treat early whiplash pain is mobilization, not rest or a cervical collar. It is important to wait a few days after the accident to seek treatment. This allows the initial scar tissue to knit, which is an important part of the healing process. If there is a chance of a fracture, a concussion, any disc problem or other serious injury, the client should make sure to see a physician first. Myofascial damage is by far the most common source of neck pain in whiplash injuries. Therefore, a multidisciplinary approach is often the best and safest way to treat whiplash. With direct soft-tissue manipulation, massage therapy provides a quicker recovery process, avoiding a lifelong pattern of pain. Chiropractic treatment shows effectiveness in treating acute neck pain.

A client who has neck pain following a motor vehicle accident must first be seen by a physician to rule out serious injury. In addition to soft tissue damage, doctors must determine if the whiplash has caused a concussion or nerve-root compression. Once massage therapy is deemed safe, bodyworkers must assess the injured musculature involved to formulate a treatment plan. In addition to taking a detailed history of the accident, muscle resistance testing can help the bodyworker pinpoint the muscles most in need of release. Massage therapy is one of the most effective therapies for releasing muscle tension and restoring balance to the musculoskeletal system. Massage therapy can help relax the muscles, increase and maintain range of motion, decrease stress and tension, increase circulation, and prevent and breakdown scar tissue formation.

Myofascial Release
Myofascial release techniques can free restricted neck muscle and fascia to help restore fluidity, thus relieving the stiffness of whiplash. Additionally, myofascial unwinding can unlock dysfunctional fascial holding patterns established at the time of injury.

Static Compression
Applying static compression to affected trigger points creates an influx of oxygen that relaxes the contracted musculature. Since myofascial trigger points often develop in the cervical muscles following a whiplash injury, this treatment prevents prolonged muscular dysfunction that can linger for months or years after the initial trauma.

Deep Tissue Massage
Once the superficial muscles relax, deep tissue work can liberate contracted deep fascia, adhesions and scar tissue. Making sure to stay within the client’s pain tolerance level, deep tissue massage can free tissue that had tightened around local nerves.

The goal is to get the patient to a pain-free state and moving normally again. The sooner the fascial treatment begins – that is, before chronic changes occur – the better. However, if treatment begins years later, massage therapy can still help the body heal the “memory of injury.”

Whiplash is traumatic and should be addressed soon after the injury to avoid any chronic problems. In the end, chiropractic manipulation and massage therapy are simply more effective than medical treatment in speeding up recovery, increasing quality of sleep, reducing the amount of sick leave needed after the incident, and relieving post-accident anxiety.

Certified in whiplash recovery through NMT Midwest, I also work directly with clients and the auto insurance companies to determine if treatment is covered under the driver’s policy. If so, I handle the medical billing as well so reimbursement can be sought.

See you on the table!

References:

The Complete Guide to Whiplash, Michael R. Melton, Body-Mind Publications, 1998

http://www.massagetherapy.com/articles/index.php/article_id/1107, Whiplash – How to Heal a Pain in the Neck, Hope Bentley, Associated Bodywork and Massage Professionals, 2008

http://www.integrative-healthcare.org/mt/archives/2008/09/a_whiplash_guid.html, A Whiplash Guide For Massage Therapists, Nicole Cutler, L.Ac., Institute for Integrated Healthcare Studies, September 23, 2008

http://www.massagetherapyreference.com/whiplash-massage/, A Massage Therapist’s Quick Reference Guide

http://www.bothellintegratedhealth.com/massage-for-whiplash/, Massage for Whiplash: A primer for Physicians, Therapists, and Medically Savvy Patients, BJ Erkan, Bothell Integrated Health LLC