Whiplash Associated Disorders WAD. What a whiplash injury is and what you should do about it

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1 Whiplash Associated Disorders WAD What a whiplash injury is and what you should do about it

2 Page 2 Whiplash Injury What is it and what to do about it? Dr. G. McMorland, DC As a chiropractor in Calgary, I have a lot of people come to see me because they have injured their neck in a car accident. It helps most people if they understand what a whiplash injury is and what can be done to speed their recovery. In this paper, I will try and explain what a whiplash injury is and what you can expect to experience as your body recovers. This includes important things you can do to speed your recovery. What is a Whiplash Injury? This type of injury is most commonly associated in North America with Motor Vehicle Collisions. For example, you might hear someone say he got whiplash when his car was rear-ended by another car. But what does this mean? The term Whiplash can be confusing to most people because it is often used interchangeably to describe both a mechanism of injury and the injury itself. For our purposes, the term Whiplash will be used to describe how the injury occurs (a mechanism of injury). The head is sitting on top of the neck, much like a ball on a stick. When an unexpected, jarring movement occurs, such as when you are hit from behind by another car, the weight of the head causes the neck to snap backwards and forwards. This extreme movement is similar to the lash of a whip and can result in damage to the bones and soft tissues of the neck, which can be quite painful. Although most often associated with motor vehicle collisions, this type of movement and injury can occur in work injuries or sports injuries. Key Point The Term Whiplash refers to how the injury occurs! What is WAD and why do people keep telling me I ve got it? The health care community and insurance industry uses the term "Whiplash Associated Disorders" or WAD to describe the actual injuries that occur as a result of the whiplash movement.

3 Page 3 This is important to understand, because you will likely hear the term WAD if you are talking to a healthcare professional or your insurance company. "My Chiropractor tells me I have a WAD 2 injury I hope it isn t contagious!" WAD injuries are divided into four different categories depending on the severity of the symptoms you are experiencing. The idea for grading the severity of the injury came from the sport medicine community. The nature and severity of the injury will determine the most appropriate type of treatment. This grading also allows us to predict how long it will take to get better and what you can expect to experience. That way, you won t be surprised by things and can make plans for getting back to your normal activities. To illustrate this grading system, we are going to use an injury that hopefully, most of us are familiar with an ankle sprain. If you were walking along and went over on your ankle, the degree of your sprain would be classified as follows: Ankle Sprain Grade 1 Mild Sprain This means that the tissues were overstretched but no tearing occurred. This would mean there is no bruising and only slight swelling. There may be localized tenderness usually on the outside of the ankle. You likely wouldn t need to favor the ankle but may have a mild limp for a few days after the injury. Although uncomfortable, you can raise up on toes slowly. Grade 2 Moderate Sprain This means that the tissues were overstretched and there was a partial tear. There would probably be bruising on one side of the foot, usually on the outside of the ankle. You would see more extensive swelling. If you feel the ankle, there would be more severe tenderness, which may occur on both sides of the ankle. You would probably have to favor the ankle because of pain. You would likely have a noticeable limp for a week or two, and may find it difficult to go up on your toes, hop or run. You would experience pain with most movements, especially when turning the ankle inwards. Grade 3 Severe Sprain This means the tissues were overstretched to a point where some, if not all of the ligaments were torn completely. You would see diffuse bruising and swelling on both sides of foot. If you feel the ankle, tenderness would be found generally, rather than in just a few, specific spots (likely on both sides of the foot as well as in the front and back). You would be unable to stand on the foot (weight bear) and would experience almost a complete loss of movement.

4 Page 4 WAD Classification Grade 0: This means you have no complaints about the neck and there are no physical signs on an examination. Grade1: You experience neck pain, stiffness, or tenderness only, however there are no objective physical signs on examination. Grade 2: You experience neck pain, stiffness or tenderness and there are objective signs of injury on examination. An example of an objective sign on examination would be reduced range of motion of the neck. Grade 3: You experience neck pain, stiffness or tenderness, there are objective signs of neck injury on examination as well as objective signs of nerve injury. Examples of objective signs of nerve injury on examination would be reduced sensation in a part of your arm or hand (e.g. you can't feel the prick of a pin along the top of the forearm), weakness in specific muscles of the arm or hand or a reduced or absent reflex. Grade 4: You experience neck pain, stiffness or tenderness and have suffered a fracture of the neck or dislocation of one or more of the joints in the neck. In addition to neck complaints, you may experience other symptoms and disorders including deafness, dizziness, headache, memory loss, dysphagia (difficulty swallowing), and TMJ (Temporomandibular joint or Jaw joint) pain.

5 Page 5 WAD's all the fuss about? OK, so now you know how we diagnose or classify whiplash injuries...so what? It is Key Point important for you to WAD is the nature and understand this part, extent of the injury you because once you know have! what type of injury you have, you will then be able to better understand treatment recommendations as well as know what to expect as your body heals. OK, I have WAD What should I do? While it is important to know and understand what you have, it is probably more important to know what to do about it. There are a few things you can do that, if done properly, will speed your recovery and minimize the chances of your injuries going on to cause chronic problems. Phases of healing Sport Medicine research has shown us that the body heals in a very specific fashion. The timeline of this healing is broken down into three phases. Phase 1: Inflammation. This occurs from when the injury occurs up to 72 hours. It is characterized by pain and swelling in the damaged areas. Phase 2: Repair. This begins approximately 72 hours after the original injury and, depending on the nature and severity of the injury, can extend over the next 8 to 12 weeks. The body removing the damaged tissue and replacing it with new tissue, typically in the form of scar characterizes this stage. Phase 3: Remodeling. This generally begins approximately 8 to 12 weeks after the original injury and can continue on for months, or even years. During this phase, the body reorganizes the newly formed tissue (scar) to better cope with the stress and strain it undergoes.

6 Page 6 Knowing what stage of healing you are in as well as what to do in each stage will help your recovery. Phase 1 Reassurance First and foremost, if you have suffered a whiplash injury because of something like a car accident or sports injury, it is important not to worry. The health care community has spent considerable time and effort studying this problem and understands it quite well. This research has shown that the vast majority of whiplash injuries, while quite painful and debilitating in the early stages, are not serious. Our bodies have an amazing ability to heal themselves, so given the appropriate management and treatment, the vast majority of these injuries recover fully and you are able to get back to all of your normal activities. When I say don't worry, it does not mean you should ignore or minimize your injury. Quite the opposite, it is important, no matter how minor you may think your injury is, that you be evaluated by a properly trained health professional such as a chiropractor, physiotherapist or medical doctor. Get checked It is very important you be checked as soon as possible after your injury. The research is quite clear that the earlier in the injury process you can be evaluated and started on appropriate management or treatment, the better the outcome. One of the biggest mistakes we consistently see is people ignoring their problem for a week or two after the injury, hoping the pain will go away on its own. We find that the longer people wait to seek attention, the harder it is to help them get out of pain and get going again. I practice in Calgary, Alberta and if you have been injured in a car accident, this province's insurance industry has changed its processes to encourage you to get in early to be evaluated. In order to claim any treatment costs under your car insurance benefits, they generally need you to be checked by a chiropractor, physiotherapist or a medical doctor within 10 days of the injury. If you live somewhere other than Alberta and are reading this, then I suggest you check with either your health care provider or your insurance agent (claims manager) to get advice on what you should do. This is especially true if you felt pain or symptoms immediately following the injury. You should also monitor your condition over the next few days to see if you begin developing any nerve-type symptoms such as numbness or weakness in the extremities. These could be signs of a more serious injury that needs to be properly evaluated. While it may seem like common sense, it bears saying that if you experienced any cuts or are bleeding, you will require immediate medical attention. Also, if you have hit your head in the accident, you need to evaluated for concussion. This is especially true if you experienced a loss of consciousness. Typically, if this has occurred, EMS (Emergency Medical Services) that

7 Page 7 attends the scene of the accident will evaluate you there and determine if you need to be transported to the emergency department. Sometimes, EMS doesn't attend the scene so you will have to self-evaluate your condition. If you have hit your head, you will also need to monitor you symptoms over the next few hours for symptoms of a more serious injury. Things to watch for include: 1. Severe and progressive headache 2. Dizziness 3. Blurred vision 4. Slurred speech If you experience any of this, you require immediate medical attention. Minimize or control inflammation Sport Medicine research has identified how the body heals any tissues that have been injured. Phase 1 of healing is predominated by inflammation (swelling) of the injured area. Depending on the severity of the injury, the swelling and bruising that occurs as a result of the damage to the tissues peaks within the first 72 hours of the injury. The more you can do in these first few days to minimize and control this inflammation, the better you will recover. A few tips to help with this include: 1. Ice. Cooling the area with ice reduces the pain and inflammation. A good rule of thumb is to lay down with an ice pack on the back of your neck, extending from your head down to between your shoulder blades. You should have the ice on for 15 minutes and repeat this process every two to three hours. I have found the Gel packs you can keep in your freezer most effective for this, because they are moldable to your neck and will stay cold long enough to be effective. Make sure you have a towel or cloth between the ice pack and your skin so you don't frostbite the skin. 2. Rest. In the early stages, it is helpful to unload the injured and painful structures. This means lay down to get the weight off your neck. Your head weighs at least 10 pounds so gravity will strain your neck if it has to work to hold up your head. Sitting won't rest your neck. You need to lie down. As mentioned in point #1, combining the rest with icing is most effective. 3. Medication. You need to be careful taking any kind of medication because of potential negative side effects. Either you doctor or a pharmacist is a good resource to ask about what kind of medication may be helpful. Over-the-counter NSAID's (Non-Steroidal Anti-inflammatories) such as Advil, Motrin (which contain an anti-inflammatory ingredient called Ibuprofen) or Tylenol (which contains a pain relieving ingredient called acetaminophen), can help with pain and inflammation control. Stronger medication requires a prescription from your doctor. 4. Soft collars. We don't usually recommend the use of soft collars any more because research has shown that prolonged immobilization of the neck can lead to chronic problems. For more severe injuries, a soft collar may be permitted for the first 72 hours to help offload the painful structures. You need to discuss this with

8 Page 8 Phase 2 either your chiropractor, physiotherapist or medical doctor prior to wearing one. Modern treatments rarely use collars on a prolonged basis. Restore normal function and mobility Phase 2 of healing begins within 3 or 4 days of the injury. The body's natural repair mechanisms remove the damaged tissue and replace it with new tissue. Depending on the nature and severity of the injury, this process can take 8 to 12 weeks. There are some important things to do during this part to ensure things heal properly. Effective management strategies in this phase include: 1. Self-help advice and instruction. Your health care provider can customize pain management strategies as well as activity modification advice so you can do things yourself to help you recover quickly. 2. Hands-on treatment may be required to reduce pain and restore mobility. 3. Active rehabilitation. This includes resuming your normal activities as well as specific stretching and strengthening exercises you may need to rebuild the flexibility and strength of the injured area. Chiropractors and Physiotherapists have the expertise to guide you through this. Phase 3 Phase 3 of healing involves remodeling of the tissue. Once the damaged tissue has been repaired, the body continues to reorganize it to better deal with the stresses and strains the injured area needs to cope with. This generally begins 8 to 12 weeks after the original injury and can go on for months or even years. Whether or not you have had appropriate treatment, you may continue to experience neck pain, back pain or headaches months after your original whiplash injury. This may be normal as your body continues to heal, however there are a few things you should watch for to know if you may benefit from more advanced treatment options. Depending on the severity of the injury, the damaged tissues can take 8-12 weeks to fully repair. This doesn't mean that your neck pain is gone, however. Research has shown that 59% of Whiplash Associated Disorder (WAD) injuries remain symptomatic 6 months after the injury % continue to experience pain up to 2 years and approximately 10% go on to experience pain and symptoms for the rest of their life. So what, if anything, should you do if you are still experiencing neck pain, headaches or other symptoms 3 months after the original whiplash injury? Normal recovery The first approach is to determine if the symptoms you are experiencing are normal considering the nature and extent of the injury you had. Consultation with your health care provider should help you sort this out. Should this be the case, you may just need more time to finish recovering. The emphasis of any treatment you may still be receiving should be on active rehabilitation (i.e. exercise and resuming your normal activities). You

9 Page 9 may still need some hands-on treatment for pain control. This type of treatment is referred to as passive care, and includes things such as joint manipulation, soft tissue treatments such as massage, and trigger point injections. This type of treatment should be minimized at this stage. If you find you are still dependent on going for this type of treatment two or three times per week, then it may be time to seek another opinion to ensure there isn't anything missing from your care. Facet joints The general consensus in the literature is that the most likely culprit for causing ongoing neck pain following whiplash injuries are the facet ("Fah - set") joints. These are tiny joints located in the back part of each vertebrae that connect one vertebrae to the other. These joints are damaged from the extreme movements that happen during a whiplash injury. While the ligaments that hold the joints together may repair themselves, there is some evidence that injury to the cartilage that lines the joint surfaces, or even the bone surfaces just underneath the cartilage could have been injured and are the source for ongoing pain. In situations like this, treatments such as facet joint injections or even ablations may be considered to help relieve your pain. These treatments are obviously more invasive and should therefore only be considered if your condition hasn't responded to the normal treatments such as chiropractic, physiotherapy, massage therapy and active rehabilitation. Muscles Chronic shortening of the muscles can be another cause of ongoing pain. These tight, short muscles may also have developed trigger points in them. Trigger points are local, painful areas within the muscle, which also can refer pain to other parts of the body such as the head, jaw or shoulders. Effective treatments for chronically shortened muscles include Massage Therapy, Intramuscular Stimulation or IMS or trigger point injections. Remember, however, these are passive treatments, meaning the treatment is done to you. You don't have to do anything active, which we know, on their own, won't give you longterm relief. The key is to work with your health care provider to use treatments such as these judiciously to relieve your pain enough so that you are able to actively stretch and rebuild the strength of the injured area. Common sense tells us that it is much easier to do appropriate activity and exercise if the area isn't painful. Active rehabilitation One of the most common, but often overlooked causes of recurring trigger points in the muscles causing ongoing neck pain is weakness. It is a catch-22 because the pain has caused your body not to use the neck muscles properly. Because the body is "use it or lose it", weakness or disuse atrophy occurs. Most active exercise regimes involve strengthening of the upper body and shoulders but may overlook the neck itself. The structures in the neck are somewhat delicate, requiring a specific, targeted rehabilitation program in order to regain their function. A very successful active rehabilitation program that was pioneered in Melbourne Australia uses sophisticated computer-based technology to measure whether your neck is weak and then acts like a gym workout for your neck.

10 Page 10 Their research has shown that this supervised, strengthening program using the multicervical unit (MCU) offers significant relief for chronic neck pain. Take home message Normally, following a whiplash injury, the damaged tissues have repaired themselves within 8-12 weeks of the injury. If you continue to experience neck pain, headaches or other symptoms beyond the 3-month point, it may be part of the normal recovery time depending on the nature and extent of your injury. The focus of the treatment in this case should be on active rehabilitation rather than being dependant on passive treatments. In a smaller percentage of the cases, however, ongoing pain and symptoms could indicate that your problem requires more advanced treatment. Key Point Ongoing pain 3 months after the injury may be normal, however any ongoing treatment should largely consist of active rehabilitation!

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