• Whiplash as a total-body injury

THERESA A. CISLER, DO

In our highly active society, indi­ speed capability increases, and competent drivers viduals and groups push their physical lim­ interact with noncompetent ones, the incidence of its. Consequently, the incidence of whiplash trauma to the neck and spine sharply increases. injury is increasing. Patients may not recov­ Similarly, with participants in various sports are­ er rapidly or fully from a whiplash injury, nas becoming more physical, whiplash injuries thus leading to chronic neck and spinal symp­ abound. Basketball, for example, once was a min­ toms and litigation. Physicians must recog­ imally physical game. But today, basketball play­ nize whiplash injury as a manifestation of ers-like so many participants in other sports----com­ total-body trauma and treat accordingly, pete so much more aggressively. with particular emphasis on alleviating abnor­ Even in the noncompetitive realm, individuals mal tension of the fascia. Precise descrip­ are physically pressing themselves to the point of tion of the accident, followed by healing injury. Runners stumble, mountain climbers slip, methods tailored to well-defined bodily injury, bicyclists suddenly jam on brakes, swimmers hit aids in effective management. Whiplash injury waves, divers attempt shallow or high dives. All are poses a challenge to the osteopathic physician thereby susceptible to injury. to sharpen skills in defining the injury based As Magoun1 illustrates, the traditional birth on the details of the accident and to incor­ experience itself whereby a delivery attendant porate myofascial release treatment into tra­ spanks the neonate's delicate body while held ditional modes of whiplash treatment. For­ upsidedown can result in whiplash injury. Just tunately, many highly respected osteopathic routine, everyday actions like missing a step or physicians have written extensively on the bumping the head into a wall in the dark can subject and the tools are at hand to refine cause injury. Amusement park rides can stretch treatment for both acute and chronic whiplash. the neck to its limits in all directions, as can speed­ (Key words: Whiplash, hyperllexion, lesion, boating, sailing, and bungee-jumping. So innu­ myofascial strain, myofascial release, super­ merable are the sources of injury throughout life ficial fascia, total-body trauma, total-body that every person is vulnerable to neck injury at treatment, litigation, accident description, any time. impacted regions, linguistic problems) Obviously, the occasions for injury are many and the osteopathic physician must be prepared One of the most difficult injuries the osteo­ to deal with injury from an unlimited number of pathic physician encounters with ever-increasing accident situations. It is essential that the prac­ frequency is the condition generally referred to as titioner define both the exact forceful sources of injury "whiplash." Classically, whiplash, or cervical neck as well as design the precise nature and extent of sprain, occurs secondary to a rear-end collision in treatment modes necessary to alleviate or elimi­ which the occupants of a vehicle experience unex­ nate (or both) the discomfort and pain of such pected hyperextension followed by hyperflexion injury. overload to the cervical spine. Diagnosis and treatment Occasions for injury Unfortunately, the litigious climate of our society As highways become more congested, vehicular has made diagnosis and treatment, particularly Correspondence to Theresa A. Cisler, DO, 4002 E Grant Rd, Suite of vehicle-related whiplash injuries, even more D, Tucson, AZ 85712. difficult. Lawyers specializing in accident cases

Clinical practice • Cisler JAOA· Vol 94 • No 2 · February 1994· 145 hark their services on public media, and so encour­ Further diagnostic exploration becomes essen­ age many people who might ordinarily not do so tial in this difficult group of patients whose dis­ to cry, ''Whiplash'' on sustaining a hard jolt whether comfort continues regardless of the intensity and or not they are seriously injured. long-term duration of traditional treatment regimens. The usual lesion is cervical disc protrusion The practitioner must readily recognize and deal with progressive pain and aching from dural with those few patients who may not authentical­ stretch. When there is neurologic involvement, ly want to recover, such as the patient who is com­ the patient complains of neck pain, referred to fortable with a legal compensation arrangement. It the medial scapular border, with varying degrees may be helpful to refer such patients to a suitable of radiation to the arm with possible numbness and other source of assistance or alternative mode of upper extremity muscle weakness. However, the therapy. However, for the majority of patients with same injury may simply stretch the posterior and long-term whiplash injury, the frustrated practi­ anterior neck muscles, causing similar pain and tioner may wish to consider treatment that address­ radiation. es the whole body that has been victimized by Conservative treatment modalities are well trauma to just one region. known to practitioners,2 and are outlined in any In regard to whiplash incurred in accidents, number of osteopathic medical texts. Harakal,3 Carroll and associates6 caution against two dan­ for example, discusses the use of cervical spine gers. One, it should not be assumed that litiga­ traction with manipulation. He details the neces­ tion is a great motivating factor in patients hav­ sity of highly specific evaluation of the patient's ing whiplash. Their research indicates that only 5% injuries and recommends treatment techniques of such injuries remain chronic, whereas healing based exactly on that evaluation. He advocates occurs in the other 95% within 1 year. They also such treatment modalities as (1) osteopathic manip­ found that healing occurs at a specified pace regard­ ulative treatment (OMT); (2) heat and cold appli­ less of any pending legal actions. Second, they cations; (3) muscle relaxants; and (4) spinal trac­ caution practitioners against playing an iatrogenic tion as the core of treatment. These measures may role in such treatments. Whiplash, as these then be supplemented with "force and fluid man­ researchers indicate, may predispose to degener­ agement techniques," treatment of myofascial trig­ ative arthritis. Nevertheless, the practitioner should ger points with ice massage, acupuncture, ultra­ aim to make the patient as free of symptoms and sound and vitamin therapy, and the use of various as independent of treatment as soon as possible. types of neck collars. Heilig4 designed a "man­ How is this goal accomplished? agement of injury approach" focused on treatment methods administered in three stages, namely, Total-body approach the first 5-day period, the following 3-week stage, The physician must first assume that whiplash is and then the long-term, ongoing, treatment peri­ not an injury isolated to one region of the body. od. He, too, emphasizes traditional treatment Therefore, isolating certain tissues or regions for modes, including bed rest, OMT, medication, and treatment may be too confining an approach. In addi­ physical therapeutic adjuncts, such as ice wraps and tion to nerves, discs, and bones, the osteopathic ethyl chloride sprays. physician will be dealing with myofascial strains Osteopathic physicians know and apply such via the fascial continuity of the entire body, includ­ treatment methods. Nevertheless, despite their ing the dura matter-as the connective tissue spe­ meticulous adherence to such traditional applica­ cialist-surrounding the central nervous system. tions, there continues to exist a group of patients Fascia tenses under the influence of muscle action. who manifest symptoms of cervical pain and dis­ Under abnormal physical conditions common to comfort well beyond 6 months or even several years. whiplash injuries, the fascia itself can thicken and These patients continue to have pain unconfirmed shorten, causing painful symptoms. by neurologic evidence or objective x-ray findings. Superficial fascia, as Becker7 indicates, hous­ In 1977, Hoppenfeld,5 stated, "The practitioner es Pacinian corpuscles, which can receive deep should have confidence, despite the patient pressure, pressure of forces applied to the body surface. In spe­ to continue conservative (non-operative) therapy, know­ cific regions, where fascial tension is great due to ing that the patient may have permanent soft tis­ associated muscular attachments or closely relat­ sue injury, not involving the anterior primary nerve ed articulations, skeletal disorders are likely to be roots or the intervertebral cervical discs." Such an the site of a marked, burning type of pain in local­ attitude is a difficult one to maintain today. ized fascia.

146 • JAOA • Vol 94 • No 2 • February 1994 Clinical practice • Cisler Abnormal tension of fascia may have sev­ tion of the accident as possible is vital to such a eral causes, namely: determination. • faulty muscle activity; Following is a brief description of an acci­ • alternation in position for relationship of bones; dent situation containing possible points of tis­ • change in visceral position; and sue trauma: • sudden or gradual altered vertebral mechan­ • The accident victim suddenly experiences ter­ ICS. ror and surprise, accompanied by a huge gasp of Some of the fascial specializations function air with the diaphragm, the largest muscle of the in posture and, as such, are among the first to body, reacting to the event; this reaction is termed show changes in the presence of postural defects; shock. these fascia include: • The accident victim locks hands and elbow • lumbodorsal fascia; tightly onto the steering wheel. • iliotibial band of the fascia lata; • The victim slams on the brake with the right foot • gluteal fascia; and while possibly tending to jam the clutch or floor­ • cervical fascia. board with the left foot. Because the origin of many muscles is gen­ • If worn, the seatbelt locks tightly over the vic­ erated from within the deep surface offascia and tim's pelvis, restricting the left shoulder more each muscle is invested by fascial sheaths, both than the right one. fascia and muscle are often treated together in • The victim's neck is thrown, or actually whipped, myofascial release techniques.8 Such techniques into hyperextension and hyperflexion. Simulta­ relate directly to what Greenman9 views as a neously, a sudden upward and downward com­ major principle of therapy, namely, "that of assur­ pressive force is exerted on the base of the skull, ing adequate arterial blood flow to the cellular spine, sacrum, and coccyx bones. The victim's milieu in the region of the head and neck and head may actually hit the ceiling of the vehicle, adequate return circulation through the venous and adding to the force of impact on the body as a lymphatic systems." Application of myofascial whole. The vehicle may be thrown off course, treatment to the spine, as a whole, assures further adding a sideward twist to the neck, thus com­ that the body benefits throughout from increased plicating the injury. improvement of the circulatory system. Such total­ • Soft tissue changes occur throughout the body, body treatment may affect and improve the con­ some immediately after impact, and some arising dition of the chronically troubled whiplash patient, as a result of fluid, swelling, and tissue adjustments as injury sustained in accidents extends beyond during the night and day following the accident. the neck region itself. The sooner the initiation of fascial treatment­ Comment that is, before chronic changes occur-the better. The foregoing represents only one common The body has "memory of injury," making injuries description of the etiology of whiplash injury tend to become additive. sustained in a vehicular accident. Many more detailed descriptions of injurious situations exist Description of accident situation and must be studied. Such descriptions must be It is essential to visualize the total-body effect studied and unique ones constructed as the from any type of whiplash injury, regardless of means for designating remedial and corrective treat­ its external source. BeckerlO discusses the con­ ment processes for each individual. cept of the "arc of force." He describes this con­ When undertaking this kind of accident cept as a unidirectional arc of force that affects description, it is wise to avoid complex linguis­ the victim's entire being. He advises that, "To tic and nomenclature problems. BeckerlO warns begin at the patient's body is to adopt a too-near against language becoming a stumbling block approach to the problem." Therefore, the practi­ when one carries the description to an extreme tioner must try, with the aid of the patient's recall, degree. To attempt to define every possible stra­ to reconstruct the specific details of the accident ta of fascia (for example, Camper's, Cruvielheir, situation. It is essential to determine precisely Scarpa, Colles, Buck, et cetera) is to invite diag­ what internal and external regions of the body nostic obfuscation. He advises that definition be sustained impact, the directions from which the simplified with reference to the three main tissue impact was received, and what level body sur­ types, namely: superficial, deep, and subserous. faces were injured. Constructing as exact a descrip- It is through relating these tissue regions to the

Clinical practice • Cisler JAOA • Vol 94 • No 2 • February 1994 • 147 elements of the accident situation that the osteo­ pathic physician can offer improved treatment plans, with resulting improved prognosis for the patient. That which creates total-body trauma calls for total-body treatment. Whether a patient sus­ tains a neck injury in recreational, business, or routine everyday pursuits, that individual has been injured-quite literally-from head to foot. Thus, management of such a patient calls for soft tissue treatment directed to more than the head and neck region in addition to application of traditional whiplash treatment plans. Fur­ thermore, such treatment proves most effective when administered as soon as possible after the accident occurs. By incorporating myofascial techniques into initial treatment programs, the osteopathic physician may succeed in reducing or eliminating the chronic suffering and symp­ toms often persisting for many months or years after a whiplash injury.

References 1. Magoun HI: Whiplash injury: A greater lesion complex. JAOA 1964;63:524-535. 2. Matthews M: The physiotherapy of the whiplash patient, in Grieve G (ed): Modern Manual Therapy of the Vertebral Column. New York, NY, Churchill Livingstone, 1986. 3. Harakal JH: An osteopathjcally integrated approach to the whiplash complex. JAOA 1975;74:941-956. 4. Heilig D: 'Whiplash' mecharucs of injury: Management of cervi­ cal and dorsal involvement. JAOA 1963;63:113-120. 5. Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. New York, NY, JB Lippincott Co, 1977. 6. Carrol C, McAfee PC, Riley LH: 'Whiplash' injuries and how to treat them. Journal ofMusculosheletal Medicine 1992;9(6):97-113. 7. Becker RE: An osteopathically integrated approach to the whiplash complex, in Grieve G (ed): Modern Manual Therapy of the Vertebral Column. New York, NY, Churchill Livingstone, 1986. B. Cathie AG: The fascia of the body in relation to function and marupulative therapy. Philadelphia College of Osteopathic Medicine Notebooh No. 17, 1960. 9. Greenman PE: Fascial considerations in treatment. Osteopath· ic Annals 1975;3(2):51-54. 10. Becker RF: The meaning offascia and fascial continuity. Osteo· pathic Annals 1975;3(2):38-50.

14B • JAOA • Vol 94· No 2 · February 1994 Clinical practice • Cisler