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Auto accidents & whiplash in Boston

autoaccidents1AUTO ACCIDENTS AND WHIPLASH IN BOSTON:

How Chiropractors excel in the treatment of certain car accident injuries.

Whiplash injury occurs when the body reacts to a deceleration or acceleration force by hyperflexion or hyperextension of the neck.

Whiplash injuries are very common in car accidents. The whiplash injury is in part due to the fact that the muscles do not have enough time to brace. Whiplash, or " Cervical Acceleration/Deceleration" {CAD}accidents most often occur when a patient is stopped at a light or a stop sign and is rear-ended. Often is the case where a car skids and slams into another car or pole and still another common scenario is when a person is driving and gets "T-Boned" by another moving vehicle in the side. *MVC=motor vehicle crash.

autoaccidents2Uncomplicated cases of whiplash are the result of sprained ligaments in the neck. The muscles naturally spasm as a protective mechanism. Pain from the whiplash may be a stiff neck and may go down one or both arms. The sudden jerking motion of the head either front to back or side-side forces muscles and ligaments supporting the spine and head to move past their normal physioligical limit and can thus be overstretched or torn. Additionally, vertebrae can be forced out of their normal alignment thus reducing range of motion (ROM). Interestingly, in some extreme cases, the neck muscles and ligaments are so damaged and stretched that a patient's ROM actually exceeds all normal ranges. Additionally, the actual spinal cord and/or nerve roots in the neck can get stretched and irritated causing even more pain that we call "radiculopathy." Research has also shown that facet injury(where the vertebrae interlock) is a major locus of pain. Add to that disc damage that will cause pain issues. All of this damage and instability can result in pain in the entire neck (cervical spine), mid-back (thoracic spine) and even the low back (lumbar spine). Patients will often complain of headaches, dizziness, blured vision, face pain, nausea, shoulder pain, knee pain and a other seemingly unrelated health issues. Be advised that all these symptoms are normal after a MVC (motor vehicle crash). *NB: Most of the citations on this page have been duplicated with actual experiments or cited in Foreman & Croft, Whiplash Injuries: Cervical Acceration/Deceleration Syndrome, 3rd Ed., Lippincott Williams & Wilkins, 2002. **cervical accerleration/decleration can be shortened to CAD. Go to SRISD for more details.

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WHIPLASH STATISTICS:
The numbers are shocking. Each year in the U.S., about 3 MILLION people experience whiplash neck and back injury. This should indicate to anyone, the sizeable nature of this issue and what a public health problem whiplash has become. Actually, a further analysis of the 3 Million people shows that number is about HALF of all who are actually exposed to these types of trauma. Of the 3 Million, about 1.5 million will eventually recover. Another 600,000 will continue to have long-term symptoms and pain and another 150,000 will become disabled to one degree or another, each year as a direct result of Whiplash. Research has shown that nearly half (45%) of all Americans with chronic neck pain attribute the pain to car accidents with Whiplash being the most commonly cited problem. (Ibid.) According to both the US Dept. of Transportation (
USDOT) and the National Highway Traffic Safety Administration (NHTSA), traffic accidents can be broken down this way:

On average, from year to year, Motor Vehicle Crashes (MVCs) in the U.S. are statistically similar;

 

i)     6,000,000 total accidents per year
ii)    3,000,000 claimed injuries per year
iii)   42,500 deaths per year
iv)   2,000,000 of the claimed injuries result in permanent damage to some part of the body
v)   Every 12 minutes, a person dies in a MVC; every 14 seconds, someone is injured in a MVC
vi)  Accidents are largely the result of; 1) drunken drivers (40%), 2) speeding (30%), 3) Reckless driving (33%).

 

EXAMINATION:
Chiropractors are leaders among the professions in treating uncomplicated CAD injuries. A thorough case history is taken along with a thorough examination. Often is the case where X-Rays are indicated. According to the literature (Foreman,S., Croft, A., Ibid; and Yochum, T, Rowe, L, "Essentials of Skeletal Radiology," 3rd Ed., Vol. 1, Lippincott Williams & Wilkens, 2005), with cervical trauma, several views of the cervical spine are often performed. Especially so if the clinical exam and history includes; 1) Loss of consciousness, 2) head trauma, 3) neurological signs. Other X-Rays may be indicated. After accepting the patient and after the exam and X-Rays (if taken), treatment is initiated and that may include certain therapies to inhibit pain in addition to manipulation of the spine. *See our X-RAY page for more information on "Essentials of Skeletal Radiology" and Terry Yochum, DC, DACBR. ** If X-Rays were taken elsewhere, Boston Spine Clinicswill make every attempt to obtain those films, interpret them and render a professional report on said outside films. If the outside films or reports simply can't be found for whatever reason, we may proceed with our own set.

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SPEED OF IMPACT:
It must be noted that the acceleration-deceleration movements of the neck are typically completed within 250 milli-seconds. The astounding brevity of the time frame precludes any voluntary or reflexogenic muscle response that might arrest, limit or otherwise exert some control on the movements of the Cervical motion segment. This sets the scene for a variety of injuries. (Lord, "State of the Art Reviews, Cervical Flexion-Extension/Whiplash Injuries," Spine & Hanley & Belfus, 9/1993. Teasell & McCain, "Painful Cervical Trauma," Williams & Wilkins, 1992.  Havsy, "Whiplash Injuries of the Cervical Spine and Their Clinical Sequelae," Am J of Pain Management, 1/94. )

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TIMING:
Often is the case where a patient will feel a bit of pain at the time of the accident or no pain at all. Later, various pain issues will occur several hours, days, a week or even months AFTER the initial impact. Delayed reactions are the norm, not the exception in whiplash injuries according to the literature. In fact, there are no published reports I am aware of that say otherwise. (Foreman & Croft, ibid). There has been some research to show that after this, or any kind of serious trauma, the body's natural opiate system kicks into gear. The pituitary gland and hypothalamus both initiate the release of "endorphins." These are natural pain killing opiates that your own body generates and releases after trauma. The initial release of these endorphins would explain why people don't seem to have pain until after several days. (Vernon HT, Dhami MS, Howley TP, Annett R, "Spinal manipulation and beta-endorphin-a controlled study of the effect of a spinal manip. on plasma beta-endorphin levels in normal males," J Manip. Physio. Ther. 1995, 18 (8): 530-6)   Delayed reactions to pain after car accidents IS widely cited. Here are a few: Farbman A, "Neck Sprain:Associated Factors,"
JAMA, 1973, 223 (9): 1010-1015; Hirsch S, Hirsch P, Hiramoto H, et.al., "Whiplash Syndrome: Fact of Fiction?" Ortho. Clinics of North America 1988, 19 (4); Gay, J, Abbott K, "Common Whiplash Injuries of the Neck," JAMA 1953, 152 (18): 1698-1704;

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CAR DAMAGE V. HUMAN BODY DAMAGE:
Another popular myth concerns car body damage. Specifically, the anecdotal thinking is that if the car doesn't "look" too bad, then there must not have been any human body damage. More than half of all Whiplash injuries occur in crashes where there is little to no car damage. It is now widely known that car bumpers are engineered NOT to deform but rather give and recover up to 5 mph. Ironically, it was the insurance lobby itself that paid off congress to pass laws that compelled auto manufacturers to make "low impact proof" bumper systems - not to save people of course, but to reduce car repair bills. As we shall see, there is still energy transferred into the car. If the bumper doesn't crumple as most don't now days in low impact collisions, the people in the car absorb the energy. The fact is, there is more whiplash now than ever before precisely because of the way cars are engineered and because of the widespread occurance of Low Impact Collisions. *See, Ivancic PC, MM Panjabi, et.al., "Injury of the Anterior Longitudinal Liegament During Whiplash Situation, Eur Spine J, Vol 13, Jan/2004, Pg: 61-68. And, Batterman S, Batterman S, "Delta-V, Spinal Trauma, and the Myth of the 'Minimal Damage' Accident," J Whiplash & Related Disorders, Vol 1

(1), 2002.  

autoaccidents7The reality is this: Newton's Laws of Linear Momentum hold true to this day. Which is to say, energy is transferred during a car crash. Even if the car that got hit (yours for example) doesn't "look" too bad, there was still a huge amount of energy transferred from the impact that went somewhere. People are suffering whiplash syndromes at epidemic rates these days precisely because cars are built like steel cages. The cars are designed NOT to crumple in most cases.Much like billard balls; there is no physical damage but one ball stops and the other goes flying across the billard table. This is known as "Elastic Collision." The energy or momentum of the crash transfers into the car and the passengers get whiplashed even more than they did when cars used to crumple up like empty milk cartons. *That is referred to as "Plastic Collision"-where the car or cars crumple up.  The fact is, there is no statistical correlation between vehicle damage and patient outcome. (Macnab, in The Spine, Saunders, 1982 pg. 648; Hirsh, Whiplash Syndrome, Orthpedic Clinics of North America, 10/88, p. 791) **NB: In the Boston Globe (3/27/06), there was an article about a tragic car crash yesterday. The two restrained (ie. with seat belts) parents were killed instantly while the unrestrained 4 year old hardly had a scratch. The car rolled over and was half crushed. Here, the parents died while a 4 year old being thrown around inside emerged in generally great condition. It serves as yet another every-day example of the folly of trying to predict the who, why and how of MVC injuries. See also Robbins MC, "Lack of Relationship Between Vehicle Damage and Occupant Injury," Soc. of Auto. Engineers, 1997; 970494.  It is well known that a favorite area of testimony by accident reconstructionists (at the behest of insurance companies) is to assert that a lack of damage to the vehicle bumper suggests that the occupants could not have been injured. It has given rise to the ridiculous euphamism "No Crash, No Cash." More recently, insurance companies have created a legal strategy based on MIST (Minor Impact Soft Tissue) segmentation strategy. The MIST protocol calls for accidents producing less than $1000 in damage are to be adjusted for minimal compensation. Legitimate experts now acknowledge that this testimony is a MYTH since, after 1973, car bumpers were generally designed to absorb impact forces - not protect vehicle occupants; "There is no validity to the argument that a jury should see a bumper photo because it reflects the damage to the car or lack thereof. "Plaintiff's Lawers Guide to Minor Impact Cervical & Lumbar Injury," Litigation One, 2001. Also consider the following references: MacNab, "The Spine," Saunders, 1982. ~MacNab tells us; "The amount of damage sustained by the car bears little relationship to the force applied." Ameis, "Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury, " Canadian Family Phys., 9/86. ~"Each accident must be analysed in its own right. Auto Speed and damage are NOT RELIABLE indicators." Emori, "Whiplash in Low Speed Vehicle Collisions," SAE, 2/1990. ~" . . .neck extension becomes almost 60 Degrees which is a potential danger limit of whiplash, at collision speed as low as 2.5 km/h." It is also now known that examination of the undercarriage of the car will usually yield more ballistic damage such as the car frame or the frame rail. The car bumper is the LEAST reliable indicator of car damage in low impact rear end collisions (LOSRICs). A recent article by the venerable Arthur Croft, DC substantially answers this entire question: Is there a correlation between car body damage and human body injury? The answer, it seems, is a resounding NO. His sizeable metanalysis covered all known, reliable literature on the subject going back to 1970. See Croft A, Freeman M, "Correlating Crash Severity with Injury Risk, Injury Severity, and Long Term symptoms in Low Velocity Motor Vehicle Collisions," Med Sci Monit, Vol. 11(10), 2005. See also, Schofferman J, Bogduk N, Slosar P, "Chronic Whiplash and Whiplash Associated Disorders: An Evidence Based Approach," J Am Acad Ortho Surgeons, 10/2007, Vol. 15 (10).

HEAD-RESTRAINT GEOMETRY:
This has to do with how close or far the head rest of the vehicle that you suffered your accident in, was located with relation to your head. More than two inches away from the head and the efficacy of head restraints drops off significantly. Go to
http://www.iihs.com/  (Insurance Institute for Highway Safety, not Integral Handwriting Studies) to find out the crashworthiness of your car and the effeciency of your headrestraint as rated by the Insurance Institute for Highway Safety. At Boston Spine Clinics we include this data in our reports as well as take digital photos of the patient, the car and the patient sitting in the car relative to the headrestraint. See Panjabi, MM, "A Hypothesis of Chronic Back Pain: Ligament Sub-failure Injuries Lead to Muscle Control Dysfunction," European Spine J, July, 2005.  *Sub-failure injury of spinal ligaments is defined as an injury caused by stretching of the tissue beyond its physiological limit, but less than its failure point. In short, this is a classic definition of whiplash. As well, please note this ground breaking article; Kaneoka K, Ono K, et. al., "Motion Analysis of Cervical Vertebrae During Whiplash Loading," SPINE, 1999,Vol 24 (8): 763-770. This study clarified the actual mechanism of injury which is now known to be known to be mostly in the zgapophysial joints. To wit, "Most whiplash injuries occur during low-speed rear-end collisions and rarely produce morpological changes such as a fracture of the joint. The zygapophysial joint is a synovial joint and has a synovial fold (meniscus) between the articular facets that is innervated with nociceptive receptors. Thus, we hypothesize that facet collisions are likely to impinge on and inflame the synovial folds in the zygapophysial joints, causing neck pain." Famed NZ anatomist Nikolai Bogduk, MD, Ph.D. commented in this too; "The study by Kaneoka et.al., fills a critical gap in the story of cervical facet pain. It provides the missing biomechanical link. Theirs is the most significant advance in the biomechanics of whiplash since the pioneering studies of Severy et.al. in 1955."  

 

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Head Restraints and Safety Seats: The Volvo Whiplash Protection System:(WHIPS) 

Reducing long-term neck and spinal injuries by more than 50 percent. Finally at least one major car manufacturer is taking Whiplash seriously. Note that many of the crucial articles being published on Whiplash lately have been through VOLVO engineers and scientists.

Irvine, CA (June 30, 2003) - First introduced in 1999, Volvo's WHIPS is still being thrust into the spotlight. A new survey from Volvo's traffic accident research team shows that WHIPS reduces short-term injuries by 33 percent and long-term injuries by 54 percent. However, Volvo is not alone in drawing this conclusion. Several independent surveys reveal major reductions in whiplash injuries thanks to WHIPS.

In Sweden, the Swedish Road Administration and Swedish Insurance Institute, Folksam, published findings of their survey and conclude that the number of whiplash incidents leading to serious injury would drop by 50 percent if all cars had the same system as that found in Volvo. Recent studies in the United States also support these findings. The Insurance Institute for Highway Safety (IIHS) compared seats in car models featuring the new head restraint with the seats fitted to previous model years. Volvo (with WHIPS) topped the average injury-reduction ratings with 49 percent. Volvo has been awarded the highest rating for headrest safety by the IIHS on every one of its models since 1995.

Seven out of ten car accidents resulting in personal injuries involve whiplash injuries. The IIHS has discovered that "the key to reducing injury risk in rear-end crashes is to keep the head and torso moving together." They further add that to effectively protect occupants' necks, a head restraint must be high enough to catch the head and close enough to catch it early in a crash. As Volvo continues to lead the market in safety innovations, WHIPS has no doubt added to that success. WHIPS is offered standard on all Volvo vehicles. The 2003-8 Volvo automobile line includes the award-winning XC90, the sporty S60 sedan - including the award-winning performance sedan - S60 R, the flagship S80 luxury sedan, versatile V70 wagon and rugged XC70 (Cross Country), the C70 convertible, and the compact S40 and V40 models.

A Note about WHIPS:

The WHIPS seat provides improved spinal support by virtue of its modified backrest characteristics and close proximity of the head restraint's position to the occupant's head. WHIPS utilizes a specially designed hinge mount that attaches the back rest to the seat bottom, which has a pre-determined rate of rearward movement in the event of certain types of rear impacts. The seatback also has a series of springs that allows the cushion to move slightly rearward upon impact, thereby helping to cradle the body within the seat. This, combined with high-mounted head restraints, help to limit the "whipping" motion of the head that often occurs during a rear-end impact.

 Source:  Volvo

CAR DAMAGE PHOTOGRAPHY:
What often happens in MVCs is that Accident Reconstructionists and/or an adjuster for the insurance company itself will take pictures of the car after an accident. In the LOSRIC scenario, where there "appears" to be little damage to the car, these photographs are used to deny a claim altogether or limit payments to people who have been injured. As we alluded to in the previous paragraph, simple photos of the outside of a car after a LOSRIC should NEVER be admitted as evidence in car accident settlement situation. To properly documnent a LOSRIC car accident, photos of the undercarriage of the car are needed. It is the frame and the frame rails of automobiles that are consistently warped and damaged in impacts of all velocities. The IIHS (Insurance Insititue for Highway Safety) has admitted that a sigfificant portion of whiplash injuries occur with minimal to no visible car body damage. (Croft, ibid). The Supreme Court of Deleware ruled in Rosetta v. Franz Maute, No. 307, 2000, 770 A. 2d, 36, that crash photographs were inadmissible unless the lawyer displaying them brought in an expert to testify as to their significance and meaning to the case. Please revisit our WEB page on "The Daubert Decision" listed on our HOME page.  That case went a long way in establishing what can and cannot be presented as evidence at trial.  Exceptions to this of course would be a LOSRIC with extensive, visible car body damage. Again, in this paragraph we are emphasizing the low speed rear impact collision scenario that often reveals minimal to no car body damage when the exterior of the car is casually viewed.

EARLY TREATMENT:
The literature is clear on this; early active treatment is far more effective than "doing nothing" as some have suggested. (Waddell G, "A New Clinical Model for the Treatment of Low Back Pain," SPINE, Vol. 12 (7), 1987; Volvo Award Winning Article. "There is remarkably little scientific or clinical evidence to support the value of bed rest for low back pain or even sciatica.") Even now, in the second decade of the new millenium, there are some doctors parading as "insurance consultants" who strongly suggest the do-nothing "strategy" for whiplash/CAD injuries. It has been my experience in over 27 years of clinical practice treating CAD injury patients that early, active management greatly alleviates future pain and scar issues. In a highly interesting article (Mealy K, Brennan H, Fenelon GCC, "Early Mobilization of Acute Whiplash Injuries," Brit. Med. Journal,  Vol. 292:8 3/1986), the authors clearly showed that early active care including movement/cavitation of the spinal joints was more effective than cervical collars and bed rest. See also, (Kellet J, "Acute Soft Tissue Injuries-A Review of the Literature," American C. of Sports Med., Vol 18 (5), 3/86. *Hard to find article on the efficacy of early intervention with rehab and modalities in acutely injured patients. Schofferman J, Wasserman S, "Successful Treatment of Low Back Pain and Neck Pain after a Motor Vehicle Accident DESPITE Litigation," SPINE, Vol 19 (9), 1994. ~ The conclusion here is that LBP or Neck Pain resulting from a motor vehicle accident showed a statistically significant improvement WITH treatment despite ongoing litigation. Khan S, Cook J, Gargan M, Bannister G, "A Symptomatic Classification of Whiplash Injury and the Implications for Treatment," J Ortho Med., Vol 21(1) 1999. ~ The conclusion here is that Whiplash is very common and the Chiropractic is the only PROVEN effective treatment in chronic cases. Furthermore, conventional treatment(medical and/or rest) is disappointing. Mooney V, "Where is the Pain Coming From?" SPINE, Vol 12 (8), 1987. ~ The upshot here was about how heavily impregnated the intervertebral disc is with nociceptors. It is a far reaching paper discussing things such as chemoreceptors, many and varied other causitive agents of pain but he concludes with, "Prolonged rest and passive physical therapy modalities no longer have a place in the treatment of this chronic problem."

GENERAL THOUGHTS ON NECK PAIN:
In a recent issue of JMPT (J Manip. Phys. Therapeutics, Supplement, Vol. 32 (25), Feb. 2009; we see a robust article entitled, "The Bone and Joint Decade 2000- 2010 Task Force on Neck Pain and Its Associated Disorders," by Scott Haldaman, Linda Carroll, David Cassidy, Jon Schubert and Ake Nygren. Needless to say, it's all about neck pain of any origin including whiplash associated disorder (WAD):

1) WAD complaints have increased steadily over the past three decades.
2) Most people with neck pain do not experience a complete resolution of symptoms.
3) For both WAD and other neck pain without radicular symptomsm inteventions that focus on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus. (*ie: rehab and active manipulation compared to bedrest and drugs)

  1. There has been a significant rise in spinal fractures and spinal cord injuries that is apparently due to the sharp increase in automobile accidents as well as aggressive sports activities. Fractures of the spinal column are found most commonly at C1-C2, C5-7, and T12-L1. Spinal cord injuries occur in 10- 14% of all spinal fractures. Bear in mind however, that spinal cord injuries jump markedly with cervical spine fractuers, at about 40%. Interestingly, in 10% of the cases of spinal cord injury there was no assoicated fracture.

Flexion is the most common line of force in spinal injuries, with extension, rotation, shearing, compression and distraction all occuring less frequently. Thus, since we know fractures occur frequently, a thorough radiological examination should be performed and the radiographs must be of good diagnostic quality. Therefore, a complete series in each region in question in the spine should be performed and when indicated, CT, Bone Scans and perhaps pillar views should be ordered when there is a question about the image. (see Yokum TR, Maola CJ, "Whiplash Injury," The Am. Chiro., Vol. 31(9), Sept. 2009.  *At Boston Spine Clinics, we send most of our radiographs out for an over-read with a qualified DACBR.

MADYMO:
Is an acronym for "Mathematical Dynamic Model." According to the literature, it is the world's most sophisticated and well validated multi-body mathematical model. So what does that mean? It means that this computer model is essentially a very complex series of equations and relationships describing the human body for one thing. Every major body part becomes a three-dimentional ellipsoid mass with a known center of gravity, dimentional size and known inertial properties. Each of these body parts is connected to others with linear elastic springs and viscoelastic dashpots using the appropriate type of joint model to best simulate a human. A finite seat belt/shoulder harness with and airbag system completes the package.

 Here we see the MADYMO driver with seat belts and airbag capability. The driver is fully modifiable as are the dimensions of the seat, stiffness of the seat, timing, seat ramping and just about every variable consistent with a MVC.

This model, therefore, can then be exposed to computer simulations to various kinds of trauma and through a mathematically challenging series of computations, joint forces, torques and accelerations - can be plotted. These can then be compared to known human tolerances and injury assessment reference values (IARVs) such as the neck injury criteria (NIC), the head injury criteria (HIC) and others.

To calculate the internal/external forces acting on a human body that is exposed to a complex crash scenario, including seat belts, a should harness and the loads of each; ballistic impaction with an airbag, sterring wheels and/or other internal car parts; to account for all of the major joints of the body/spine, muscle loads, weight, etc., would require a team of mathmeticians a year to calculate. MADYMO can do it all in a matter of minutes in simple cases. In more complex cases in which airbag deployment was involved, the calculations could take a full day; and all this for an MVC that took perhaps one full second to happen. With programs like this, it is clear to see why we field practitioners keep insisting that people really do get injured in even relatively slow (5 mph) rear impacts. MADYMO confirms for us that injuries do take place. Often, very serious injuruies.

SEAT BELTS:
It is now widely documented in the literature, that with the introduction of mandatory seat belt laws, there indeed has been a reduction in deaths and serious injuries after motor vehicle crashes (MVCs), but, there has been a significant INCREASE in neck sprains. That's right, seat belts actually make the soft tissues of the neck and pain issues more painful after a MVC. It does this by anchoring the body in place and thus allowing the head free, or in many cases, wild unrestrained movement during a car crash. Also, even with a shoulder strap in place, the body can rotate "out" of the protection area with the free shoulder leading the way thus causing even more injury. {Navin F, Romilly D, "Investigation into Vehicle and Occupant Response Subjected to Low-Speed Rear Impacts," SAE, 1989, 159-168;  Hirsch S, Hirsch P, Hiramoto H, et.al., "Whiplash Syndrome: Fact of Fiction?" Ortho. Clinics of North America 1988, 19 (4): 791-795; Porter K, "Neck Sprains After Car Accident," Brit. Med. Jour., 1989, 298 (973-974); Evans R, "Some Observations on Whiplash Injuries," Neurologic Clinics 1992, 10 (4): 975-997.

NB: Speaking of fractures and seat belts, we note this new and perhaps first ever citated article regarding how seat belts actually caused two fractures in the same person. See: Nourbaksh A, Patil S, et. al., "A Noncontiguous 2-Level Spinal Injury in a Young Female Driver Due to a 3-Point Seat Belt Restraint," JMPT, Vol. 32 (7), Sept. 2009. See the digital pictures of the CT scan images below. Once again, we are reminded that seat belts are not the panacea they are made out to be.

  The top two images tell the story: there are frank fractures at the Thoracic 3 and L5/over S1 levels. Both happened simultaneously in the same car accident to the same person, specifically due to seat belts.

PRE-ACCIDENT DEGENERATION:
Patients often already have pre-existing issues. The literature tells us that this will compound an injury. Pre-existing degeneration aka: "degenerative joint disease/DJD" should NOT be confused with the new injury itself. Often is the case where an opinion will be rendered stating the patient already had some degree of degeneration so any new pain or discomfort experienced by a motor vehicle crash is really just the old injury. This is NOT true! (Turkek, Orthopedics Principle and their Applications, Lippincott, 1977, p. 740; Calilliet, Neck and Arm Pain, F.A. Davis Company, 1981, p./ 103. Webb, "Whiplash:Mechanisms and Patterns of Tissue Injury," J Australian Chiro. Assoc., 6/84. Mairmaris, "Whiplash Injuries of the Neck: a Retrospective Study," Brit. J of Accident Surgery, 1988. Watkinson, "Prognostic Factors in Soft Tissue Injuries of the Cevical Spine, " Brit. J of Accident Surgery, #4, 1991.)

Dr. Croft, seen below lecturing.

SYMPTOMS AND/OR INJURY RESULTING FROM A MVC:
The health issues and problems that arise after a MVC, particularly from Whiplash, are legion. We'll list the more common and prominent pain and injury scenarios here; be advised, some may surprise you.
1) Brain Injury: Yes, brain injury. Believe it or not, brain injury occurs relatively commonly as a result of the physical movement of the brain inside the skull after impact. It is roughly similar to being struck in the head several times during a boxing match. Biochemical reactions also occur for up to 96 hours AFTER the the initial trauma. This involves the formation of free radicals and other toxic bio-chemical reactions that occur at the cellular level. The resultant symptoms usually manifest as confusion, difficulty in concentration, sleep disturbances, irritability, forgetfullness, excess anger, decrease in libido, altered moods, etc. In fact, some studies have shown a permanent loss of IQ.
2) Cranial Nerve Injury: These are the nerves that exit the brain directly. These nerves are a combination of sensory, motor or both. They control such things as smell, sight, taste, facial function, tongue movement, shoulder movement, scalp and internal organ function. Blurred vision is a common complaint after an accident. Uncontrollable tearing, smell dysfunction as in either a lack of the ability to smell and/or the sensation of smelling something that isn't in the area, blushing, irregular heart beat, upset stomach. These are a few of the functions that are mediated by the cranial nerves and can be adversely affected by a Whiplash accident.

3) Dizzyness: A very common complaint after a MVC. This most often results from injury to the joints of the cervical spine. Chiropractic care is especially beneficial in relieving this problem. This due to the fact that the vast majority of balance information sent to the brain comes from the neck. Restoring the neck to proper position via chiropractic adjustments is what chiropractors excel at. More serious complications may arise causing dizzyness through injury to the brain stem or the brain itself. However, commonly, it is the so-called mechanoreceptors of the cervical spine that detect our place in time and space. This information is relayed to the central vestibular and reticular systems in the brain for integration and balance coordination. If the neck has been traumatized, the messages going to the vestibular system from the neck will be aberrant and thus lead to dizziness. (see Guyton A, Hall J, "Textbook of Medical Physiology," 10th Ed., 2000, pg. 645, W. B Saunders Co.)
4) Headaches: After basic neck pain, headaches are the next biggest complaint patients speak of after a Whiplash. Most are related to neck injury and the subsequent muscle spasm that occurs in the neck that then affects the skull. Chiropractic excels in treatment of headaches of all varieties as a result of Whiplash.
5) Neck Pain: By far, the single most prevalent complaint in a MVC is that of neck pain. Over 90% of the patients studies reported neck pain after a Whiplash. This often leads to shoulder, arm and upper mid-back pain. Again, this condition, barring the unusual, is remedied nicely via chiropractic care.
6) Low Back Pain: Another common and yet surprisingly misunderstood issue after a MVC. Various studies have shown that even in cases of primarily Whiplash, the low back is often involved; up to 50% of the time. Seatbelts are often involved in the mechanism of low back pain in a car accident. Why? Because the belt anchors a person to the seat while the upper back and particularly the neck often get "whipped" in the accident which aggravates the low back. Additionally, there is the phenomena of "ramping" to consider. Ramping is when the human body loads up on the seat back initially. In other words, you, the passenger, tend to climb UP the seat back several inches. The entire spine experiences a straightening of all curves and as a result, there is compression of the spine. Ramping occurs in almost all cars, yet the seat belt is anchored to the seat belt hooks and thus, there is a tremendous amount of pressure put on the waist line and low back as the seat belt attempts to hold the person down while the force of the accident is pushing the person upward. Along with this painful condition is the SI syndrome. This stands for Sacro-Illiac joint. It is the hip joint that connects the upper body to the hips and lower body. This joint is frequently pushed out of its normal alignment. It is a gliding joint with a synovial lower section and a fibrous upper section. Chiropractic manipulation is successful at reducing this problem as well as low back pain.
7) TMJ: This stands for Temporal-Mandibular-Joint. The mandible (lower jaw) inserts itself into your skull via a notch in the temporal bone. This hinge joint is your jaw joint, hence the name TMJ. This joint is frequently injured in a MVC. Clicking and popping noises are often found in the jaw joint after an accident. This condition is not as common as the others mentioned but it is still seen frequently. This condition is easily reduced with chiropractic care. As a matter of fact, TMJ is often nicely reduced by manipulation to the neck WITHOUT having to directly apply manipulative forces to the TMJ itself.
8) Blurry Vision: Still another normal concomitant of Whiplash/CAD accidents is blurry vision. It is often the result of disrupted blood flow to the eyes and/or aggravation to the "Sympathetic Nervous" system. This side effect, thankfully, usually goes away within a day or two but it is very disconcerting to the average accident victim.
9) Hearing Loss: Approximately 10% of patients who suffered injuries from a whiplash accident will also develope otological symptoms such as tinnitus (ringing in the ears) and deafness. (Murphy D, "Hearing Loss Following Whiplash," Am. Chiro. Vol. 31 (5), May, 2009.

PROGNOSIS:
Over the past four decades, numerous studies have been undertaken trying to demostrate and predict long term prognosis for Cervical Acceleration/Deceleration (CAD) injuries. Foreman & Croft analyzed this vast body of studies and excluded those lacking proper scientific methodology such as blinded studies, accurate descriptions of injury mechanisms and so forth. What remained are 43 scientifically reliable studies published in graph form in Foreman & Croft's book, 3rd Ed. on page 408. The literature is clear and consistent; virtually all existing research points to the same conclusion: long term affects can and do appear in CAD. People were shown to be suffering long term affects of CAD for months to YEARS after the fact. This body of literature based evidence cannot be ignored. In the alternative, there is NOT ONE study available that shows patients automatically heal within a few weeks after a CAD experience. Nor is there a single study that shows that people automatically heal after a CAD experience "with or without" treatment as is sometimes alleged by the "insurance consultants" and IE doctors. See also Davis C, "Chronic pain/dysfunction in Whiplash-associated Disorders," J Manipulative Physio. Therapy (JMPT) Vol. 24 (1) 1/2001: p 44-51. Another way of putting this is to consider the lingering effects of whiplash. In a great article gaining more and more coverage lately, the authors (listed below) brought to attention the following data:

One additional article should be mentioned here as well with regard to prognosis;

Berglund A, Alfredsson L, Cassidy JD, et.al., "The Association Between Exposure to a Rear-End Collsion and Future Neck or Shoulder Pain: A Cohort Study," J Clin. Epid., Vol. 53 (11), 11/2000. ~Their conclusions were i) 39.6% of those injured in a rear-end MVC have chronic neck pain 7 years later, ii) A carefully matched control group who had never been injured in a MVC had neck pain prevalence of 14%, iii) This 14% incidence of neck pain is probably equivalent to the incidence of neck pain in the general population, iv) This means that there is an approximate 3X increased probablility for neck pain for those injured in a MVC 7 years later, v) Whiplash injury results in chronic neck pain in a large percent (40%) of those injured, 7 years after the injury, vi) This chronic neck pain is organic, it is not related to malingering or compensation neurosis, vii) The 2 Lithuania studies were flawed and the conclusions were erroneous.

ACCIDENT RECONSTRUCTIONISTS: 
The new rage in recent years is when Insurance Companies began retaining "experts" in the field of biomechanical engineering to provide "expert testimony" that the forces of a particular auto accident were incapable of causing significant injury to the occupants. Typically, defense (insurance company) attorneys use these so called biomechanical experts to argue to a jury that a particular plaintiff could not have been injured in a low impact and/or low property damage accident. This new trend has emerged in numerous trial courts, not only in Michigan, but throughout the United States. Most often, these experts pop-up in cases where the Plaintiff has sustained an injury to the neck or back (such as a herniated disc) or in cases involving a traumatic brain injury (a/k/a closed head injury).

Essentially the biomechanical expert opines that based upon a specific Delta V (change in acceleration) or a specific amount of g force in the auto accident, an individual is incapable of being injured. In fact, many of these experts will testify that an auto accident cannot cause a herniated disc without a fracture to the spine. In support of their "opinions," the defense biomechanical experts routinely rely on a small body of literature involving human volunteers (mostly male), crash dummies, animals, and cadavers who are subjected to impact collisions on sleds and in crash tests. Further compounding their flawed methodology is the biomechanical expert's seemingly intentional failure to consider significant variables in their calculations, such as changes in an occupant's physical characteristics, body position, seat position, pre-existing physical condition of the occupant, as well as the position and location of the headrest. The controlled studies upon which most biomechanical engineers rely on all involve mostly healthy men who were sitting in normal seated positions, head forward with a properly placed headrest. These staged collisions in no way replicate real world events or real world people involved in collisions. The insurance industry has inundated the citizens of the United States with propaganda claiming that our civil justice system is a lottery, and that rogue juries ignore the law and award uninjured Plaintiff's millions of dollars. This propaganda has resulted in the so-called "Tort Reform" movement. Use of these "junk science" biomechanical experts prey upon this perception of greedy trial lawyers and plaintiffs.

Fortunately, the efforts to inject "junk science" into motor vehicle accident litigation have not gone unchallenged and courts throughout the United States have overwhelmingly barred this type of testimony. For example, the following decisions in Federal and State jurisdictions have recognized that scientifically unsound opinions of biomechanics are not admissible at trial. They include, but are not limited, to:

*Cromer v. Mulkey Enter., Inc., 562 S.E.2d 783 (Ga. Ct. App. 2002); Clemente v. Blumenberg, et al., 183 Misc.3d 923, 705 N.Y.S.2d 792 (1999); Mattek v. White, 695 So. 2d 942 (Fla. Dist. Ct. App. 4th Dist., 1997); Salerno v. Tudor, 2002 W.L. 120608 (Cal. Ct. App. 2002); Schultz v. Wells, 13 P.3d 846 (Colo. App. 2000); Smelser v. Norfolk So. Rywy. Co., 105 F.3d 299 (6th Dist.), cert. denied, 118 S.Ct. 67, 139 L. Ed. 2d 29 (1997; Suanez v. Egland, 801 A.2d 1186 (N.J. Super. 202); Titsworth v. Robinson, 252 Va. 151, 475 S.E.2d 261 (Va. 1996); Whiting v. Coultrip, 755 N.E.2d 494 (Ill. App. 2001).

Finally, it is also important to note that most defense biomechanical experts are professional witnesses and are particularly adept at deceiving juries into accepting their theories. Thus, a Defendant's attempt to introduce testimony from a biomechanical expert in any auto accident injury case should be strongly opposed.

TREATMENT:
For the majority of Whiplash/MVC cases, substantial relief can be found with chiropractic adjustments of the spine and extremities, supportive procedures like electrical muscle stim/ gentle traction/ early but limited use of pain inhibiting medications/procedures like ice and a cervical-orthopedic pillow. We quite like and often recommend the use of a specific orthpedic pillow for neck support while sleeping. It is low tech but highly effective for supporting the cervical spine and helping to restore/maintain the basic cervical lordosis. As for pain meds, we usually suggests that the patient move off of them early in the course of treatment. This is because if a patient becomes too dependent on pain meds and gets too anesthetized by the medication, they will tend to continue their normal lifestyle routines which often actually cause more long term damage to the soft tissues of the body. By being aware of the pain and constitutional symptoms of a ballistic impac injury, patients can better modify their lifestyle to DECREASE stress to the tissues of their body. Rehab is often used in this clinic to complete the therapy for the more severe cases of injury after a car accident. A more severe case of whiplash is indicated by persistent pain that lasts for a month and half or more as well as the physiologic status of being "De-Conditioned." This suggests that the whiplash more extensively damaged the soft tissues, failed to lay down scarring along normal stress line and/or irritated local nerves. Whiplash and similar injuries to the rest of the spine can also lead to discs rupturing in the neck like a "slipped" or herniated disc in the back. 'Chiropractic is a proven effective treatment in chronic whiplash cases'-Woodward MN, Cook JC, Gargan MF, Bannister GC, "Chiropractic treatment of chronic Whiplash injuries," J. of Injury, 1996, 27 (9): 643-5;  'Another study of chiropractic treatment of whiplash  injuries showed 75% of the patients improved following treatment,' Khan S, Cook J, Gargan M, Bannister G, "A Symptomatic classification of whiplash injury and the implications for treatment," J. Orthopedic Med. 1999, 21: 21-5. Be advised, 30% of intervertebral disc herniations are MISSED by MRIs. (Owens W, "Thirty Percent of Intervertebral Disc Herniations are Missed on MRI," Am. Chiro., Vol 31 (5), May, 2009. See also the article we quoted above: Schofferman J, Bogduk N, Slosar P, "Chronic Whiplash and Whiplash Associated Disorders: An Evidence Based Approach," J Am Acad Ortho Surgeons, 10/2007, Vol. 15 (10).

Your chiropractor thus incorporates functional orthopedic and neurological testing along with his/her experience to determine if there is disc involvement in a given injury in lieu of advanced imaging results.

Other symptoms from a car accident and whiplash may include radiating pain into the shoulder, elbow, wrist or hand. Likewise, there are many other factors in car crashes that could be discussed but would totally exceed the length of this one WEB page such as whether or not the victim was male or female (females are more likely to be hurt worse), seat back stiffness, head rest placement, position of the head (was the victim turned sideways at impact and/or struck from the side and if so, did their head strike the side windows), brake use or not, size of the car(s), impact vectors such as whether or not the victim's car was hit head on/from behind, in the side, or on an angle, awareness of the impending accident or not and air bag deployment.

An article published in the Journal of Orthopedic Medicine in 1999 pointed out the superiority of chiropractic care for patients suffering from long term whiplash. The authors of the article noted that a previous study had shown that 26 of 28 patients, or 93 percent, of patients with chronic whiplash benefited from chiropractic care. In the authors' own study, they interviewed 100 consecutive chiropractic referrals of patients with chronic whiplash. Their results also showed that of the 93 patients who remained in the study, 69 of them, or 74 percent, found improvement. The researchers concluded their opening comments with the statement, "The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms."

The standard textbook on this subject was written by two chiropractors. The book is considered the "Gold Standard" in analysis, diagnosis, research and treatment algorithms regarding whiplash. The name of the book, as already heavily referenced, is Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome by Foreman and Croft. I have a link to their WEB site in the LINKS section of this WEB site. www.srisd.com

Dr. Haberstroh is a Boston Chiropractor.

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