Motor Vehicle car accident – whiplash pain
Frequently, the direct and indirect effects of motor vehicle accidents are not felt immediately. The pain typically intensifies days later; irritated muscles continue to stiffen, and the spine torques. The irritated nervous system signals the muscles and abnormal movement patterns cause “spread of the pain.” Over the following months, patients may insidiously experience dull headaches and difficulty sleeping due to spinal torque. It becomes difficult to sustain a single posture for long periods. For example, sitting at a desk or working on the computer. Because the pain emerges later, patients may not recognize that a previous motor vehicle accident is the original source of their pain.Motor vehicle accidents create certain injuries that are frequently overlooked by most practitioners. Typical complaints are neck pain from whiplash caused by the head “bobbing” back and forth leading to neck muscle contraction and spasms. However, the major problem is usually in the thoracic spine. It cannot absorb the forceful impacts associated with a motor vehicle accident without “locking up.” On impact, the belt locks restraining the torso. Because the shoulder belt crosses the chest, one shoulder is restrained and the other “whips forward and backwards” usually around an axis centered over the T6 vertebra. This causes disruption of rib articulation to the vertebra and the thoracic spine locks. Muscle tension increases around T6 and over time the body adapts to this contracted muscle state to ultimately cause chronic symptoms. Depending on the person’s height the thoracic pivot point could be above or below T6.One of the most important muscles typically injured in a motor vehicle accident is the serratus muscle, which attaches to the ribcage.When the serratus muscle develops dysfunctional myofascial trigger points, patients may experience shortness of breath, anxiety, and/or panic as the ribcage cannot expand completely. The shortened serratus also affects the mechanics of the shoulder, stability of the scapula, and referred shoulder pain will occur. The cervical muscles will attempt to compensate, thus eliciting neck pain.The trauma sustained from the restraint of the seat belt also causes spasticity of the iliopsoas muscle. The iliopsoas is one of the body’s most important spine stabilizing muscles. It directly affects lumbar vertebral alignment, range of motion in the hips, sacroiliac joint function, low back pain, and pelvic torsion. The iliopsoas indirectly affects thoracic and cervical spine movement. Force from a shortened iliopsoas muscle causes the patient to stand pitched forward at the waist. For every inch the head is in front of the shoulders it is an additional 12 lb. load on neck muscles and the upper thoracic spine.The mechanics of injury may be different when the airbag deploys. There may be more intense thoracic spine dysfunction or involvement of more vertebral levels if bruising is extensive over the chest wall.By far, the most notable features of pain associated with a motor vehicle accident are the result of rib cage complications, thoracic spine fixation, and iliopsoas muscle spasticity. Why do only certain victims of these accidents—regardless of impact intensity— develop persistent pain?If an accident victim is of average height and weight, does not smoke, and has no history of chronic medical illnesses; for example, diabetes mellitus, rheumatoid arthritis, congenital scoliosis, the body absorbs impact, and may feel no discomfort at all after a few days. This person is beginning at a healthy biomechanical set point, and has elastic and well-hydrated muscles and joints. However, if the victim of an accident has previously undergone spinal surgery, is hypermobile or has degenerative joint disease, the body will not be as flexible, and therefore less able to absorb impact. Connective tissue is less compliant, and dormant myofascial trigger points are activated. Painful vertebral segments fixate, and as the victim functions outside the body’s ability to adapt or compensate, every step compounds pain. The longer the pain persists, the more dysfunctional the nervous system becomes. The more dysfunctional the biomechanics become, the longer the treatment must last.If practitioners do not understand the complexity of the sternocleidomastoid muscle (major neck muscle) and the sympathetic nervous system, they may simply assume patients are exaggerating their painful symptoms. The sternocleidomastoid muscle attaches to the sternum (sterno), clavicle (cleido) and mastoid (a process of the skull) and, invariably becomes shortened and spastic from a car accident. It receives its neural innervation directly from the eleventh cranial nerve (spinal accessory nerve) and from level C2 of the cervical spine. When whiplash occurs during an accident, this muscle can develop myofascial trigger points and subsequently cause teeth and facial pain, headaches, and ringing in the ears. Teeth pain may lead patients to consult their dentist, but he/she will be unable to find a dental problem.The scalene (anterior, middle and posterior) muscles frequently tighten as a result of whiplash, thereby entrapping the brachial plexus. Because this nerve entrapment involves the plexus instead of a single nerve root (such as in a herniated disc), a patient may complain of diffuse arm pain and numbness. However, diagnostic tests such as a cervical MRI may be negative. Inexperienced practitioners may not understand the mechanics of this pain, and as a result, imply their patient is exaggerating. Subsequently, psychosocial complications ultimately remain for the treating pain physician to address. Nerve entrapment from the scalene muscles may not elicit pain that is consistent in location or intensity. Pain varies depending on the body’s activity and position, as well as its capacity to unload neural tension.As time passes, and the cervical and upper thoracic segments remain fixed, neuropathic “wind up” will invariably cause hypersensitivity (allodynia). If the sympathetic nervous system is also dysfunctional, patients may report abnormal sweating, flushing, and anxiety. Cardio-accelerator fibers are connected to the upper thoracic vertebral levels, and patients can even experience cardiac arrhythmia if the spine is critically torqued. The sooner a patient receives treatment, the better the outcome.Case Study – Pain After a Motor Vehicle AccidentA 13-year-old boy was referred to the clinic approximately one year after a school bus accident. Impact from the accident caused him to strike his head on a window. He had intractable headaches, neck pain, and back pain, along with severe tingling and numbness down his right arm. Because the pain interfered with his concentration, he could not complete his school work, nor could he participate in choir or sports. He was evaluated by numerous physicians, including two orthopedic surgeons, a neurologist, a general practitioner, a pediatrician, and an oral surgeon. Previous physical therapy included some soft-tissue mobilization, which changed his pain from a ten to seven. However, his pain was still constant, and it was exacerbated by stress, changes in weather, and recreational activities. The patient had x-rays of his head and neck and nerve conduction studies, which showed no abnormalities. He had been discharged by his previous physical therapist as maximally medically improved. He did not want to try oral braces as recommended by the oral surgery specialist.The patient had a dramatic forward head carriage. Evaluation of his face showed that his left eye appeared much lower than his right eye, and his left neck muscles were severely contracted, causing left rotation of several neck vertebrae. Palpation of these muscles caused tingling and numbness in his right hand. The right shoulder was elevated and shifted forward, and the pelvis was tilted forward, making the patient’s lower back appear swayed. His chest was indented, and palpation of lower back trigger points made the patient’s heart race and his skin perspire.The above body distortions were individually addressed. The pelvis was balanced with lower back trigger point injections and myofascial release physical therapy. The increased heart rate and skin perspiration abated after the pelvis was balanced and the thoracic spine was mobilized. Muscle energy techniques performed over several visits realigned the spine. Intensive myofascial release of chest muscles and neck muscles corrected the forward head carriage. Gradually, the patient’s mood went from silent and despondent to talkative, entertaining and enthusiastic. After treatment the patient returned to choir and sports. He was also able to resume writing, a personal passion.