How to Prevent Whiplash! (Part 3)

            Previously, we discussed the topic of whiplash prevention which included the importance of a properly positioned head restraint, airbags, seat belts, and anti-lock braking systems. This month, we will conclude this important topic!

            Electronic Stability Control (ESC): The importance of the ESC safety feature becomes VERY APPARENT when you start to lose control on snow or ice. The ESC helps a driver retain control on slippery roads or when a driver needs to steer around an obstacle (like a fallen tree) at high speeds. As with anti-lock braking systems, ESC compares your intended steering and braking direction to the vehicle’s response related to side and turning acceleration and individual wheel speeds. The ESC can then apply the brakes to individual front or rear wheels and/or decrease engine power to help correct under- or over- steer conditions. It also controls the “all-speed traction control” by sensing drive-wheel slip during acceleration and individually applies the brake to the slipping wheel(s), and/or reduces the engine power until control is regained. Studies have shown ESC can reduce the risk of rollover, especially in sports utility vehicles (SUVs), some vans, and pickup trucks, due to their higher center of gravity. ESC is now a “standard safety feature” on most vehicles with a high roll-over risk. Though ESC cannot prevent a crash in all situations, it definitely helps avoid some! The Insurance Institute for Highway Safety reports that if ALL vehicles had ESC, about 10,000 fatal crashes could be avoided each year!

            Traction Control (TC) Systems: TC (also called ASR - Acceleration Slip Regulation) is designed to prevent loss of traction from the drive wheels when the gas pedal is applied too fast by the driver. When a wheel “slips,” TC senses this and continually adjusts the braking pressure to ensure maximum tire-to-road contact. This is especially useful on icy and/or wet roads to prevent a loss of control. The best way to understand TC is that it’s the reverse or opposite of ABS (anti-lock braking system), as TC limits over acceleration while ABS prevents too much deceleration. For example, when a light turns from red to green and the pavement is icy and the wheel(s) begin to slip, TC will instantaneously slow the wheel(s) down to eliminate the spinning.

            Daytime Running Lights (DRL): These are lights that automatically switch on when a vehicle is moving, typically emitting white, yellow, or amber light. This is a low-cost method to improve the visibility of a vehicle with the objective to reduce daytime crashes. 

            OTHERS: Blind Spot Detection Systems are usually markers on the side of the rear-view mirrors to help drivers keep track of nearby motorists in blind spots. If another car is in a blind spot and a driver activates their turn signal, the system will alert the driver with a sound or light to bring the other vehicle to their attention. This is projected to reduce approximately 450,000 crash cases per year! Another is the Back-up Warning System which sounds an alarm if an object or person is behind the vehicle. Similarly, a Forward Collision Warning with Automatic Braking detects when a driver is about to collide into a vehicle in front by sounding an alarm, flashing a light, or both. The brakes are automatically applied to warn drivers of a hazard. The Lane Departure Warning system warns you that you’re drifting out of your lane by a sound, light, and/or steering wheel vibration. Some system will even nudge you back into your lane!

How to Prevent Whiplash! (Part 2)

            Last month, we covered the importance of your car seat's head restraint for preventing whiplash. This month, let's discuss additional measures one can take…

            AIRBAGS: In addition to a correctly positioned head restraint, having a vehicle that is equipped with airbags has been described as “essential in the prevention of injuries and/or death,” especially in frontal or head-on collisions. Airbags are inflatable devices that fill up in a fraction of a second during a serious motor vehicle collision (MVC). Depending on the year, make, and model of your vehicle, airbags are located in the front of the steering column, by the glove compartment on the passenger side, and possibly in the doors and/or in the column between the doors. These offer additional protection that seatbelts alone cannot provide and can prevent the head and chest from striking the steering wheel, dashboard, or the door in the case of side-impact airbags. The front airbags typically do not deploy in rear or side impact collisions whereas the side airbags will deploy in side impacts and rollovers, thus providing protection between the occupants and doors, side windows, and roof. In order to maximize your protection from injury in a front-end collision, make sure you do the following each time you get into your vehicle: 1) always wear both your lap and shoulder seat belts as airbags are designed to work WITH the lap/shoulder belt system; 2) maintain a safe distance between you and the driver's side airbag of at least 10 inches / 25 centimeters (if you're too close, you risk making contact with the airbag as it inflates which can cause abrasions and bruising); 3) position the steering wheel towards your chest (not your head or neck); 4) move the passenger seat back as far as possible because of the greater distance/larger airbag that exists between the passenger and dashboard; 5) make sure passengers avoid putting their feet up on the dash or placing any objects between their body and the dashboard.

            SEAT BELTS: It has been estimated that in Canada alone, if all drivers and passengers wore their seat belts, 300 road fatalities could be avoided each year! Seat belts have always been considered the BEST way to protect against injury or death in a car crash. These typically cross the lap and chest and prevent the occupant from being ejected or thrown about inside the vehicle in an accident. Here are some important points to remember: 1) wear a lap/shoulder belt system whenever possible; 2) sit up straight, positioning the lap belt low over the pelvic bones/hips, NOT over the stomach; 3) place the shoulder harness over the shoulder, across the chest, and NEVER place the belt under the arm or behind the back; 4) all occupants must wear a seat belt regardless if the vehicle is moving or not; and 5) a pregnant occupant should place the lap belt over the pelvic bones below the baby, not over or above the stomach/baby.

            ANTI-LOCK BRAKE SYSTEMS (ABS): Here, electronic controls stop your wheels from locking up when the brake pedal is forcibly pressed to help the driver maintain control on rough, wet, and slippery surfaces. This helps prevent skidding and can result in a shorter stopping distance.  An ABS can also help drivers more safely steer around what they're heading towards while allowing for maximum braking pressure. Tips include: 1) HOLD / DON’T PUMP the brake pedal firmly; 2) keep steering around objects while fully braking; 3) DO NOT expect the braking distance to be shorter; 4) have the ABS inspected at the recommended number of miles noted in your vehicle’s manual; and 5) MOST IMPORTANT, stay a safe distance behind the vehicle ahead of you – NO TAILGAITING!

How to Prevent Whiplash!

            When we hear the term “whiplash,” we usually envision a rear-end motor vehicle collision that results in the head being thrown to and fro, in a “crack-the-whip” manner resulting in a neck injury. What we DON’T usually think about is “how to prevent whiplash,” which is this month’s topic. Let’s take a look!

            According to the “Whiplash Prevention Campaign,” the most effective way to prevent whiplash injuries in the event of a crash is to purchase a car with a highly-rated head rest and then TO ADJUST THE HEAD RESTRAINT PROPERLY! Although airbags and seat belts (and other safety devices and systems) help protect us in front and side impact collision, a properly designed seat and adjusted head restraint will protect us the most from sustaining a whiplash injury in a rear-end collision.

            Here’s how it works! The most common problem with head restraints is how they're positioned. In most cases, the head restraint is placed too low and too far from the back of the head. In a “typical” rear-end impact, the car and car seat are propelled forwards while the unsupported head stays still resulting in a relative extension of the cervical spine (neck). This “hyper-extension” is exaggerated by a seat that is set in a semi-reclined angle, which causes a ramp-effect that allows the head and neck to slide up and over the head restraint! Also, the “springiness” of the seat back can further augment the forward propulsion of the body upon impact and exaggerates the forward “bounce” of the body and head AFTER the hyper-extension of the neck as the body is propelled forwards in the second phase of the whiplash injury. A properly adjusted head restraint (and seat back angle) does NOT allow the head to ride up and over the head rest thus preventing injury in the initial phase of the rear-end collision.

            To properly adjust your head restraint, have another person assist you while you are properly sitting in the seat. Once the restraint’s position is properly set, place a piece of tape and/or a marker on the head restraint brackets/posts so if someone else drives the vehicle and alters the position, you can easily return it to its proper height FOR YOU! Note: 1) Do NOT recline the seat back greater than 20 degrees; 2) While sitting comfortably, have the other person slide the head restraint upwards until the top of the restraint is EVEN WITH THE TOP OF YOUR HEAD; 3) Move the head restraint forwards so that it is about 5 cm (2 inches) from the back of the head because closer head restraints are two times more effective at injury prevention vs. those set further back!

            Unfortunately, a Canadian study in 2002 found that only about 14% of the headrests evaluated were properly adjusted! In the United Kingdom, the percentage was a little better (28%), but that means 72% of front seat occupants failed to properly adjust their head restraints or they had head restraints that could NOT BE PROPERLY ADJUSTED! Of the remaining 28% who did have the head restraint in the proper position, 11% had a fixed / non-adjustable one piece design and the protection was limited to only a shorter person!

Whiplash and PTSD

            Whiplash injuries commonly result from motor vehicle collisions (MVC) and are caused by a sudden jolt that initiates a startle response that has been found to tighten the muscles deep inside the neck, which has been reported to increase the risk of injury to the joints and structures of the cervical spine. The amount of physical injury to the person is highly variable depending on many factors that include, but are not limited to, the size of the involved vehicles, speed at impact, amount of energy absorbed by crushing metal (especially the lack thereof), a slender female neck vs. shorter muscular male neck, the stiffness and angle of the seat back, the direction of the impact, head position (rotation is worse vs. straight), headrest position, and more. A cervical sprain/strain is commonly diagnosed in MVCs and these tend to resolve with chiropractic care, often without complications. However, this is not always the case. What factors are involved that result in one case improving and/or resolving but not another, especially when everything seems identical (or at least similar)?  What does post-traumatic stress disorder (PTSD) have to do with MVCs? Is this a factor triggering a prolonged recover? Is PTSD commonly associated with whiplash injuries?

            In a group of 112 PTSD whiplash patients, researchers examined the role of pain as well as pain-related psychological variables. Participants completed various questionnaires at three different time points after admission into a standardized multidisciplinary rehabilitation program. The findings revealed consistency with other studies showing injury severity indicators including high pain levels, reduced function / disability, and more severe scores on pain-related psychological variables in those suffering from PTSD following a whiplash injury. However, contrary to expectations, pain severity did NOT contribute to the persistence of PTSD. Rather, the most significant variables were self-reported disability, catastrophizing, and perceived injustice. These results suggest that early intervention that focuses on pain management and disability following whiplash might reduce the severity of PTSD but not the persistence of it. Rather, interventions that focus on resolving perceptions of injustice appear to be most important for helping patients recover from PTSD.

            Similarly, another study looked at the factors that result in the best treatment outcome for patients involved in motor vehicle collisions (MVCs) with the subsequent onset of PTSD. Here, researchers carried out a review of prior studies to identify the risk factors associated with a prolonged recovery and a treatment strategy proposed to resolve the PTSD. They reported that at least 25% of study participants who sustained a physical injury developed PTSD and that the prevalence is most likely even higher in those who developed chronic whiplash.

            Looking at what factors of PTSD are the most accurate predictors of duration and severity of PTSD, another study investigated the relationship between PTSD symptoms of avoidance, re-experience, and hyperarousal and their role in interfering with the resolution, the severity and duration of neck complaints following MVCs. Questionnaires were sent to 240 MVC injured patients that had initiated compensation claims with a Dutch insurance company and were evaluated three times – initially, at six months, and again at twelve months. They found that the hyperarousal symptoms of PTSD initially had predictive validity for persistence and severity of post-whiplash syndrome at six and twelve months. They concluded that the hyperarousal symptoms of PTSD had the greatest detrimental effect on the severity and recovery of PTSD and focusing treatment at that was most important.

Managing Whiplash

            Whiplash is a common injury that is often ignored or improperly treated due to a lack of understanding of the condition. Common whiplash symptoms include (but are not limited to) neck pain/stiffness, headache, shoulder pain and stiffness, dizziness, fatigue, jaw pain (TMJ symptoms), arm pain, numbness and/or weakness, visual disturbances, ringing in the ears (tinnitis), and back pain. In more severe cases, symptoms may include depression, anxiety, anger, frustration, stress, drug dependency, post-traumatic stress, sleep disturbance, sick leave, and lost productivity. Traumatic brain injury symptoms can include difficulty formulating thought, losing one’s place in conversation, fatigue, and “mental fog.” If litigation is involved, it can complicate the situation as well. While most people involved in car crashes recover quickly, some continue to experience symptoms that can last for years after the incident, and chronic pain can have devastating effects on an individual and his/her family.

            A whiplash injury occurs as a result of a “crack the whip” mechanism that occurs very fast and before the muscles have time to react (within 300 milliseconds, which is too fast to voluntarily contract our muscles). About half-way through this process, the lower cervical spine extends while the upper half flexes resulting in significant pressure on the joint capsules in the lower half and the disks in the upper half of the neck. Recently, an interesting study found that there might a way to “trick” the neck muscles so they relax prior to the crash, thus reducing the amount of pressure exerted on the neck structures and potentially reduce the amount of tissue injury. A rear-end collision typically results in neck muscle contractions from a combination of postural and startle responses. Using surface EMG (electromyography) to measures muscle activity, researchers found that the superficial muscle tightness of the neck could be attenuated (decreased) by a loud tone (105dB) 250 milliseconds BEFORE impact. Then, they investigated whether the deep cervical spine stabilizing, involuntary muscles (specifically the multifidus) would respond similarly to a loud tone. (This is important because these muscles attach directly to the small facet joints located in the back of the spine and have the potential to increase the strain in the joint capsules during a crash and contribute to the whiplash injury.) The researchers subjected twelve study participants to simulated whiplash situations both with and without a loud tone. Their results suggest that a loud pre-impact tone may reduce the strain in the cervical spine facet joint capsules, which in turn may reduce the amount of tissue injury during a rear-end collision. These findings are exciting as the degree of injury may be reduced from using this tone prior to an impact.

           

            Early range-of-motion types of care and exercises appear to result in better outcomes than the use of a cervical collar and rest. Similarly, manual therapies including early manipulation, mobilization, traction, and soft tissue therapies have also been demonstrated to produce better outcomes for whiplash patients. Chiropractic offers these treatment approaches to whiplash patients more frequently when compared with other healthcare professions. We also include patient education and advice on posture, proper bending, lifting, pulling and pushing methods, the use of ice over heat (especially initially), and many self-care, home-based treatment approaches. Exercises often include range-of-motion/stretching, cervical curve retraining, strengthening, stabilization exercises, and balance exercises. If dizziness is present, we can show you special exercises to help manage it. An emphasis of transitioning the patient to these active, self-managing approaches is truly appreciated by our patients!

How to Avoid Whiplash!

            Whiplash is a common problem following motor vehicle collisions and because prevention is considered the best medicine, here are some tips to AVOID car crashes altogether …

            Don’t eat, take your eyes off the road while talking, fiddle with the radio or iPod, talk on your cell phone, or text while driving! The National Safety Council estimates 1.6 million crashes are caused by cell phone use, and you're four times more likely to have a crash while talking on a cell phone. In 2011, 23% of auto collisions involved cell phone use, and of those, 21% involving people between ages 16 and 19 were fatal. A good website to check out WITH YOUR CHILDREN is www.textinganddrivingsafety.com. Texting while driving results in a minimum of five seconds of eyes off the road, which is equal to the length of a football field if you're traveling at 55 mph (~88 km per hour). While talking on the phone increases your crash risk by 30%, texting increases your risk 2,300%! About one in seven drivers between ages 16-20 involved in car wrecks admit to texting or talking on their mobile devices at the time of the crash, and 82% of Americans age 16-17 own cell phones. A third say they text while driving, 52% say they talk on a cell phone while driving, and 77% of young adults are very or somewhat confident that they can safely text while driving. About half of young drivers have seen their parents drive and talk on a cell phone, and 15% have seen them texting while driving. One in four adults have sent or received text messages while driving and half of kids age 12-17 have been in a car while the driver was texting. One in five drivers of ALL ages confess to surfing the web or texting while driving AND they “justify it” with excuses like “reading a text is safer than composing and sending one,” “the phone is held near the windshield for better visibility,” “I increase the following distance,” and “I text only at a stop sign or red light.”

            So WHAT CAN BE DONE to change this behavior? Ten states in the United States prohibit ALL drivers from using handheld cell phones while driving and 32 states prohibit novice drivers from cell phone use. Thirty-nine states prohibit ALL drivers from text messaging. Parents can “DRIVECAM” their kids' cars – a device that monitors a driver’s activity and provides real-time feedback with video. Use the AT&T “Drive Mode” app. It's a FREE APP for Android & Blackberry that prohibits texting while driving. Teens and parents can also take the text-free-driving pledge at textinganddrivingsafety.com. Social media sites for anti-texting & driving awareness include Facebook & Twitter: @RayLaHood, @DistrationGov, @NHTSgov, @DriveSafely. Check out blogs such as FromReidsDad.Org, RookieDriver.wordpress.com, ctdrive.blogspot.com, and EndDD.org.

            One Belgium-based project tricked teen drivers into thinking that in order to pass their driving test, they had to be able to successfully text and drive on a tight course. The results on You Tube are both funny AND frightening. Student reactions included: “If this becomes law, I’ll stop driving,” “It’s impossible,” “What you’re asking is dangerous,” “People will die,” and “Honestly, I feel like an idiot who can’t drive.”

            Drive safely and enjoy a long, happy life!

Whiplash – What is It?

            Whiplash -- or “whiplash associated disorders” (WAD) -- is a relatively common injury usually linked with a motor vehicle collision (MVC) during which the head is whipped forwards and backwards (when rear-ended) or sideways (if T-boned). Let’s look at some facts: 1) WAD is often ignored or mistreated due to a lack of understanding about the condition; 2) WAD often occurs as a result of a rear-end collision while stationary, such as stopped at a red light; 3) Early mobilization, manipulation, and exercise can lead to a more rapid, complete recovery vs. prolonged rest or immobilization or the use of a cervical collar; 4) Failure to properly educate and treat the whiplash patient (especially in the first three months) can lead to chronic pain, including psychosocial problems such as depression, anxiety, and poor coping. So, what is whiplash?

            The term “whiplash” encompasses the damage that occurs to the bony spine, and in particular, the soft tissues, while the term “WAD” encompasses ALL the associated injuries and symptoms including the psychosocial problems that can arise due to injured tissues and associated loss of activity tolerance. The good news is that WAD is usually NOT life-threatening, but it can alter the injured person's quality of life and bring economic hardship due to poor work tolerance and high medical expenses while insurance companies dispute over who is at fault. The economic burden on society in the United States is estimated to be as high as $30 billion a year due to medical expenses, disability, sick leave, lost productivity, and litigation!

            Some more facts: 5) While many WAD patients recover without chronic ongoing symptoms, some continue to have problems for years after the injury. 6) A low-speed collision can create significant injury due to the forces being transferred to the occupants rather than absorbed by crushing metal. 7) If the head is turned at the time of impact, the injuries can be worse. 8) Mild traumatic brain injury can occur without hitting the head on anything and create significant cognitive problems (like “mental fog”) and headaches. 9) High-speed cameras have shown that the lower half of the neck extends backwards while the upper half flexes forwards creating an S-shape, which injures the muscles, tendons, and ligaments that hold the cervical vertebrae together. 10) The ENTIRE whiplash process takes place within 500 milliseconds. We cannot voluntarily contract our muscles in less than 800 milliseconds. Therefore, even if we “prepare” for impact, it all happens too fast to prevent the “crack the whip” process to the head and neck.

            Common symptoms of WAD include: neck pain/stiffness, headache, shoulder pain/stiffness, dizziness, fatigue, jaw pain, arm pain/tingling/numbness/weakness, visual disturbances, ringing in the ears (tinnitis), chest/breast injury, and mid and low back pain. When not properly managed, depression, anxiety, anger, frustration, stress, drug dependency, post-traumatic stress syndrome, sleep disturbance (insomnia), restless leg syndrome, fibromyalgia, and more can occur.

            As previously stated, patient education, immediate treatment emphasizing movement (NOT immobilization), proper home/self-management (such as cervical traction), range of motion exercises, strengthening exercises (when appropriate), and positive thinking (as we covered last month) together can help to avoid long-term chronic, disabling problems. You need a “quarterback” to guide you through this process – proper chiropractic care is the answer!

Whiplash – The Power of Positive Thinking!

            When discussing the topic of whiplash injury recovery, prompt assessment, treatment, education, reassurance, and advice can be VERY EFFECTIVE in helping the injured crash victim improve during the acute stage of the injury (first three months). But after three months, when the condition becomes more chronic, which interventions are the most beneficial? More specifically, what is the role of having a “positive outlook” on the outcome of care?

            We can “classify” injuries associated with whiplash into three primary categories: Type I WAD (Whiplash Associated Disorders) - Soft tissue injury without range of motion loss; Type II WAD - Soft tissue injury with cervical or neck motion loss; and Type III WAD - The above PLUS neurological findings (numbness, tingling, and/or muscle weakness). Statistically, patients with Type I and II WAD generally have good treatment results with plans that include exercise and group therapy. At six months, 65% are able to return to work, 92% are able to return to work on at least a part-time basis, and 81% report that no further care is needed. Coordination exercises are also reported to be helpful and are recommended to be included in treatment plans.

            In those with chronic WAD (more than three months of symptoms), patients with negative thoughts did worse than those who were not afraid to perform tasks and who were less emotional in stressful situations. Most importantly, negative thoughts and increased pain behavior can be IMPROVED using a structured treatment approach that includes education about the neurophysiology of pain and how to overcome the fear factor associated with chronic pain behavior. In fact, the MOST important predictor of persistent disability in patients with chronic WAD is how well the injured patient believes he/she CAN perform a task and their emotional reaction to stressful situations. So, how is this done?

            As stated above, an improved knowledge about pain and how the nervous system is “wired” -- from the tip of the finger hitting a hot stove to the central processing center in the brain -- REALLY HELPS. When this process is understood, it reduces much of the “fear of the unknown” that chronic WAD patients experience. When you think about it, pain is actually a good thing, as it warns us when to slow down or stop AND tells us when it’s OK to continue with tasks or desired activities. It helps define boundaries within which we can SAFELY FUNCTION by forewarning us to SLOW DOWN or modify. Exercise and staying active are some of the most important factors for success in  managing almost ALL musculoskeletal conditions, and knowing the difference between “safe” vs. “harm” when it comes to interpreting pain can result in a lower risk for chronic pain problems.

            Once this “knowledge” is understood and appreciated, the injured whiplash patient literally “proves” to him/herself that they are in CONTROL of their condition and can begin to return towards more normal function. The success of this approach centers on introducing the WAD patient to a step-by-step activity re-integration process through structured exercises and careful guidance. For example, muscles can become weak and shrink within 24-48 hours of being inactive. After days, weeks, months, and/or years of modified or stopped activity, this kind of weakness becomes obvious and the whiplash patient may gradually become more and more afraid of performing an activity / exercise in fear that doing so could make the problem worse. This negative thought is a HUGE HURDLE to overcome but must be dwelt with systematically to gain success in returning to life’s required and desired ADLs. As chiropractors, we will guide you in this learning process. When needed, we often work with other healthcare professionals as a team to reach this goal. Remember, THE POWER OF POSITIVE THINKING can make or break a successful outcome – let us help you in this process!

10 Facts You Should Know About Whiplash (Part 2)

           Last month, we reviewed the #1-5 of “10 facts” that you should know about whiplash. Here are #6-10!

6. “Rest = rust” when it comes to whiplash: When we hurt, we often instinctively choose rest over activity, as we may be afraid that any activity will make the pain worse. But after just a few days of rest, both our injured AND healthy muscles become stiff and weak, which prolongs the healing process. Most studies show that returning to normal activity as soon as possible results in faster healing and resolution of pain. Also, the longer you remain inactive, the greater the chance for chronic pain to develop, which can result in permanent problems. We will guide you GRADUALLY back into normal, desired activities. DON’T LET PAIN OR THE FEAR OF PAIN keep you from getting on with life! This is both physically and mentally harmful!

7. You don’t have to be in a car to get whiplash: Even though car crashes account for the majority of whiplash injuries, a slip and fall or participating in a high-impact sport such as football, snowboarding, skiing, boxing, soccer, or gymnastics can result in head/neck trauma, which is more common than you think! With this said, other conditions, such as concussion, can occur in car crashes even if you don't hit your head! The term, “mild traumatic brain injury” or MTBI is frequently used when it pertains to car crashes. Here, common symptoms include difficulty finding words to express yourself, losing your place when talking, and difficulty concentrating, focusing, and communicating. Many people are self-conscious about these types of problems and often do not discuss them with their doctor!

8. Aging increases the risk of whiplash injuries: The elderly are more likely to suffer from a whiplash injury compared with younger individuals. This is because as we age, we lose flexibility in the joints, muscles, and tendons in the neck. This REDUCES the ability for these tissues to stretch, making them MORE likely to be injured during the whiplash process. Also, the shock-absorbing cushions between our vertebrae (the intervertebral disks) lose their water content and literally dry up and crack as we age. This, along with the gradual onset of osteoarthritis in our joints, results in a reduced cervical range of motion.

9. Females are at greater risk of injury than males: This is because there is simply less neck muscle mass and strength among medium built females vs. males. This difference is even more dramatic in slender-necked females. Add the age component to this and the older slender female neck is particularly vulnerable to a cervical spine injury due to whiplash.

10. DO NOT ignore symptoms:  Although most neck-injured crash victims experience immediate pain, some do not. This delay in symptom onset can be hours, days, and even sometimes weeks! Although it’s “human nature” to procrastinate and NOT seek immediate chiropractic care, you should! Studies show that the longer you wait, the longer it may take to help you! Also, in most cases, neck pain should gradually improve within the first month or two, but this does not always happen. The longer pain persists, the lower the odds for resolution, especially if the pain has lasted more than six months. Persisting symptoms may include (but are not limited to) headache, fatigue, shoulder pain, blurred vision, dizziness, difficulty concentrating, communicating, sleeping and/or swallowing. BOTTOM LINE: COME IN ASAP after the crash as prompt care yields the best results!

Whiplash – Why Does it Happen?

            Whiplash injuries are most commonly associated with motor vehicle collisions (MVC), although they can happen from anything that results in a sudden movement of the head -- from slip and fall injuries, carnival rides, sports-related injuries, and more. When associated with MVCs, the terms “acceleration/deceleration injury” or “whiplash associated disorders (WAD)” are often applied, depending on the direction of the collision. When the striking vehicle rear-ends the target vehicle, the term “acceleration/deceleration injury” is used. WAD encompasses all scenarios and also includes the type and extent of injury. The degree of injury has been broken down into four main categories with the least amount of injury = WAD I, and the worst soft tissue injury category as WAD III. Fractures are covered separately in the WAD IV category. It has been found that the more severe the soft tissue injury (WAD III > WAD II > WAD I), the worse the prognosis, or the greater the likelihood of long-term injury-related residual problems.

            We are often asked why the neck is so vulnerable to injury in a MVC. The simple answer is the head, which weighs about 12-15 pounds (~5-7 kg), is supported by the neck and not all necks have the same length, strength, and mass. This is the reason women (especially those with longer, thin necks) are most vulnerable to the forces that occur in a WAD injury. Another reason whiplash injury can occur is the relatively “slow” speed at which we can voluntarily contract our muscles (>600 msec.) vs. relatively fast speed at which a typical rear-end collision takes to move the head on the neck during whiplash (~300 msec.)! Though the whiplash time duration will vary somewhat, depending on the speed of the collision, angle of the seat back, the distance between the head and the headrest, the “springiness” of the seat back, the weight of the two vehicles, the slipperiness of the road, if the brakes are locked, (…AND MORE!), here’s a typical breakdown of what takes place in a rear-end collision (within a 300 millisecond “typical” time frame):

0 ms	The rear-end is impacted and the car is propelled forwards and/or crushes while the occupant(s) remain stationary. No force is yet applied to the occupant.
100 ms	The seat back accelerates the torso forwards while the head stays stationary (due to inertia).
150 ms	The torso/trunk may “ramp up” the seat back (esp. if reclined); the lower neck is pushed forwards by the accelerating torso/seat; the upper neck/head rotates and hyper-extends backwards.
175 ms	The head is still moving backwards while the torso starts to spring and accelerate forward, as the head reaches a peak of full extension.
300 ms	As the head, neck and torso continue to accelerate, the neck/head is “whipped” forwards hyper-flexing the neck.

            The degree of injury is affected by all the items previously listed above and more. For example, if the headrest is more than two inches (~5 cm) away from the back of the head, and/or if “ramping” occurs and the head “misses” the headrest, hyper-extension can result and the soft tissues in the front of the neck can become over-stretched and/or the back of the neck can become over-compressed. Or if the rebound phase into flexion exceeds the tissue capacities, the back part of the neck can become over-stretched and the front part over-compressed.

Whiplash "Basics"

            Whiplash is a non-medical term typically describing what happens to the head and neck when a person is struck from behind in a motor vehicle collision. Let’s look at some basic facts about whiplash:

·         Before cars, trains were the main source of whiplash and was called “railroad spine.”

·         Better terms for whiplash injuries include “cervical acceleration-deceleration” (CAD) which describes the mechanism of the injury, and/or the term "whiplash associated disorders" (WAD), which describes the residual injury symptoms.

·         Whiplash is one of the most common non-fatal injuries involved in car crashes.

·         There are over one million whiplash injuries per year due to car crashes alone.

·         An estimated 3.8 per 1,000 people per year have a whiplash injury.

·         In the United States alone, 6.2% of the population has “late whiplash syndrome” (symptoms that do not resolve at one year).

·         1 in 5 cases (20%) remain symptomatic at one year post-injury of which only 11.5% returned to work and only 35.4% of that number returned to the same level of work after 20 years.

·         The majority of whiplash cases occur in the fourth decade of life, females>males.

·         Whiplash can occur from slips, falls, and brawls, as well as from horse-riding, cycling injuries, and contact sports.

·         Injury from whiplash can occur at speeds of 15 mph or less.

·         In the “classic” rear end collision, there are four phases of injury (time: 300msec)

o        Initial (0msec) – before the collision (the neck is stable)

o        Retraction (1-150msec) – “whiplash” starts where the head/neck stay in the original position but the trunk is moving forwards by the car seat. This is where the “S” shaped curve occurs (viewing the spine from the side).

o        Extension (150-200msec) – the whole neck bends backwards (hopefully stopped by a properly placed head rest).

o        Rebound (200-300msec) – the tight, stretched muscles in the front of the neck propels the head forward immediately after the extension phase.

·         We simply cannot voluntarily contract our neck muscles fast enough to avoid injury, as injury to the neck occurs within 500msec. and voluntary contraction or bracing takes 800msec or longer.

·         Injury is worse when the seat is reclined as our body can “ramp” up and over the seat and headrest. Also, a springy seat back increases the rebound affect.

·         Prompt treatment is better than waiting for a long time. Manipulation is a highly effective (i.e., COME SEE US!) treatment option.

Whiplash “101” (Part 2)

            Our current Whiplash topic continues from last month when we reviewed the “mechanism of injury,” the “type of injury,” and “prognosis.” This month, we will review the “nuts and bolts” of the whiplash injury or, whiplash associated disorders (WAD). 

Whiplash diagnosis: The diagnosis of whiplash first and foremost requires a thorough history. Here, we discuss the factors leading up to the MVC (motor vehicle collision), the angle or direction of impact (front end, angular, side or T-bone, rear end), whether the head was pointed straight or rotated, whether the head hit anything inside the car, airbag deployment and any related injury, seat belt location and effectiveness, the conditions of the day (weather, road, lighting, etc.), the onset of each injured area including neck, upper/lower back, headache, memory loss, and radiating symptoms (time lapse to symptom onset), ER/ambulance involvement, the initial 24-48 hours, the point of maximum pain intensity, job and non-vocational capabilities, prior test results (x-ray, CT, MRI, lab, etc.), prior treatment effectiveness, and more! The physical examination centers on observation (posture, patient distress, mood); palpation or touching the injured areas; orthopedic tests (looking for positions that either relieve or increase symptoms); range of motion (how far forward, back, sideways, and in rotation can the head be voluntarily moved and its related level of comfort, speed/quality of motion); neurological exam (sensory, motor, cranial nerves, etc.); and special tests (x-ray, CT, MRI, lab, etc.) if not previously done.

Course of care: The type and length of treatment will vary based on the degree of injury (see last month’s “prognosis” discussion), the initial response to care (improvement vs. worsening), the compliance of the patient in modifying their activities, performing home-based care (ice, rest, exercise, etc.), and the patient’s motivation to get better. The latter may be partially dependant on factors like whether there is litigation planned or occurring, their belief that they will “get better,” and how the health care provider manages the care (the use of passive approaches where the patient must go and see the doctor vs. active approaches where the patient is taught how to self-manage through diet, exercise, activity modifications, education, etc.)

Treatment options: The patient has the choice of following a traditional medical model of initial anti-inflammatory medication, patient education, wait and watch, and/or a physical therapy referral. The chiropractic approach includes patient education, anti-inflammatory approaches (ice – NOT HEAT, anti-inflammatory herbs), exercise training and manual therapies including spinal adjustments. The latter, when applied properly, has been found to return patients to work faster than other approaches with a shorter recovery time and is less costly and more satisfying. When comparing treatment options beyond 6 or 12 months, the differences are more subtle. Other treatment options include acupuncture, massage therapy, and various forms of exercise. When necessary, injections, narcotics, and other pharmaceutical options exist but are not recommended as initial care approaches. Behavioral and cognitive therapy can help people cope with chronic, permanent pain related problems. There are many approaches to the management of whiplash and the patient needs a “quarterback” or someone to help them with these decisions. This is perhaps the most important role of the chiropractor!

Whiplash “101”

            Whiplash refers to an injury to the neck resulting from a rapid movement, usually associated with a motor vehicle collision (MVC). However, it can occur with a slip and fall injury, a bar room brawl, during a sports event like being tackled in football, among other things. For the sake of this discussion, we will stick with the classic example of a rear-end MVC.

            Mechanism of injury: So what really happens during the MVC that causes injury? The answer centers around movement of the neck which exceeds the normal tissue’s stretch limits, sometimes referred to as “the elastic barrier.” When the MVC occurs, during the first 100-200 milliseconds the trunk supported by the back of the car seat rapidly moves forwards leaving the head unprotected in its original position resulting in a backward glide or motion of the head and neck. Next, the head (which weighs about 12-15 pounds) drops back (HOPEFULLY) into the headrest stopping the motion, but if the head rest is too far back (>1/2 inch) or too low, then the head keeps going backwards until the tissues in the front of the neck stretch to the point of either stopping the motion or tearing (or both). Next, the highly stretched front of the neck muscles, ligaments, disks, and tendons (in a “crack the whip” like manner) propel the head forwards to the point of over stretching the tissues in the back of the neck, which similarly stops the movement &/or tears. The degree of injury depends on many things, but is notably worse in the long-necked, skinny female where the “crack the whip” reaction is the greatest. Several factors determine the degree of injury, including the “G-Force,” or the amount of energy produced during the impact. The greater the G-force applied to the head/neck, the greater the potential for injury. The G-force affecting the occupants inside the vehicle is related to many things: the speed of the crash, the size of the two vehicles (worse if a large automobile hits your smaller car), the angle and springiness of the seat back, the amount of energy absorbed by crushing metal vs. no damage to the vehicles (worse when there is no damage as all the energy is transfer to the occupants), whether the head was rotated or looking straight at impact, and more. The KEY to all of this is that we cannot voluntarily contract our muscles quicker than 800-1000 msec and the whiplash process is over after about 500 msec, so we can’t effectively “guard” or protect ourselves against injury even if we try by bracing ourselves before the MVC!

            Type of injury: The classic injury is called a sprain (ligament tear) and strain (muscle and/or muscle tendon tear) to either or both the front of the neck and/or back of the neck. Sprains and strains come in 1st, 2nd, and 3rd degree tears, getting progressively worse as more tissue is torn. Please refer to previous issues of the Whiplash Health Update where the anatomy is reviewed so you can “picture” this properly.

            Prognosis: The length of time to recovery or maximum improvement varies by the amount of tissue damage. A “prognosis scale,” first introduced in 1995 and validated by 2001, showed that in Type 1 injuries pain without loss of neck motion healed the quickest. Type 2 injuries where neck movement was reduced after the MVC (but no neurological findings occurred) healed next quickest. Type 3 injuries, which included BOTH motion and neurological loss, healed the slowest and had the worst long-term outcomes. Other factors enter into this, of course.

            We will continue this “Whiplash 101” discussion next month…

Whiplash “Syndrome”

            The term “whiplash” is a slang term for a neck injury most accurately called a cervical acceleration-deceleration (CAD) injury. Now you know why we call it “whiplash”! It suggests that the head was forced through a range of motion that exceeds the barriers of our normal tissue, resulting in injury to the neck.

            Though a slip and fall, or even a bar-room brawl, can cause whiplash, whiplash is usually associated with injuries that occur from a car accident or “motor vehicle collision” (MVC). The term “syndrome” refers to a cluster of symptoms that can include neck pain, headache, light-headedness, ringing in the ears, visual disturbances, memory loss, nausea/vomiting, noise and/or light sensitivity (usually associated with mild traumatic brain injury or, post-concussive syndrome), TMJ (jaw) pain, radiating pain, numbness, and/or weakness in the arm, limited neck movements, and more. Even the low back can be injured in a whiplash injury!  In other words, a whiplash injury can affect MANY different parts of the body, and the clinical picture can vary widely from case to case.

            Whiplash is diagnosed through a thorough history, paying particular attention to the mechanism of injury – that is, how fast were you and the opposing vehicle traveling, in what direction did you get hit (front, side, rear, angular, or combinations), what size was your vs. the opposing vehicle, was your head turned or pointed straight at the time of impact and did you hit your head? Also, we will ask, what were your immediate symptoms compared to 30 min., 60 min., 3 hrs, 6 hrs later, the next morning, and when did your symptoms peak? What activities (including work) have been affected, and to what degree? What self-management approaches have you tried, and how have they worked? The more we can learn about the accident and your immediate symptoms, or delay in symptom onset, the better we can address your problems. The physical examination is also very important as we will observe your movement quality, posture, pain expression, palpate for muscle guarding, trigger points, and swelling of the injured joints. We will also evaluate your neck and back range of motion, assess your neurological functions, and assess extremity issues that might be present. X-rays will more than likely be done and may include “stress views” where you bend the neck forwards and backwards to assess the stability of your spine. Comparison to older x-rays can be very helpful, if they exist. Depending on the degree and type of the injury, special tests will be considered such as MRI, EMG/NCV, laboratory tests, and perhaps others.

            Treatment will consist of: addressing the acute inflammatory painful symptoms by the use of gentle massage, mobilization and/or manipulation, electrical stim or a different anti-inflammatory modality, review how to apply ice and/or heat, how to bend/lift/pull & push properly to avoid irritation. We’ll teach you exercises, proper sleep positions, and other home applied, self-help techniques. The goals of pain management, functional restoration, and prevention will be applied. If needed, coordinating care between our office and primary care, orthopedic, neurology, or others will be smoothly managed as the need arises.  

Whiplash Facts

            “Whiplash” is considered a non-medical term that encompasses a range of injuries. These injuries typically affect the neck and are caused by a sudden movement of the neck associated with extension or forceful backward bending. The medical term “cervical acceleration-deceleration” (CAD) is considered to be a more accurate description of what happens during a car accident, and the term “whiplash associated disorders” (WAD) describes the injury’s residual signs and symptoms.

            WAD or CAD is most commonly associated with motor vehicle collisions (MVCs), when a vehicle is struck from behind. Other less common causes include: dancing (especially “headbanging”), falls from stools or ladders, bicycle injuries, horse related injuries, and many others. In the UK in 2007, 430,000 people made an insurance claim for WAD, accounting for 14% of every driver’s premium. In the US, over 1 million WAD injuries occur annually due to car accidents alone with an estimated 3.8 cases per 1000 people per year. An estimated 6.2% of the US population has “late whiplash syndrome” or long-term problems associated with WAD.

            Prior to the advent of the automobile, WAD was referred to as “railroad spine” (as it resulted from a train crash), first documented in 1919. WAD also occurred frequently in pilots landing on aircraft carriers due to the rapid deceleration that occurred as the planes landed and suddenly braked. When one thinks of “whiplash,” the visual of a high speed crash comes to mind. However, WAD can occur at speeds less than 15 mph due to less crash energy absorption by crushing metal. Since there is less car damage at lower speeds, that energy is transferred to the contents (the people) inside the car.

            The neck consists of 7 vertebrae, the 6 disks, the 8 pairs of nerves, and the muscles, ligaments and other “soft-tissues.” There are 4 phases of injury (initial, retraction, extension and rebound), which all occur within 300 msec. Whereas, it takes about 800msec to voluntarily contract a muscle. Therefore, you can’t really “prepare” or fully brace for the impact. Most injuries occur at C5 and C6 in the lower part of the neck between 150 and 300 msec. of the cycle. Factors that influence injury include: the seat back angle, the seat back rebound, the headrest position, the direction the head is positioned at impact (worse if rotated), the occupants gender (females are at greater risk due to a more thin, less muscular neck), the size of each vehicle involved, and more. All these factors make it extremely challenging to accurately reconstruct a MVC on paper.

            The most common symptoms associated with WAD include neck and upper back pain and headache, referred pain into the mid-back or down an arm and sometimes legs. The onset of symptoms can be immediate or delayed for days. Risk factors that worsen the prognosis of a case include: the presence of radiating pain from the neck to the arm and hand that follows a specific nerve, failure to respond to initial treatment, a delay in getting treated, and being placed in a cervical collar (especially if not allowing to be mobilized and exercised -- i.e. chiropractic care). The key to the success of WAD treatment is to get treated immediately, don’t restrict yourself to a cervical collar, unless you have an unstable fracture, and do your exercises!

Whiplash Avoidance (…continued)

            Last month, we discussed car safety features, proper headrest position, how to prepare for a crash, and to seek immediate treatment as ways to minimize the chances of suffering from whiplash in the event of an accident. Here are four more ways to avoid or minimize whiplash:

PAY ATTENTION WHILE YOU DRIVE. Too often, we get distracted while driving. Any time our eyes leave the road, the potential for an accident increases significantly. This can occur when changing the radio to a different station, eating while driving, reading while driving, talking on the phone, texting (equals the effects of 2-3 alcoholic beverages), driving under the influence of certain prescription medications (pain killers for example), driving under the influence of alcohol or other chemical agents, and turning your head during conversation. We have a responsibility when we are driving to keep our eyes on the road, as many accidents occur within split seconds of time. If we are not paying attention, we will not be able to avoid a potential collision.

THE CONCEPT OF "NO CRUSH, NO CRASH INJURY" IS SIMPLY NOT TRUE. In fact, just the opposite is true. That is, the greater the amount of crushing metal at the time of collision, the greater the amount of energy absorption that occurs, resulting in less force transferred to the contents inside the vehicle (namely you or me). This is why, many times, people are injured in low speed collisions because there is no energy absorbed by crushing metal as noted by the absence of or, minimal damage to the car.

FOLLOWING YOUR DOCTOR'S ORDERS. It is very important that we do not inadvertently hurt or harm ourselves further by NOT following the advice of our health care practitioner. This means initially using ice to reduce inflammation and swelling, possibly wearing a soft cervical collar during the first few days after the injury to “rest” the injured structures, following proper nutritional advice for optimal healing benefits, and following exercise recommendations. This last treatment approach is vital in the prevention of long term, chronic neck complaints. Other ways you can REALLY help are to follow cervical traction orders. Cervical traction is a very effective method of reducing muscle spasm, separating the joint spaces, improving disk nutrient transfer and water content, reduce the pinching effect of the nerves, and as a result, speeding up the recovery process. Follow your treatment schedule; that is, DON’T SKIP APPOINTMENTS! During office visits, it is necessary to discuss not only what is working well, but also what may not be working so modifications to your care plan can occur on a timely basis. The primary goal of whiplash management is to prevent the condition from becoming chronic and long-term, and the first few weeks of treatment are critical!

ERGONOMIC MODIFICATIONS. An important part of managing whiplash injuries is preventing daily irritations from tasks that we have to do. Hence, we will discuss adjusting your work station for optimum positioning and avoidance of poor posture, such as using office chairs with arm rests, sitting posture modifications, and computer monitor positioning. Proper sleep positions and pillow design are also reviewed.

Whiplash Avoidance

            Whiplash, or more properly stated, Whiplash Associated Disorders (WAD), is usually associated with car accidents, slip and falls and sports injuries. It is a very common injury affecting millions of people around the world, and costing health care systems billions of dollars. The question of the month is, what can we do to AVOID or prevent whiplash?

STEP 1. SHOP FOR A SAFER CAR. There are many resources that you can review such as the “Insurance Institute for Highway Safety” that have published ratings for the safest seats, head restraints, and include many makes and models of cars, SUV’s and trucks. For example, Volvo and Saab have recently designed car seats where the seat back collapses backwards upon impact so as to minimize the rebound response in a rear-end collision, thus minimizing the head and neck from whipping back and forth. Therefore, before YOU purchase your next car, compare the vehicle’s structural design, its size and weight, the restraint systems, the airbags, the head rests, as well as crash avoidance features. Remember, in general, small cars put you at greater risk simply due to the small mass equaling less protection.

STEP 2. POSITION THE HEAD RESTRAINTS PROPERLY. This means put them in their “up” position. The most common problem with head restraints is that they are placed too low and offer little to no protection if and when you are struck from behind. In fact, 80% of cars have the head restraint in the low or “down” position, which (surprisingly) is WORSE than having no head restraint at all! This is because when the head restraint is too low, it acts like a fulcrum, hitting the middle of the neck promoting MORE hyperextension when compared to having no head restraint whatsoever. Remember, head restraints are designed to fit an “average man,” making it challenging for a tall or short person to obtain a good "fit." A good position for a head restraint is within 1 inch of the back of the head and 1-2 inches above the mid-portion of the head as “ramping” often occurs especially if the seat back is reclined backwards, and the whole body slides up and over the head restraint.

STEP 3. PREPARE FOR THE CRASH. This actually may NOT be possible since the “whipping” action happens within 500 milliseconds and voluntary muscle contraction is about twice as slow, not to mention that the crash can occur at lightning fast speeds leaving you with little time to prepare. However, if you do have time to prepare, do the following: 1. Put your head and neck all the way back into the seat back and a properly adjusted head restraint so that there is firm contact. 2. Extend the elbows and straighten the arms gripping firmly onto the steering wheel in preparation to brace yourself. 3. Place your foot on the brake as firmly as possible (assuming that you are stopped in traffic). 4. Look straight ahead avoiding neck or head rotation. 5. Tilt your head back slightly so that your eyes are pointed toward the top of the windshield. 6. Prior to impact, shrug your shoulders upwards toward the ears and brace yourself firmly.

STEP 4. SEEK IMMEDIATE TREATMENT. It is critical to obtain treatment as quickly as possible as there is a tremendous advantage to start treatment especially with the first 2 weeks post-collision to avoid the likelihood of a chronic potentially disabling condition.

The Whiplash Syndrome

The term “whiplash” was coined by Dr. Harold Crowe in 1928 during an interview on car collision related neck injuries but he reportedly “…regretted it later.” The term “whiplash” quickly became a household word and relates to a sudden movement of the head producing a neck sprain. It is now accepted that not only forward/backward movements during motor vehicle collisions (MCV) result in neck injury but also side to side and angular movements at the time of impact. In the past, we’ve discussed the number of milliseconds that takes place during the whiplash process after impact (~500 msec.) and the fact that voluntary muscle contraction takes longer (~800 msec.) making it next to impossible to adequately “brace” prior to impact, even when the collision is anticipated. Today, we’re going to look at the symptoms and complaints that are commonly described by whiplash patients.

“Early whiplash syndrome” is defined as the condition where immediate or very close to immediate symptoms are noted. One study reported symptoms commonly described after a MVC include the following: neck pain (93%), headache (72%), shoulder pain (49%) and back pain (38%) and, 87% of patients had multiple symptoms. Others reported nausea (48%) and dizziness (38%) as initial symptoms. For some, many of these symptoms resolve within days, weeks or months leaving a smaller percentage with symptoms that last beyond 6 months, which is then referred to as “late whiplash syndrome.” In one study of 52 patients, symptoms improved over a 2 week to 12 month time frame but then remained static or unchanged for the following year. Another study of 117 patients at the 2-year point, reported the following symptoms (the frequency of occurrence is in parentheses): Neck pain (17%), headache (15%), fatigue (13%), shoulder pain (13%), insomnia (12%), anxiety (11%), concentration loss (10%), and forgetfulness (10%).

Reasons for the continuation into a late syndrome are supported by two possible causes. 1. It is due to a high level initial symptom, including severe neck pain and headache often with radiating arm pain (radiculopathy). 2. It is caused by the stressful events that are present either at the time of the motor vehicle collision or soon thereafter. These stressors could include work loss, marital stress, financial stress, and/or depression or anxiety issues associated with being injured. It was also reported that the specific type of headache suffered in the late whiplash syndrome in a 47 patient study, 74% had tension-type headache, 15% had migraine and 11% had cervicogenic headache. Some authors have reported that the type of headaches that occur as a result of an MVC are similar to almost identical to those seen after head trauma from other causes including sports injuries such as football, hockey, and boxing.

Because “whiplash” results in a mechanical type of injury to the small joints of the neck, muscles and ligaments, the only logical choice for management and treatment is chiropractic.  This is because chiropractic addresses the mechanical injury with a manual, hands-on approach specifically aimed at restoring function in the injured area. Studies are clear that whiplash patients make a faster, less painful recovery, return to work and desired activities faster and are the most satisfied when utilizing chiropractic when compared to covering up the symptoms with medications that have negative side effects that interfere with being able to think and ultimately, reduce productivity.

           

We realize you have a choice in where you choose your healthcare services.  If you, a friend or family member requires care for whiplash, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.