Whiplash – an expert view from Dr Ramos-Galvez
In his recent article for Your Expert Witness, Dr Ivan Ramos-Galvez examines the complexities of diagnosing and treating whiplash. He explores the devastating effects whiplash can have on a claimant’s quality of life, as well as the challenges, from a litigation perspective, proving the extent of whiplash injuries.
A whiplash injury can be inherently challenging to prove and manage for both the claimant and the defendant in a claim because there is often a lack of physical evidence of structural anomaly. Whiplash is a type of neck injury caused by a sudden movement of the neck in any direction that sprains and stretches the soft tissues of the neck.
The most common event associated with this type of injury is a road traffic accident. However it can be seen following sports injuries, falls or even forceful blows in the head or back. Essentially any sudden change in speed that allows the head to move in a different direction to the body. High speed cameras and dummies in crash tests have shown that in a high-speed crash from behind whilst stationary, the base and the top of the cervical spine flex in opposite directions creating an abnormal S that can cause damage to the supporting structures of the neck, including the facet joints.
Because of its inherent lack of structural abnormality, the natural history of an injury of this type is one of spontaneous improvement within a few weeks. However, in some cases, the symptoms may persist for months or even years, when it can cause significant disability.
The primary symptoms of whiplash relate to the soft tissues of the neck. The head is a significantly heavy structure that is only supported by the small cervical spine at the back of the neck and most of the weight of the head hangs at the front. The spine is a column of bone upon bone that is only held together by a system of strong muscles that wrap around it. Instinctively, the natural reaction of those muscles in case of potential injury of the neck is to protect the spine by tightening up. Therefore, neck pain with loss of movement of the neck and stiffness are commonplace complaints.
If the neck suffers from intermittent spasms within the muscles that hold the spine, headaches can happen, as the nerves that supply the scalp cross those muscles and will get compressed within the muscle fibres. These headaches are normally related to the back of the head and move around the ear towards the front of the head. Because of the neck spasms and stiffness with pain, finding a position that is comfortable to stand, walk or even sleep can be not only painful but also challenging. The most frequently reported injury is the C5/6 segment. The natural radiation pattern of this segment is towards the shoulder blades and upper arms.
As sleep is difficult, an abnormal pattern of sleep that starts to affect the natural day-night cycle can set in. With time this will impair performance and affect memory, attention and ability to react. Over time, the inability to rest as well as the frustration of the constant pain and lack of ability to do “normal things” will affect mood. Eventually the full sequence of loss of quality of life at all levels, but primarily social and economical will follow some sufferers of whiplash.
The aim of the treatment is to try and stop the injury spiralling at the earliest opportunity. In the early stages physiotherapy can help to stop the deterioration and restore normal function. This however may not be effective for all cases. As the symptoms evolve and their effects on daily living increases, more invasive treatments such as facet joint injections can be appropriate. These can help by temporarily switching off the nerve supply to the muscles of the neck. Depending on the result of these, a more permanent treatment may be carried out by means of denervation, a treatment burns the nerves.
All patients will benefit from both a psychological and physical approach to treating the symptoms. This is aimed at increasing the physical thresholds of activity as well as reducing the impact that the lack of activity has on daily living.
From the litigation perspective, the inherent difficulty is being able to show physical evidence of structural anomaly. Imaging of the cervical spine is often normal, or at the most it shows a straight cervical spine, in keeping with tight muscles around the spine. This is compounded by the common finding of osteoarthritis affecting the spine that will be present in a large number of whiplash sufferers. The symptoms of both osteoarthritis and whiplash overlap in many areas. The role of the expert is to determine what preceded, and if the presenting symptoms are related to any pre-existing conditions. In these cases, historic records, past history, GP notes and past referral letters are key. But it is paramount to have a consistent and reliable historian. Pain can be subjective and very different between patients and what may be debilitating for one patient may be manageable for another and symptoms such as stiffness exaggerated. Accurate record keeping, repeated assessments and video surveillance will assist the expert in establishing not only the effect of the injury, but also the reliability of the claimant.
Whilst a few claimants may attempt to mislead professionals by exaggerating the extent of the pain and disability caused by a whiplash injury for a personal gain, whiplash can be extremely painful and disabling and should be taken seriously.