Is Whiplash the Cause of My Dizziness?
Whiplash, or better termed “Whiplash Associated Disorders” (WAD), is a condition that carries multiple signs and symptoms ranging from neck pain and stiffness to headache, confusion, ringing in the ears, and more. But can WAD cause dizziness? Let’s take a look! Dizziness is a general term that is used rather loosely by the general population. We’ve all experienced dizziness from time-to-time that is considered “normal,” such as standing up too quickly or while experiencing a rough flight.
Often, dizziness and problems with balance go hand in hand. There are three main organs that control our balance: 1) the vestibular system (the inner ear); 2) the cerebellum (lies in the back of the head); and, 3) the dorsal columns (located in the back part of the spinal cord). In this article, we will primarily focus on the inner ear because, of the three, it’s unique for causing dizziness. Our vision also plays an important role in maintaining balance, as we tend to lose our balance much faster when we close our eyes. It’s appropriate to first discuss the transient, usually short episode of “normal” lightheadedness associated with rising quickly. This is typically caused by a momentary drop in blood pressure, and hence, oxygen simply doesn’t reach the brain quick enough when moving from sitting to standing. Again, this is normal and termed “orthostatic hypotension” (OH).
However, OH can be exaggerated by colds, the flu, allergy flair-ups, when hyperventilating, or at times of increased stress or anxiety. OH is also associated with the use of tobacco, alcohol, and/or some medications. Bleeding can represent a more serious cause of OH such as with bleeding ulcers or some types of colitis, and less seriously, with menstruation.
The term BPPV or benign paroxysmal positional vertigo, has to do with the inner ear where our semicircular canals are located. The canals lie in three planes and give us a 3D, 360º perspective about where we are in space. The fluid flowing through these canals bends little hair-like projections, which are connected to sensory nerves that tell the brain about our spatial position. If the function of these canals is disturbed, it can mix-up the messages the brain receives, thus resulting in dizziness. Exercises are available on the Internet that can help with BPPV (look for Epley’s and Brandt-Daroff exercises).
DANGEROUS causes of dizziness include: HEART – fainting (passing out) accompanied by chest pain, shortness of breath, nausea, pain or pressure in the back, neck, jaw, upper belly, or in one or both arms, sudden weakness, and/or a fast or irregular heartbeat. STROKE – sudden numbness, paralysis, or weakness in the face, arm, or leg, especially if only on one side of the body; drooling, slurred speech, short “black outs,” sudden visual changes, confusion/difficulty speaking, and/or a sudden and severe, “out of the ordinary” headache. CALL 911 (or the number for emergency services if you’re outside the United States) if you suspect you may be having a heart attack or stroke!
Concussion, The Cervical Spine, and Spinal Manipulation
Mild traumatic brain injuries are also known as concussions. It is estimated that these injuries have a prevalence of 3.8 million per year in the United States.
Despite this high incidence, mild traumatic brain injuries and concussions are one of the least understood injuries facing the sports healthcare and the neuroscience communities today.
In the majority of patients sustaining a concussion, symptoms resolve within 7–10 days. However, approximately 10–15% of these patients develop persistent symptomatology lasting weeks, months or even years after injury. This phase of chronic symptoms is known as the post concussion syndrome. The patient is considered to be chronic when symptoms persist longer than 4- 12 weeks.
It is assumed that the post-concussion syndrome manifests secondary to brain injury leading to alterations in brain biochemistry, neurophysiology, and metabolism; the problem is assumed to be in the brain. However, four lines of evidence challenge this assumption:
First Line of Evidence The standard treatment for mild traumatic brain injury and the post-concussive syndrome is rest. This approach works well for 85-90% of these patients, but not for those suffering from the post-concussive syndrome. This suggest that perhaps an etiology other than brain injury is responsible for the ongoing symptomology.
Second Line of Evidence There is considerable overlap of the signs and symptoms of mild traumatic brain injury and of whiplash associated disorders. This would suggest the possibility that the post-concussive syndrome symptoms may in fact be arising from the cervical spine.
Concussion and Whiplash – Is There a Connection?
Whiplash or whiplash associated disorders (WAD) represent a constellation of symptoms that are very similar to those reported by patients who have sustained a concussion or minor-traumatic brain injury (mTBI). These shared symptoms include (but are not limited to): headache; neck pain; nausea/vomiting; dizziness; balance issues; vision problems; and difficulty concentrating. Chiropractic care focused on the cervical spine has been demonstrated to benefit patients with WAD. Is it possible that the same form of treatment can help the mTBI patient as well?
In the March 2015 issue of the journal The Physical and Sports medicine, researchers looked at case studies involving five patients with concussion symptoms that did not resolve within 30 days and had become chronic. The mechanism of injury in three of the cases was sports-related, while the other two stemmed from a slip and fall and a motor vehicle collision. Treatment focused on the cervical f either spinal manipulative therapy (SMT) or mobilization; active release technique (ART) to stretch tight neck muscles; and exercises aimed at strengthening the deep neck flexor muscles and/or other surrounding neck musculature.
•Case 1: A 25 year old professional mixed martial arts male injured from sparring presented four months after the injury. After three treatments, he reported a significant reduction in symptoms, with full resolution after eight treatments.
•Case 2: A 59 year old female who hit the back of her head on the ground after a fall presented with 31-month duration of symptoms that reportedly improved significantly within three months of twice-per-week treatments.
•Case 3: A 19 year old make junior hockey player presented two years after the initial injury and reportedly experienced an 80% improvement in his symptom after four treatments spread out over a three week timeframe.
•Case 4: A 19 year old male injured in a car accident presented 14 weeks after the injury and reported a nearly 50% reduction in symptoms after one treatment and full resolution after eight treatments.
•Case 5: A 51 year old female hockey player who was struck on the left side of the head presented five weeks post-injury and reported a full resolution of symptoms after three treatments per week for six weeks.
The important point here is that treatment was aimed ONLY at the cervical spine, not the concussion, with excellent results in each case. These findings indicate the need for larger studies concerning the use of conservative chiropractic care for cases of mTBI that do not resolve within a month’s time.
Collisions & Concussions – New Data!
Are you of the belief that you have to hit your head in order to have a concussion or that concussions are easily diagnosed and managed? If so, then you are not alone! In fact, traumatic brain injury (TBI)—the proper term used when bleeding occurs within the skull occurs—and mild traumatic brain injury (mTBI)—the term applied when no bleeding occurs—remains poorly understood by many healthcare providers. This is partly due to not having any definitive method of testing that yields an accurate diagnosis.
Another problem is the under-reporting of concussion, as close to 40% of people who experience an mTBI do not report it to their doctor. Because of the significant negative consequences regarding the outcome and whole life ramifications associated with concussion, the importance of improving on the ability to diagnose or identify and treat concussion is huge!
We know that mTBI results from the transfer of energy from environmental forces to the brain by a sudden acceleration followed by a sudden deceleration that literally slams the brain into the inside bony skull.
The clinical work-up must include a review of body systems, with a special emphasis on the nervous system, including cognitive and behavioral symptoms. A partial list of post-concussion syndrome symptoms includes headache, balance problems, nausea and/or vomiting, vision problems, dizziness, brain fog (problems with attention, concentration, and speed of mental processing), memory problems, fatigue/drowsiness, light/noise sensitivity, and more.
The good news is that many mTBI sufferers fully recover, but the bad news is up to 25% do not! Promising newer technologies such as Diffuse Tensor Imaging can identify injury to the neural structures (axonal shearing) in those who’ve experienced a head trauma (such as from a car accident, sports injury, or slip and fall). The Sports Concussion Assessment Tool 2 (SCAT2) has been adopted by numerous sports leagues and others, but many healthcare practitioners do not utilize a structured tool such as this.
One promising tool is a blood test that measures brain-derived neurotrophic factors (BDNF)—a chemical hormone that helps maintain the health of neurons (nerve cells)—which can help diagnose mTBI conclusively and with good reproducibility! Blood levels of BDNF typically are low in patients with TBI or mTBI, and studies have shown patients with very low levels of BDNF are more prone to an incomplete recovery.
Put simply, this type of blood test can help a doctor diagnose, determine the severity, and determine the likelihood of recovery of TBI/mTBI! Doctors of chiropractic are frequently sought out by those with mTBI and understand the importance of careful management of this common and often poorly identified condition.
Can Chiropractic Help My Concussion?
Whiplash Associated Disorders (WAD) is the appropriate terminology to use when addressing the myriad of symptoms that can occur as a result of a motor vehicle collision (MVC). In a recent publication in The Physician and Sportsmedicine (Volume 43, Issue 3, 2015; 7/3/15 online:1-11), the article “The role of the cervical spine in post-concussive syndrome” takes a look at the neck when it’s injured in a car accident and how this relates to concussion.
It’s estimated about 3.8 million concussion injuries, also referred to as “mild traumatic brain injury” (mTBI), occur each year in the United States. Ironically, it’s one of the least understood injuries in the sports medicine and neuroscience communities. The GOOD NEWS is that concussion symptoms resolve within 7- 10 days in the majority of cases; unfortunately, this isn’t the case with 10-15% of patients. Symptoms can last weeks, months, or even years in this group for which the term “postconcussive syndrome” (PCS) is used (defined as three or more symptoms lasting for four weeks as defined by the ICD-10) or three months following a minor head injury (as defined by the Diagnostic and Statistical Manual of Mental Disorders).
There have been significant advances in understanding what takes place in the acute phase of mTBI, but unfortunately, there is no clear physiological explanation for the chronic phase. Studies show the range of force to the head needed to cause concussion is between 60-160g (“g” = gravity) with 96.1g representing the highest predictive value in a football injury, whereas as little as 4.5g of neck acceleration can cause mild strain injury to the neck. In spite of this difference, the signs and symptoms reported by those injured in low-speed MVCs vs. football collisions are strikingly similar!
Research shows if an individual sustains an injury where the head is accelerated between 60- 160g, it is HIGHLY likely that the tissues of the cervical spine (neck) have also reached their injury threshold of 4.5g. In a study that looked at hockey players, those who sustained a concussion also had WAD / neck injuries indicating that these injuries occur concurrently. Injuries to the neck in WAD include the same symptoms that occur in concussion including headache, dizziness/balance loss, nausea, visual and auditory problems, and cognitive dysfunction, just to name a few.
The paper concludes with five cases of PCS that responded well to a combination of active exercise/rehabilitation AND passive manual therapy (cervical spine manipulation). The favorable outcome supports the concept that the neck injury portion of WAD is a very important aspect to consider when treating patients with PCS!
This “link” between neck injury and concussion explains why chiropractic care is essential in the treatment of the concussion patient! This is especially true when the symptoms of concussion persist longer than one month!
Can a Low-Speed Crash Cause a Brain Injury?
There is certainly a lot of interest in concussion these days between big screen movies, football, and other sports-related injuries. Concussion, traumatic brain injury (TBI), and mild traumatic brain injury (mTBI) are often used interchangeably. Though mTBI is NOT the first thing we think about in a low-speed motor vehicle collision (MVC), it does happen. So how often do MVC-related TBIs occur, how does one know they have it, and is it usually permanent or long lasting?
Here are some interesting statistics: 1) The incidence rate of fatal and hospitalized TBI in 1994 was estimated to be 91/100,000 (~1%); 2) Each year in the United States, for every person who dies from a brain injury, five are admitted to hospitals and an additional 26 seek treatment for TBI; 3) About 80% of TBIs are considered mild (mTBI); 4) Many mTBIs result from MVCs, but little is known or reported about the crash characteristics. 5) The majority (about 80%) of mTBI improve within three months, while 20% have symptoms for more than six months that can include memory issues, depression, and cognitive difficulty (formulating thought and staying on task). Long-term, unresolved TBI is often referred to as “post-concussive syndrome.”
In one study, researchers followed car crash victims who were admitted into the hospital and found 37.7% were diagnosed with TBI, of which the majority (79%) were defined as minor by a tool called Maximum Abbreviated Injury Scale (MAIS) with a score of one or two (out of a possible six) for head injuries. In contrast to more severe TBIs, mild TBIs occur more often in women, younger drivers, and those who were wearing seatbelts at the time of the crash. Mild TBI is also more prevalent in frontal vs. lateral (“T-bone”) crashes.
As stated previously, we don’t think about our brains being injured in a car crash as much as we do other areas of our body that may be injured—like the neck. In fact, MOST patients only talk about their pain, and their doctor of chiropractic has to specifically ask them about their brain related symptoms.
How do you know if you have mTBI? An instrument called the Traumatic Brain Injury Questionnaire can be helpful as a screen and can be repeated to monitor improvement. Why does mTBI persist in the “unlucky” 20%? Advanced imaging has come a long way in helping show nerve damage associated with TBI such as DTI (diffuse tensor imaging), but it’s not quite yet readily available. Functional MRI (fMRI) and a type of PET scanning (FDG-PET) help as well, but brain profusion SPECT, which measures the blood flow within the brain and activity patterns at this time, seems the most sensitive.
A Brief Look at Whiplash Injuries
Whiplash is an injury to the soft-tissues of the neck often referred to as a sprain or strain. Because there are a unique set of symptoms associated with whiplash, doctors and researchers commonly use the term “whiplash associated disorders” or WAD to describe the condition. WAD commonly occurs as a result of a car crash, but it can also result from a slip and fall, sports injury, a personal injury (such as an assault), and other traumatic causes. The tissues commonly involved include muscle tendons (“strain”), ligaments and joint capsules (“sprains”), disk injuries (tears, herniation), as well as brain injury or concussion—even without hitting the head!
Symptoms vary widely but often include neck pain, stiffness, tender muscles and connective tissue (myofascial pain), headache, dizziness, sensations such as burning, prickly, tingling, numbness, muscle weakness, and referred pain to the shoulder blade, mid-back, arm, head, or face. If concussion occurs, additional symptoms include cognitive problems, concentration loss, poor memory, anxiety/depression, nervousness/irritability, sleep disturbance, fatigue, and more!
Whiplash associated disorders can be broken down into three categories: WAD I includes symptoms without any significant examination findings; WAD II includes loss of cervical range of motion and evidence of soft-tissue damage; and WAD III includes WAD II elements with neurological loss—altered motor and/or sensory functions. There is a WAD IV which includes fracture, but this is less common and often excluded.
Treatment for WAD includes everything from doing nothing to intensive management from multiple disciplines—chiropractic, primary care, physical therapy, clinical psychology, pain management, and specialty services such as neurology, orthopedics, and more. The goal of treatment is to restore normal function and activity participation, as well as symptom management.
The prognosis of WAD is generally good as many will recover without residual problems within days to weeks, with most people recovering around three months after the injury. Unfortunately, some are not so lucky and have continued neck pain, stiffness, headache, and some develop post-concussive syndrome. The latter can affect cognition, memory, vision, and other brain functions. Generally speaking, the higher the WAD category, the worse the prognosis, although each case MUST be managed by its own unique characteristics. If the injury includes neurological loss (muscle strength and/or sensory dysfunction like numbness, tingling, burning, pressure), the prognosis is often worse.
Chiropractic care for the WAD patient can include manipulation, mobilization, and home-based exercises, as well as the use of anti-inflammatory herbs (ginger, turmeric, proteolysis enzymes (bromelain, papain), devil’s claw, boswellia extract, rutin, bioflavonoid, vitamin D, coenzyme Q10, etc.) and dietary modifications aimed at reducing inflammation and promoting healing.