A Physician’s Palpation Exam For Whiplash
By B.J. Erkan, L.M.P. , Bothell Integrated Health
Whiplash need not be one of those conditions, the treatment of which, doctors loathe overseeing. After 18 years of treating whiplash I have had the opportunity to earn the respect of many referring physicians in the Bothell, Woodinvilee, Kenmore, Mill Creek, Kirkland and Lynnwood area. Many physicians over the years have asked for my opinion on how to most effectively prescribe massage for a patient suffering from whiplash, which is why I decided to write this article.
Whiplash Patients’ Most Common Symptoms
When a patient comes to see you with whiplash, shortly after being involved in a motor vehicle accident (MVA), they will often be in a great deal of pain. Neck pain is the complaint you will hear most often. In addition to active neck pain, there are other structures commonly involved which will cause latent pain and will be very tender upon palpation. It is not necessary for you to do a long and exhaustive exam; you need only focus on discerning which regions will require treatment.
The most complete RX possible for Whiplash
Many times MVA patients have shown up at our clinic with a prescription that is for cervicalgia or cervical sprain/strain alone (C – spr/str). After we do our thorough intake and palpation exam, we regularly find that most, if not all of the spinal muscles are indirectly involved in guarding. When the spinal muscles themselves are injured, and directly involved, they will be inflamed and tender when palpated. In these cases, a more global diagnosis of Cervico-Thoracic-Lumbar Sprain/strain (C-T-L spr/str) is helpful and will allow the attending therapist to treat all of the structures involved. Addressing all involved structures is crucial in preventing habitual neuro-muscular guarding resulting in long-term postural dysfunction, which, if left untreated, can lead to a myriad of secondary of complaints.
The situation described above is understandable. Almost all whiplash patients only have awareness of tightness of their posterior side. Pain and tightness in the back of the neck, the traps, and the spinals, are most often indicated by the patient. The anterior body, lower spine, and peripheral structures involvement tends to be gated out of the patient’s awareness until palpated or until the primary complaints resolve. Restoring the anterior/posterior muscle balance to address all structures involved will be one of the therapist’s main goals.
This is only meant to be a cursory exam to aid in a more complete diagnosis.
The Most Important Points to palpate with Whiplash:
The Erector Spinae Group – Palpate bilaterally within patient’s tolerance. With the patient prone or standing and bracing against the exam table palpate from the C1 all the way to the Sacrum. Palpation of this group alone often yields enough information to justify the diagnosis of C-T-L Spr/Str.
SCMs - Normally a little bit tender. When involved in Cervical Acceleration/Deceleration (CAD) injuries they are usually extremely tender.
Optional points to palpate, time permitting:
Subscapularis insertion - Especially when patient was the driver and knew of the impending impact- most likely gripping the wheel fiercely o brace for impact.
Longus Colli – One of the most often overlooked structures by all practitioners. The main culprit in reversing the cervical lordotic curve in whiplash. Palpate with care.
The Scalenes – Ususally tight and almost always involved in guarding of the neck after trauma.
Pectoralis Minors – These tend to be tight and shortened on most people these days, probably due to time spent on computers, driving, etc. With a cervical-thoracic injury due to a CAD the pectoralis minors tend to have an exaggerated guarding response.
Suboccipitals – Normally a little bit tender. Again when involved in a CAD injury they are often extremely tender upon palpation.
Infraspinati – The antagonist to Subscapularis and is often guarded when the Subscap tendon is inflamed.
Trapezius – Normally people crave some pressure in the trap, but when injured or guarding post CAD injury they will only tolerate slight pressure.
Quadratus Lumborum and Mulitfidi – Muscle guarding in these structures can cause secondary symptoms.
Sacro-iliac Joints – Tender S.I. joints can be indicative of muscle guarding of the Glutes, Deep Lateral Rotators, and Ilio-Psoas.
Masseters/Temporali/TMJ – Often the muscles of the jaw are involved in post trauma guarding and symptoms from this guarding may not become apparent to the patient for 6 months to a year after the date of injury. An interesting aside: the theory is that the jaw muscles contract to tighten the joints of the Temporal, Parietal, and Sphenoid bones to increase the integrity of the skull in preparation for impact. Think of a person’s reaction to falling off a bicycle.
Feel free to refer the patient on the top 2 points and leave the more time consuming task to us. We have a solid hour with the patient every appointment and are happy to serve you by doing a thorough palpation exam for your patient.
What should be the Frequency and Duration of the RX?
This is obviously your call. Most often, patients are referred with prescriptions that call for a total number of treatments or for (x) treatments per week for (y) weeks.
I will post a couple of RXs here in the future.
Also we will post a couple of videos about this very topic. It is our hope that these articles and videos will be informative and make your life easier. We are here to render effective treatment for soft tissue injuries from whiplash for your patients.