Whiplash and Concussions

Introduction

Injuries to the head and neck during sports, accidents, and other traumatic events are common. Two of the most frequently occurring conditions in the head and neck area are whiplash (a particular neck injury from high velocity forces) and concussion (a closed-head injury, sometimes called mild traumatic brain injury). These two injuries could both occur during the same incident, but not always in ways that are immediately obvious.

What Exactly is “Whiplash”?

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The term “whiplash” is actually not a very good description of this type of injury as it is describing the movement of the head and neck during a collision or other high velocity forces on the body. Logically, it can be described as the head going through acceleration (picking up speed) and then rapid deceleration (slowing down). These excessive forces on the neck are known to cause soft-tissue (ligament, tendon, muscle) injury and sometimes can affect bony tissue. Generally, the injuries obtained are sprains, strains, and other varying amounts of soft-tissue damage.

Concussion Defined

Similar to whiplash, the term concussion is a term that describes the cause of the injury rather than giving an idea of the structures affected. Concussions, also known as mild traumatic brain injuries (mTBI) have been defined by the American Academy of Neurology to be “a trauma-induced alteration in mental status that may or may not involve loss of consciousness.” It is very important to realize that this injury is a brain injury as in many situations there is a tendency to minimize this fact. For this discussion, we will describe this closed-head injury as “concussion” even though any traumatic brain injury (TBI) could go beyond the classification of mTBI and actually be a moderate or severe injury. One misconception regarding brain injury is that internal bleeding (hematoma) needs to be present in or around the brain tissues for concussion to be identified. Most cases of this head injury do not involve any obvious hematoma on MRI or CAT Scans, despite the fact there is damage to the tissues that are not readily observable.

Relationship Between Whiplash and Concussion

It is obvious that during a whiplash event that, in addition to the soft-tissue neck injuries that there could be direct contact of the head on an unforgiving surface. A blow to the head can produce jarring, shaking, or excessive movement of the brain inside the skull. This would be a logical circumstance in which concussion could occur. But what about situations in which there is whiplash yet there is no direct contact of the head on any surface? The high velocity movement of the head during a whiplash event alone could produce the same effects. One example of this phenomenon occurred recently to an athlete in American professional baseball playing for the Milwaukee Brewers in Major League Baseball. In 2006, Corey Koskie suffered a concussion without a direct force to the headduring a routine play in the field. While attempting to catch a ball batted in the air into shallow left field, he fell backward, landing on his upper back. The force of the fall did not cause his head to hit the playing surface but produced a whiplash-like force at the cervical spine. At this point, Koskie has missed two and one half baseball seasons because of concussion-like symptoms and his progress has been atypically slow. Victims of motor vehicle accidents have the potential for a similar response to a whiplash mechanism of injury. Recognition of the potential for these scenarios is important for proper treatment of the injured athlete or accident victim.

Picture 1. Whiplash related concussion can occur in games like baseball

Importance of Early Concussion Recognition

Recognition of potential concussion during this “whiplash-concussion” event can often be difficult, despite the appearance of sudden or delayed signs and symptoms of concussion or even a more severe traumatic brain injury.

In many cases, other injuries (including the whiplash injuries) can be assessed as the primary injury and thus the concussion injury may be minimized, seen as secondary, or not seen at all. A typical list of concussion symptoms consists of many or more of the signs and symptoms listed below (this list is taken from the Center for Disease Control (CDC) .

  • Nausea (feeling that you might vomit)
  • Balance problems or dizziness
  • Double or fuzzy vision
  • Sensitivity to light or noise
  • Headache
  • Feeling sluggish
  • Feeling foggy or groggy
  • Concentration or memory problems
  • Confusion

Care and Treatment

In any situation where the head and neck have been subjected to trauma, regardless of whether the head has been contacted directly or not, there should be a high index of suspicion for brain injury. One of the most important treatment principles to remember is (from The National Athletic Trainers’ Association Position Statement on Concussions) “when in doubt, sit them out”. This statement is intended to give a generalized protocol on management of sports concussions based on the presence of concussion symptoms from the above list. It is a good guideline for any brain injury – if there are any symptoms, no matter how minor, monitor the individual and keep them out of any sporting or strenuous activity until symptoms have cleared. In some situations further testing conducted by medical professionals is necessary. There is no “wonder drug” or immediate treatment that can lessen the effects of concussion, as time and decreased activity are the best methods. One potentially dangerous condition that can occur if an individual is allowed to participate in physical activity after an apparent “simple” concussion has been termed “Second-Impact Syndrome”. This is a potentially fatal condition that occurs when already injured brain tissue is subjected to further trauma before the tissue has had a chance to heal properly. This is very good rationale behind letting symptoms clear before a return to activity is allowed. There is no consensus on how long an athlete or accident victim should refrain from physical activity after a concussion – a general testing guideline is that the individual should be able to tolerate daily activities or physical activity without the recurrence of symptoms. There has been considerable discussion in the last ten years about how to grade concussions. Literature coming out of one of the several International Conference on Sports Concussions (Prague 2004) changed the way that these injuries are classified. Simply put, there are simple and there are complex concussions – determining which type an individual has experienced sometimes cannot be assessed until after symptoms have cleared. This system has replaced the long-time standard system of using grading levels of concussion severity (Grade 1, 2, 3, etc.).

Summary

Brain injury in any form or from any cause is cause for concern in the athletic and accidental injury arenas. Recognition of symptoms and causative factors for one level of brain injury, concussion, can be difficult even when there is direct contact to the head and the injury may seem obvious. Even more difficult to recognize is brain injury when there is minimal or no direct injury to the head, as in the case of whiplash. The key is to know for what symptoms to observe and to be appropriately suspicious that brain concussion and brain injury can occur even in not-so-obvious situations.

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