an osteopathically integrated approach whiplash injuries

An osteopathically integrated approach

Whiplash injuries

to the whiplash complex

JOHN H. HARAKAL, D.O., FAAODallas, Texas

Osteopathic physicians can offer the mostunique and effective treatment forinertial injuries (so-called whiplash).These total body injuries alter theanatomic and physiologic balance.Diagnosis requires awareness of thechanges in the force fields of the body aswell as anatomicophysiologic variationsfrom normal. Immediate treatmentshould include osteopathic manipulativetherapy, especially of the force-and-fluidmanagement type, as well as the use ofheat and cold and spinal traction. Musclerelaxants give disappointing results. Thepatient's cooperation and activeassistance in therapy are necessary for agood result. Such preventive measures astraveling at moderate speeds, use of acorrectly adjusted head rest, and thewearing of a tightly fastened seat belt canlower the injury rate considerably.

The term "whiplash" for an injury to an occupant ofan automobile involved in a collision has becomeacceptable, although most persons in health-relatedprofessions and agencies realize its inadequacy. Theterm describes only the manner of injury, and wasused as early as 1928.' The meaning of the termcontinues to change. With continued study andawareness and understanding the true nature of theinjury will evolve. Then the term probably will be-come more useful and its semantics less significant tomembers of the health care professions and otherconcerned persons.

The use of the term and its origin will give a clue to

the varied pattern of the whiplash complex. Theconcept is complicated by the description of the in-jury, and there is disagreement as to its seriousness,on the therapeutic regimen to be followed, and onthe prognosis. The one area in which there is total ornearly total agreement is the anatomy involved; buteven in this area the joints of Luschka2,3 are viewedvariously.

Crowe' described whiplash in a paper presentedin 1928 at an orthopedic association meeting.Emmett4 said that Davis5 used the term whiplash"twenty-five years ago to describe 'the nature' of thegreat majority of injuries to the cervical spine." Gayand Abbott(' in 1953 described "whiplash injury ofthe neck." Macnab, 7 one of the real authorities in thefield, did much research over several years on thistype of injury. According to States and associates,8Macnab3 defined whiplash as "essentially an exten-sion strain of the cervical spine produced by suddenacceleration" and suggested the alternate term "ac-celeration extension injury." England 3 suggestedthat the term "somatic dysfunction" might serve todescribe conditions of the cervical spine such aswhiplash. In 1972 Roca" described the condition as"a complex syndrome in which symptoms closely re-semble those of a mild brain concussion." Accordingto Macnab, 7 the Symposium Committee on "Whip-lash" of the Western Orthopaedic Association hasformulated the following definition: "A traumaticexperience of short duration producing excessivejoint motion in two directions beyond the anatomicand physiologic limits, caused by a sudden change ininertia whose vector forces affect the integral sys-tems of the body."

All of these terms and definitions are only par-tially adequate. Acceptance of the term "whiplash"to indicate a total body injury due to rapid inertialchange can facilitate communication, record keep-ing, analysis of the injury, and diagnosis, so thatprescription can be improved, the initiation oftherapy can be accelerated, and the healing envi-ronment can be improved for the person who has

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Osteopathically integrated approach to whiplash complex

sustained this type of injury. Such an approach willimprove the treatment of victims of whiplash acci-dents, facilitate healing, and reduce complications,especially in the period more than 5 years after theaccident.

The osteopathic approach to trauma and diseaseutilizes the concept of an integrated anatomic-physiologic relation to body homeostasis or bodyunity. The whiplash type of injury is a total bodyinjury resulting from introduction of energy intothis system that adversely influences the anatomicand physiologic homeostatic mechanisms present atthe time of injury. The osteopathic approach to thetreatment of disease and injury, or unwellness, isunique and especially valuable in the diagnosis andtreatment of injuries of inertial type.

The mechanism of injury has been hypothesizedin several related if not similar ways." The injurygrossly and at the cellular level has been likened tothe effect of a unidirectional force on a large con-tainer of a semielastic nature filled with fluid. Gurd-jian and associates" described pressure gradientsthrough the brain that can occur in a closed body offluid.

Another suggested mechanism for inertial injuryis a change in homeostatic balance of the affectedperson brought about by the introduction of a uni-directional force into a heretofore balanced energyfield. It results in a disturbance of energy patternrequiring healing to establish a new homeostaticmechanism for the maintenance of that person.

Exceeding the normal range of motion from thecellular level through that of the soft tissues andlarger body parts produces subtle structural changes(for example, microtraumatic avulsion of tendons,microscopic hemorrhages, and microscopic muscletearing) that establish pain reflexes of the myofascialtype. It also causes alterations in function of bonyarticulations and the gross, usually palpable restric-tions of motion of limbs and actual skeleton as well ascranial membranous articular changes.

The result of inertial injuries is a change in

anatomic relations with functional changes thatcause changes throughout the body. These changesare evidenced by local ecchymoses, contusion, andabrasion and by reduction of motion of muscles.This leads to reduction in use of the body, whetherthe cause is hypertonicity, spasm, later contractureof muscles, or limitation by pain. There are changesin the organ systems both directly by trauma andreflexly through related neurocirculatory mech-anisms as well as perhaps other reflex mechanisms.The psychologic and emotional changes may bemanifest as anxiety (especially in the acute phase),apprehension, fear, and often depression (usuallyfrom 10 to 21 days after the accident). Because ofthe complete integration of the cellular elements ofthe body to the tissue fluids, no living cell of theentire body system is spared the effect of an injury ofinertial type.

Symptoms may be produced by strain contractureof fascial ligamentous structures, with pain radiatingto the scalp, arteries, and major arterial trunks, or byperineural scarring. 13.14 Congestion and edema ofthe vertebral artery also may be a mechanism ofsymptom production, and Horwich" suggested thatinjury to tiny vessels of the third nerve nucleus mayoccur.

There is a palpable unidirectional force present inor about the person who has sustained inertial in-juries. The direction is perceptible, and, dependingon the focus of the examiner, can be evaluated at thesource or as the manifestation of the injury potentialas related to the body of the person. Further, thisunidirectional force is of a magnitude related to thenature and severity of injury, the ability of the in-jured system to dissipate external force, and perhapsthe chronicity of injury. The vector of injury, then,has direction and magnitude. Its perception andmanagement add yet another facet to the diagnosis,treatment, and evaluation of inertial injuries.

Applied anatomyThe basic somatic structures concerned are soft tis-

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sues (blood vessels, muscles and tendons, ligaments,fasciae, and nerves in many variations) and osseousstructures. Each part when disturbed in its estab-lished homeostatic mechanism has the potential forproducing symptoms. Each unit of body structure isof concern in inertial injuries. A functional knowl-edge of the working anatomy of the body is essentialto adequate diagnosis and successful therapy. Theanatomic knowledge, with adequate pictures anddiagrams, may be obtained from standard anatomictexts and pharmaceutical publications.

There are some peculiarities of the cervical areaand the pelvis that present special problems and alsoprovide avenues of treatment of inertial injuries.

In the cervical area the most important considera-tion is the mass of the head relative to the compara-tively slight support of the neck. This is of specialsignificance in women, in whom the ratio of head toneck is even greater on the average than in men.

The only true articulations of the axial spine are atthe occipitoatlantal, the atlantoaxial, and the rota-tional joint of the odontoid. Other segmental articu-lations have been described 16 as "amphiarthroses"with their intervening intervertebral disks. Theperivertebral and periarticular ligaments andmyofascial structures must maintain the stability ofthe area and absorb energies that are shared with theintervertebral disks in the remainder of the spine.

The greatest rotational movement to be found inthe spine is that of the rotational component ofmotion of the atlantoaxial articulation, which ac-counts for about 50 percent of the rotation of thehead relative to the shoulders.

The movement in the sagittal plane of the cervicalarea of flexion and extension is accomplished bysome gliding of the vertebral bodies, one on theother. This gliding motion is facilitated by the facetplanes of the area and the related soft tissues. Whilegreater motion is possible in the cervical area than inthe thoracic or lumbar area, greater inertial injuriesalso are more possible than in areas of more limitedmotion.

Also significant is the fundamental anatomic factthat all of the structures necessary for survival of therest of the body pass through the cervical area.

Two special features of the pelvis and especiallythe sacrum also are important. The wedge shape ofthe sacrum describes its function on the basis ofphysical principles alone. As a wedge (actually adouble inclined plane) it exerts its forces laterally asit makes an excursion in the sagittal plane inferiorly.The anatomic and respiratory axes of motion some-what diminish the maximum lateral forces. Withinertial injuries that occur primarily in the sagittalplanes in which the body is thrust forward in anarcing trajectory,"-' 9 the sacrum tends to be dis-lodged from its floating position between the ilia. Onthe rebound, when the ischial tuberosities return toresistance first, the sacrum exerts its wedgingcharacteristic and locks or lodges itself to varyingdegrees between the ilia, limiting normal anatomicand respiratory motion of the pelvis and, by exten-sion, the normal anatomic and respiratory motion ofthe entire body.

Anatomic continuity of the fasciae and more par-ticularly of the spinal ligaments and the dural mod-ification as the filum terminale that inserts at thelevel of the second sacral segment anteriorly andprogresses to terminate as part of the coccygeal lig-aments makes for continuity of structure and func-tion from the cranial base to the sacrum. This hasbeen referred to as the "core link."

DiagnosisHistory

History taking is fundamental to adequate diag-nosis. Of concern are the following questions:

1. When did the accident occur and where?2. Where were you sitting in the automobile at the

time of the accident and in what position were you(sitting, facing the front, oblique position in the car,talking with someone in the rear seat)?

3. Have you had any previous injuries, especiallyautomobile injuries?



4. Did any part of your body come in contact withany part of the interior of the automobile?

5. Was there any loss of consciousness? If so, howlong did it last?

6. Were there any changes of awareness of per-sonality — if immediately, of what duration?

7. What emergency care did you obtain? Where?In addition, the previous medical and surgical

history and a description of the accident itself shouldbe obtained and an attempt made to elicit any historyof present or past psychoemotional deviations fromnormal.

Examination

The examination can be divided into thesecategories: general; postural with range of motion(ROM); palpatory; radiographic; laboratory; andspecial techniques.

General examination should include the proce-dures of a complete physical examination. It wouldbe well at least to determine the blood pressure (bestmeasured two or three times at various dates),height, weight, temperature, pulse, and general ap-pearance physically and psychoemotionally.

Postural examination would include observationfrom the front, back, and sides of the standing pa-tient for general anatomic variations. Points to lookfor include shoulder drop, carrying attitude of thehead, alteration in muscle development, level of theiliac crests, and postural attitude relative to the"gravity lines." Deviations from the normal walkingmechanism, such as limp or changes in method ofbody mobility, should be noted.

The range of motion of the limbs and body ingeneral may include flexion, extension, side bend-ing, and rotation of the body on the lower append-ages, the motion about the pelvis, and the motionof the head and cervical area in relation to thethorax. Cathie2° provided a good summary of ac-ceptable norms (Fig. 1).

A few interesting clinical ideas will help toevaluate injuries of inertial type. Cailliet 21 suggested

that in ascertaining the degree of flexion of thecervical area the accuracy of the determination canbe increased if the patient nods before touching thechin to the chest. When the chin is tucked in first,several additional degrees of flexion usually will bepossible. Figure 2 portrays two types of goniometersfor angle measurement. In determining cervical ro-tation it is helpful to stabilize the shoulders gently toavoid a false impression of an increase in ROM dueto the incorporation of some rotation of the thoracicarea. Similarly, in lateral flexion it is necessary todirect and observe that no cervical rotation be per-mitted. The rotational component of cervical mo-tion would allow a false impression of an increase inROM, which would not be true lateral flexion but acombination of lateral flexion and rotation.

In determining ROM, especially of the cervicalarea, it is well to be guided by palpation as well as bythe limit imposed by pain. This can compensate forerrors of examiners not trained in clinical assess-ment of tissue tone and patient response. With sus-picion, awareness, and judgment, reasonably accu-rate and clinically significant determinations can beobtained.

Palpation and evaluation for the vector of injury(Fig. 3) can be determined by several techniques.The factors essential for perception are common toall techniques. First, the examining hands are ap-plied in a "listening" manner. Contact should befirm without local pressure, and there must beawareness of the tissues being evaluated, not anyspecific anatomic structure. The examiner shouldbe seated comfortably to minimize stimuli withinhimself. Figures 4A-4C illustrate positions that havebeen effective as well as placement of the "listening"hands. At first it may take several minutes to ascer-tain the magnitude and direction of the injury. Withexperience this often can be done in a matter ofseconds.

It is not always possible to detect a vector of injurybecause of inability of the examiner at any giventime and the time factor. Usually this is more per-

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Regional Evaluation — Ranges of Motion

B.T.* A.T.tNormals B.T.* A.T.t Sacroiliac yes no yes no

Occiput to T2:Right:

Backward bending 45°Lengthens

Forward bending 90°Shortens

Left:Sidebending — right 30°-40°

Lengthens

Sidebending — left 30°-40°

Shortens

Rotation — right 90°

*Before treatmentt After treatment

Rotation — left 90°

T1 to T3:Sidebending — right 35°

Sidebending — left 35°

T4 to T8:Sidebending — right 45°


T8 to Ll:Rotation — right 90°

Rotation — left 90°

LI to Sacrum:Sidebending — right 25°


Fig. 1. Chart for recording changes in range of motion before treatmen (B.T.) and after treatment (A.T.) (from Cathie").



Fig. 2. Here are represented 2 types of goniometers, which are used tomeasure angles of the body, for example, the angle of lateralflexion of thecervical area or angle of rotation about an axis.

Fig. 3. The solid line represents a vector of injury most often perceivedshortly after an inertial injury such as a rear-end collision with the injuredperson facing forward. The direction here is from the direction of thesource of energy. The dashed line represents a vector of injury commonlyperceived after some time has elapsed permitting a resolution of forceswithin the body, which is its anatomic-physiologic response to unidirec-tional forces of injury. This vector usually is also from right-to-left in thecorona! plane.

Figs. 4A-4C. These photos illustrate the position for determining thevector of injury and also for subsequent treatment using management offluid-and-force techniques.Fig. 4A. For palpating and feeling of the sacral and pelvic component ofthe craniosacral mechanism. The physician's right hand cradles the sac-rum, with the sacrococcygeal junction resting within the area of the palmarcrease between the thenar and hypothenar eminences. The left arm bridgesthe anterior superior iliac spines.

Fig. 4B. The feeling, palpating hands allow the patient's thorax to rest onthem. The physician's elbows serve as fulcrums and rest on the treatingsurface or on the physician's knees.

Fig. 4C. The application of the physician's hands as applied in Figure 4B

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ceptible shortly after an accident and tends to di-minish with time. However, the effect does not dis-appear and becomes more generally established andless easily detected. The experienced examiner canperceive unidirectional inertial injury changes aslong as 30 years after they occur. Resolution of thevector of injury always is coincident with patientimprovement and its perception therefore is an ex-cellent diagnostic sign.

Radiographic examination in the office should bedone during flexion, extension, and easy normal useof the cervical area in the lateral projection at 72inches by standard technique, the limit of motionstudies being dictated by instructing the patient tomove to the point of pain. Directing the patient tograsp the seat with his hands and "sit tall" tends tostandardize the results and improve visualization ofthe lower cervical vertebrae. The anteroposteriorview of the cervical spine and odontoid views aredesirable. Oblique views, both right and left, may beobtained with the patient prone or sitting. (Pillarviews perhaps are best reserved for special diagnos-tic requirements.) A pelvic view with the patientstanding with the heels the same distance apart asthe femoral heads in a "normal" standing posturewith equal weight on both feet is essential.

Brogdon and associates 22 offered these recom-mendations:

Order X-rays on every whiplash injury patient. The films mayreveal little or nothing of value in the usual soft-tissue injuries, butare invaluable in ruling out or confirming serious nerve and bonedamage and in documenting this evidence for medicolegal pur-poses as well as further therapy. .

With AP or lateral views, if the patient assumes a straight neckposition — perfectly straight — you often can assume the positionis due to muscle spasm, although a few adults have congenitalstraight neck. If you see narrowing ofjointson films taken withina few hours after the injury, suspect a previous neck injury orother pre-existing condition, even though it may have been sub-clinical; the narrowing or compression usually takes months toyears to develop.

On the lateral view, in addition to checking for obvious spinalabnormalities, examine the soft tissue space anterior to the C3and C4 vertebrae. If the space exceeds 3-5 mm., you have a goodindication of cervical spine pathology in the immediate area orabove.

Also, look for the anterior lordotic curve status on a lateralview. Is it normal, straight, or reversed? Spasm of the prever-tebral muscles or fibrosis in soft tissue can cause a loss of normallordotic curve. If the straight spine from injury persists for longerthan six months, it usually is irreversible.

On oblique films, in addition to obvious fractures or disloca-tions, look for evidence of spurs — pre-existing osteophytes thatmay impinge on the cervical nerve roots.

The odontoid view will reveal abnormalities at the occiput Clor CI, C2 joints, as well as the rare but grave fracture of theodontoid process. Occasionally this is not seen initially but showson repeat views three to five days later.

You may find confusing neurological changes in the rare pa-tient with platybasia, a congenital misalignment of the occipitalbone and cervical spine. The condition can be recognized onX-ray.

I should add here that on the oblique as well as theanteroposterior views the condition of the joints ofLuschka can be determined readily and is of clinicalsignificance in the radiologic evaluation of the cervi-cal area.

Laboratory examinations should be prescribedaccording to the condition of the patient. There canbe no generally accepted minimal list of tests, andthe maximum is nearly infinite. The laboratory testsused will be dictated by the ability, interest, andjudgment of the attending physician and the statusof the available laboratory.

Such special examinations as arteriography,pneumoencephalography, and lymphangiographyare of value in selected cases, but the attendant mor-bidity and mortality must be considered. The use ofcineradiography, diagnostic ultrasound, thermog-raphy, and nystagmography are limited by the avail-ability of the necessary apparatus and of the tech-nicians and professional persons required for evalu-ation.

Routine testing of the deep tendon reflexes, thecutaneous sensation to pinprick, and the status ofthe vibratory sense, although simply done with min-imal equipment, are of much value. Bilateral graspstrength can be measured with a dynamometer de-signed for this purpose and can be of value both inthe initial assessment and in observing the progressof the patient.



A patient who is malingering and simulating hisinjuries would have some of the following charac-teristics, described by Bingham23In the first place, during the examination he resists the examiner.He tolerates very little discomfort and "jerks away" when youtouch him. He says "it hurts." The pain extends beyond the areainvolved by the injury. He complains of many areas of pain. Hisheadaches are "terrible," they are not necessarily associated withany eye strain, hearing or visual disturbances, which are almostalways present with headaches in severe whiplash injuries. A pinwheel [ Fig. 5] is run over the skin of his neck and "that hurtsterribly." He can hardly stand it. When you ask him to squeeze thedynamometer [ Fig. 5] to measure grip, he leaves his thumb out.He grips only with his fingers. In three or four tests there is a widevariation in readings. The malingerer's grip will be only a third ofwhat the normal person's should be. He tightens up all the mus-cles in his hands and arms when gripping, and yet he hardly closeshis fingers together. Such findings reveal the malingerers, andthe simulators, but these are very, very few. Most persons don'tknow how to simulate the true symptoms of whiplash injury.They don't know that the motions which are most limited andpainful are extension and rotation. The whiplash victim developsstiffness posteriorly and the most limitation in extension. So it isn'tdifficult to differentiate spurious from genuine physical signs.

It should be mentioned here that in the few pa-tients whose anterior cervical injuries exceed the

Fig. 5. From left toright, a tuning fork,percussion hammer,and neurologic pin-wheel, all diagnostictools for the whiplashcomplex. Below is adynamometer, for gripmeasurement.

posterior injuries, the findings just mentionedwould, of course, be reversed.

SymptomsDisturbance of a person's homeostatic mechanismby inertial injuries results in assorted symptoms.The severity and chronicity are functions of thenature of the accident and the nature of the personinvolved. For convenience the symptoms of inertialinjuries may be classified as somatovisceral andpsychoemotional.

S onzatovisceral symptoms

The somatovisceral symptoms include:1. Neck pain (including nuchal pain) probably is

the most common symptom and may be anterior orposterior. Injury may manifest itself in the uppercervical area as a result of the usual degenerativechanges that occur at the level of the fifth throughseventh cervical vertebrae. These changes in thelower cervical area limit motion and thus increasethe susceptibility of the upper cervical segments toinjury.' It is interesting that disk herniation in thecervical area with root irritation and impairment ofroot conduction rarely results from "whiplash" in-jury of the neck." The injury may set off subclinicalosteoarthritis or spondylosis, which often is associ-ated with a history of motion sickness in childhood,later migraine headaches, hyperacidity leading toulcers in the upper part of the gastrointestinal tractin men and irritable bowel syndrome in women, andinsomnia.22

Macnab7 found that experimental injections ofhypertonic saline solution into the supraspinous lig-aments of the cervical area would produce arm pain.This points to another mechanism of symptomproduction." The neurovascular compression syn-dromes — hyperabduction, costoclavicular syn-drome, scalenusanticus, and anatomic anomalies —must be considered in evaluation of pain and numb-ness in this area.

2. Low-back pain, although sometimes present ini-

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tially, usually occurs several days after the accident.It may be due to changes in pelvic function secon-dary to previously described sacral dysfunction, tomuscle strain, or to exacerbation of previous diseaseof the lower part of the back.

3. Shoulder and arm pain, more subtle than the ob-vious results of direct trauma, contusion, abrasion,muscle strain, and shoulder sprains, can occur.Webber" pointed out the significance and treat-ment of some trigger mechanisms. A herniated diskis rare, 7 but it compresses a nerve root and causesradicular pain, which may be more severe in thescapular region, shoulder, and arm than in theneck." Valuable in diagnosis is the fact that the painof coronary artery disease will be relieved in 3 min-utes by sublingual administration of nitroglycerinbut relief of noncardiac pain in the shoulder andarm will take longer than this.

Numbness along the distribution of the cervicalnerves and those innervating the chest and neck mayresult from irritation. Weakness of neck muscles andloss of grip may occur. Pain from the annulus fi-brosus of an intervertebral disk is segmental and un-ilateral in its referred area to the skin and occursalong the medial or vertebral border of the scapula.

4. Headache combined with stiffness of the neckhas been described as comprising the cardinal symp-tom of injuries of inertial type." It usually is occipi-tal or frontal and seldom is temporal." The sym-pathicotonia associated with accidents may explainthe absence at first of headaches of migraine type.Macnab 7 found experimentally that occipitalheadaches may be reflexly associated with injury of asupraspinous ligament of the cervical area.

5. Eye, ear, nose and throat symptoms: Daily" saidthat "severe, permanent loss of visual acuity" may oc-cur as a result of "traumatic ballottement of the vitre-ous" and recommended "thorough biomicroscopicexamination of the macula in focal illuminationthrough a flat contact lens." Blurred vision, visualstrain, fatigue, diplopia," photophobia, inability toread for more than a few minutes," pupillary

changes, a decrease in accommodation andconvergence," enlargement of the blind spot, nasaland juxtacecal scotomas," esophoria, retinal de-tachment, glaucoma, and aching of the eyeball (sec-ondary to inflammation of the sympathetic nerves)"have been observed.

In the ear, audiologic study may show hearing lossor tinnitus. 28 Vestibular symptoms such as dizziness,vertigo, and ataxia29 call for consideration of thedecompensation of a previously compensated stresssyndrome. However, Shapiro3° said:Most writers seem to consider the labyrinth findings to be by-products of cervical cord or brainstem anemia due to compres-sion of the vertebral artery caused by the hyperextension-hyperflexion process.

Changes in positional relation of the temporalbones, one to another, may be a significant factor."

Any change in the sense of smell might be ac-counted for on an anatomic basis by injury to thefrontoethmoid area, which is a common area of im-pact in automobile collisions."'"

Dysphagia may be due to damage of the anteriorlongitudinal ligaments, with swelling 32 and/orhematoma. 7 '27

Psychoemotional symptoms

Depression is one of the most frequent psychicsymptoms. It usually begins between the tenth andthe twenty-first day and normally lasts from 7 to 10days, especially if progress is noted by the patient.

"Anger, aggression, hatred, fear, and desire forrevenge" have been reported.4

Post-traumatic anxiety is directly related to themultiple alternatives facing the injured person andhis ability to manage the decisions.

Amnesia, a disembodied feeling," personality in-jury, with injury also to emotions and interferencewith work and activities," resentment, and a dazedfeeling also have been observed.

Because the automobile provides a sense of se-curity, power, refuge, and escape (to mention only afew of its uses), the occurrence of a symptom-


Owcopathwallt integrated approach to whiplash complex

producing accident must cause a major psychoemo-tional change in the relation of automobile to driverthat may merit separate study.

,11h(rIlanrou., symplinnA

States and associates° reported that pain in the tem-poromandibular joint was evidenced in 18 of 100cases of rear-end collision. This may have been dueto anatomic-physiologic changes of the temporalbones individually and in relation to their oppositepa rts.3'

Among symptoms and signs of compression of thecervical cord, Hewitt33 mentioned a feeling of heav-iness of the legs and a tendency to drag them,cramps in the calves and numbness and a feeling ofcoldness of the legs, occasional loss of sphincter con-trol, an extensor plantar response, absence of ab-dominal reflexes, and clonus and impaired vibrationsense. Flax and associates" reported bladder dys-function as well.

healment

In the first 3 months treatment is dictated by thediagnostic acumen of the attending physician, thenature and extent of injury, and the acceptability ofthe treatment to the patient. Injuries may vary inseverity and seriousness from those that threatenlife to those requiring only observation and expec-tant treatment. Active intervention may be required,or only simple reexamination for evaluation of theinjury and assessment of the extent of healing maybe needed.

The serious injuries involve shock, bony fractureother than uncomplicated appendicular fracture,spinal cord pressure and disruption, muscle tearing,and complications to previously existing diseases,injuries, and conditions. Among such conditions arepregnancy, especially if it is already complicated,healing fractures or lacerations, neurologic disor-ders, previous stress, and metabolic diseases. Seriousinjuries probably call for hospitalization for diagnos-tic tests, consultation, and observation. The initial

treatment may be the primary responsibility of theneurosurgeon, orthopedist, general surgeon,obstetrician-gynecologist, or other specialist as thecondition may dictate.

In the first 48 to 72 hours, four of the availabletherapeutic modalities are of special importance: (1)osteopathic manipulative therapy; (2) heat and cold;(3) muscle relaxants; and (4) spinal traction.

The most significant therapeutic modality avail-able is osteopathic manipulative therapy, especiallyof the force-and-fluid management type usually as-sociated with osteopathy in the cranial field." Itallows for increasing range of motion with attendantfunctional improvement in the area. Further, itpermits release of the bound-up or locked vectorenergies of the soft tissues, especially the fasciae.With such changes a diminution or disappearance ofthe vector of injury follows. The cooperative isomet-ric type of therapy originally described by Ruddy"and subsequently modified by Mitchell' s likewisehas a place in the acute stage of inertial injuries.Figures 6A-6C illustrate the use of cooperativeisometric techniques for the thoracic area, whileFigures 7A and 7B illustrate their use in the cervicalarea.

In the first 24 hours cold packs or ice massage for7 minutes per hour seem to be helpful, perhapsmore so than the use of externally applied heatingdevices such as hot moist packs, Hydrocollatorpacks, hot water bottle, infra-red radiation, ordiathermy, although these cumulatively may havesome value for the problems of selected patients. Iespecially like to use ultrasound for ecchymoses andmyofibrositis, beginning the second day if clinicaljudgment dictates.

Muscle relaxants are disappointing and too oftenused. Analgesic agents seem to offer greater helpand improve the prognosis, and in my experiencethey speed the response (or it may be that the musclerelaxants delay the response). These are clinical ob-servations and have not been evaluated statistically.

Spinal traction of the constant type with low force

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Figs. 6A-6C. These photos illustrate the use of cooperative isometric techniques to increase range of motion in the thoracic area. Fig. 6A illustrates the initial position offlexion to the level of restriction, which may be the area of a single vertebral segment or a group area. Fig. 6B shows the rotational component being carried to thepermitted range of motion or point of balanced tension for the affected area. At this point the patient is asked to reverse the previous movements by "turning back towardwhere we started." Patient cooperation may be at any level of force dictated by the nature of the involved area, from "just think about turning" to "turn as hard as youwould like." The dashed line represents a resistanci equal to that of the patient's active attempt to derotate. The patient is then asked to "let go" or "release." Here is thepoint of physiologic response. This is that point of anatomic relaxation permitting a greater range of motion. Fig. 6C represents achievement of near normal range ofmotion and may in fact be the maximum permissible for a given treatment. Usually 2 to 3 repetitions of the technique are all that are required. The technique may besummarized as: (1) neutral position; (2) permitted range of motion determined by degree of patient's resistance to further motion; (3) pause to permit anatomic andphysiologic response; (4) carry patient to new range of motion, again to be determined by degree of patient's tissue resistance and response; and (5) repeat steps I to 4 asrequired. Note: The illustration is for treatment to improve anatomic and physiologic normalization on the right side. For treatment of the left side reverse the position.

Fig. 7A. This photo shows the neutral or starting point foruse of the cooperative isometric technique as applied to thecervical area. Fig. 7B. This photo represents a nearnormal range of motion at the completion of the series ofcooperative isometric efforts. The dashed line indicatesresistance and response of the physician only equal to thatof the patient and in the opposite direction.

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weight, from 6 to 8 pounds, is useful especially in thefirst 72 hours. Intermittent spinal traction seems tobe helpful for the compressive or concussive type ofinjury, for example, from rolling over with suddendeceleration in the vertical axis. Treatment is begunwith 10 pounds for 10 to 15 minutes, with an in-crease on following days to 35 or 40 pounds for 20minutes as the patient's condition warrants. Thismay be done either before or after osteopathic ma-nipulative therapy, depending on the physician'sjudgment and the patient's response.

After the emergency treatment the diagnostic andtherapeutic challenge many times becomes appar-ent. At this time the psychoemotional symptomsmake themselves evident, and perhaps the most val-uable single therapeutic modality any physician hasto offer is an honest appraisal of the patient's condi-tion. An adequate explanation should be given thepatient at intervals. Reassurance is of paramountimportance.

Of all the complications of the injury of whiplashtype, change in the sacral mechanism most oftendefies detection. The force-and-fluid managementtechniques adapted to the pelvic mechanism haveproved especially useful and their results long last-ing. Normal respiratory mobility of the sacrum be-tween the ilia is necessary in restoring many factorsof the body to health.

Cervical collars are available in various strengths.A soft turkish towel wrapped around the neck andentwined on itself may be used. At the other extremeare plastic collars capable of producing and main-taining specific positions even to hyperextensionand hyperflexion of the cervical area. An inexpen-sive cervical support can be fashioned from news-paper folded to approximately the height of theneck and covered with stockinette, as used in prep-aration for plaster casting. Perhaps most useful is afoam or sponge rubber collar with a washable stock-inette cover. If the patient has preexisting cervicalarthritis, the use of such a collar during the sleepinghours will help to lessen the early morning soreness

and stiffness. I seldom use the stiffer collars, al-though they are valuable especially after fracture orligamentous tearing.

Also available are needle therapies. Injection of ananalgesic and/or steroid or of a sclerosing agent hasproved to have much value when myofascial,cutaneous, or scleral trigger areas have been estab-lished or exacerbated. They are useful also in themanagement of ligamentous relaxation.

Myofascial trigger areas seem to respond well toany modality that disrupts the circuit or reflexmechanism of pain and muscle spasm production.Here ice massage may be tried for not more than 7minutes per hour if the area is large, for example,the shawl area. For localized areas, for example, theinsertion of the levator scapulae at the medial angleof the scapula, the supraspinous or infraspinousmuscles and, in hyperextension injuries, the sterno-cleidomastoid and scalenus muscles, an ice cube in aplastic bag may be applied at the maximal point ofpain for 7 minutes per hour for at least 3 successivehours. Its possible value may be predicted from of-fice use of one of the vapocoolants, with care beingtaken to use it according to the manufacturer's rec-ommendations with regard to inhalation of vaporsand avoidance of frosting and tissue freezing.

If clinical judgment suggests that partial tearingof tendinous or ligamentous tissue has occurred, itmight be well to infiltrate the area involved with alocal anesthetic, such as 1 or 2 percent procaine orXylocaine without epinephrine. The response tothis can be used to predict the value of therapeuticmeasures previously mentioned. If the injectiondoes not help to alleviate the pain or if, in fact, itcauses an increase in pain, the physician should con-sider supporting the affected area with a collar,sling, adhesive strapping, or bandaging and employa couple of needling treatments in an attempt tostimulate fibro-osseous proliferation. Prolotherapyprobably has its greatest value when relaxation ofligaments or chronic partial avulsion of muscle ispresent after the first 3 months. Results will depend

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on the agent used, the skill of the physician, and thetissue reaction of the patient.

Acupuncture has been reported 36 to be useful forinertial injuries. Experience will clarify its value.Here again, results are a function of the skill anddiagnostic ability of the attending physician and theresponsiveness of the patient.

Ultrasound as a deep heat producer is active as amicromassage. Bingham" expressed the belief thatit loosens up the tissue stroma so as to permit in-creased circulation, soften calcium deposits to allowfor their dispersion, and mainly reduce scar tissue. Itis also useful in dispersal of ecchymotic areas.

Vitamin 50 mg., and vitamin B12, 500 to 1,000micrograms, have been used primarily on an em-piric basis for neuritis and neuralgia of traumaticorigin and have stood the test of time. Pharmacolog-ically and nutritionally they are helpful, and oftenthey have more than their anticipated effect.Neuritis following an accident may actually be asystemic herpes zoster without cutaneous manifesta-tions. Rubefacients seem to offer relief to some pa-tients, occasionally beyond their normally expectedpharmacologic action.

Injection therapy for general effect might incor-porate vitamin B complex, preferably with from 100to 1,000 mg. of vitamin C. Several hypotheses havebeen offered to explain its usefulness. Usually I em-ploy this only for patients who for one reason oranother have had good physiologic response previ-ously or who request "a shot to help me get wellfaster." I want to add here that I treat every patientwho has undergone trauma, especially when it in-volves total body injury, for stress syndrome. Thedegree of stress, of course, varies with the previousstress reserve of the individual and his reaction toinjury. Treatment includes administration of vita-min C, 250 mg., with bioflavinoid and rutin, for atotal of 2,000 to 3,000 mg. in the first 24 hours, witha gradual reduction of dose to 750 mg. per day individed doses. I encourage the patient to keep hisdiet low in carbohydrate, excluding all white flour

and refined sugar products as well as the syntheticsweeteners. Intramuscular or intravenous injectionof adrenocortical extract (ACE) is useful. Its useshould be guided by the patient's history and theattending physician's familiarity with this treatmentfor stress syndrome.

Recurrence or aggravation of preexisting diseasesrequires specific attention or modification oftherapy. Any total body injury requires an indi-vidualized regimen.

It is advisable to suggest proper postural attitudeswhen indicated, and directions as to how and hownot to use the body during healing are necessary. Isuggest limiting all activities using the arms to thosewhich can be done with the elbows at the sides. It ishelpful to limit activity in the "strike zone" betweenthe shoulder level and the knees. The patient shouldbe cautioned also to bend the knees in picking upanything from the floor and to avoid reaching abovethe head.

Tsumura and Hoshiga37 described a method oftotal spinal blocking (TTS) by subarachnoid injec-tion of an anesthetic agent at a high level. A localanesthetic agent, a steroid, and a thiamine prepara-tion in a dose adjusted for age, weight, and heightare injected at the level of the seventh cervical andfirst thoracic vertebrae for symptoms in the upperregion and at the first and second lumbar vertebraefor symptoms in the lower region. This illustratesthe variety of therapeutic approaches that have beenused.

The work of Tenicela and Cook" tended to con-firm that of Miyazaki and associates" on the use ofnerve block. Sympathetic neurovascular and greateroccipital-trigeminal syndromes responded best tothis type of therapy, while symptoms ofradiculopathy, myelopathy, and soft tissue injuryshowed less predictable results.

Healing and prognosisEarly active intervention offers the best prognosisfor healing. Disturbances of the sympathetic ner-

Journal ACM/sol. 74, June 1975 953/73


vous system have been thought to subside spontane-ously, in 2 or 3 months for ear symptoms and from 2to 6 months for eye symptoms. 4° Immobilization bybed rest or use of a cervical collar without otheractive therapy leads to stiffness and a decrease incervical range of motion." Flax and associates" re-ported that not one of their patients required surgi-cal intervention. As previously noted, herniation ofa cervical disk is rare. Bingham 23 stated: "The grouphaving the slowest recoveries are those going to or-thopedic surgeons, M.D.'s, physical therapists, os-teopaths and chiropractors . . . But these patients,when they do heal, have a good range of motion intheir necks."

One orthopedist tended to downgrade the seri-ousness of inertial injuries. 23 Apparently in his spe-cialty he underestimated the importance of soft tis-sue injuries. The subtle changes associated with softtissue injury in time develop into arthralgia, osseousabnormality, and articular and muscular dys-trophies, not to mention personality problems ofrejection and denial. 4 Willard L. Brown, D.O., 4 ' hassaid that neck injury may produce permanent injur-ies. Even mild whiplash can cause extensive dam-age to circulation, joints, nerves, and bones, withsymptoms lasting a considerable time.

To investigate the effect of settlement of damageclaims on the duration of symptoms of whiplash,Macnab7 reported on 266 patients who had sus-tained whiplash injury, of whom 145 were availablefor follow-up 2 years after a settlement was made. Ofthe 145, 121 still complained of symptoms. Thisrepresented 85 percent of those restudied, or 45percent of the original group.42

Shafer" reported on a patient who appeared torecover completely, but had "marked arthriticchanges in his cervical spine" after 10 years. Percep-tible changes in the anatomic-physiologic responseof affected patients have been palpated as long as 30years after an inertial injury, according to Becker,43who also stressed consideration of the patient's bodytype and accommodative pattern in assessment of

the response to therapy. 9 4An integrated osteopathic regimen of therapy

with primary emphasis on nonthrusting functionalcooperative isometric and force-and-fluid manage-ment techniques can shorten the clinical course oftreatment substantially and establish a new home-ostatic mechanism which assures maximum well-being for the patient.

PreventionIn most automobile accidents resulting in total bodyinjury of the inertial type, the driver of the rear orstriking automobile does not sustain injury suffi-cient to require care by a physician. This seems tocontradict the maxim that one should "relax and rollwith the punch," which usually is offered to explainthe freedom from injury of drunks and babies. Itwould seem, on the contrary, that awareness of im-pending injury may, in fact, reduce the degree ofinjury.

O'Neill and associates" have reported:

Head restraints are the first damage-reduction measure to beapplied to the whiplash injury problem, and in view of the smallpercentage of properly positioned adjustable head restraints, theobserved reductions in the frequencies of driver neck injuryclaims are extremely encouraging. However, it must be em-phasized that the nation-wide epidemic of neck injuries in rear-end collisions has been only partially abated, and that it promisesto remain of great severity until approached far more vigorously.

Seat belts prevent ejection, and Braunstein" re-ported that fatalities are five times as high amongejected persons as among those who are not ejected.Belts should be worn low and preferably with thethree-point harness, said Gissane. 47 Campbell" alsoemphasized this point, and in one medium-sizedforeign car that was involved in nearly 38,000 acci-dents in 1 year, there were no fatalities among per-sons using the three-point harness, although colli-sion speeds were as high as 60 miles per hour insome instances. On the other hand, unbelted occu-pants died in collisions at speeds as low as 12 milesper hour. Gikas, 49 commenting on a report by Smithand Kaufer5 ° on injuries to the lumbar area associ-

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ated with the wearing of lap belts, stated that theseinjuries occurred in severe collisions that almost cer-tainly would have resulted in death if a belt had notbeen used.

It is logical to conclude, then, that the bestmethods of prevention are traveling at speeds notexceeding 55-60 miles per hour, wearing properlyapplied, tightly fastened seat belts, especially of thethree-point type, using a correctly positioned headrest, and alertness to one's position in the trafficpattern so as to be aware of impending collision.

1. Crowe, H.E.: Injuries to the cervical spine. Read before the WesternOrthopaedic Association, San Francisco, 1928. Cited by Macnab'2. McCarroll, H.R., et al.: Symposium. Neck, shoulder and arm pain.Postgrad Med 36:385-99, Oct 643. England, R.W.: The cervical spine. Applied anatomy. JAOA 71:29-36,Sep 714. Emmett, J.: When is a cervical sprain a "whiplash"? Med Opinion Rev6:26-9, Sep 705. Davis, A.G.: Injuries of the cervical spine. JAM A 127:149-55, 20 Jan 456. Gay, J.R., and Abbott, K.H.: Common whiplash injuries of the neck.JAMA 152:1698-704, 29 Aug 537. Macnab, I.: The "whiplash syndrome." Orthop Clin North Am2:389-403, Jul 718. States, J.D., Korn, M.W., and Masengill, J.B.: The enigma of whiplashinjury. NY State .' Med 70:2971-8, 15 Dec 709. Macnab, I.: Whiplash injuries of the neck. Read before American As-sociation for Automotive Medicine, 1965. Quoted by States et al.'10. Roca, P.D.: Ocular manifestations of whiplash injuries. Ann Ophthal-mol 4:63-73, Jan 7211. Ommaya, A.K., and Hirsch, A.E.: Tolerances for cerebral concussionfrom head impact and whiplash in primates. J Biomech 4:13-21, Jan 7112. Gurdjian, E.S., et al.: High speed techniques in head injury research.Med Sci 18:45-56, Nov 6713. Billig, H.E., Jr.: Traumatic neck, head, eye syndrome. J Internat CollSurg 20:558-61, Nov 5314. Billig, H.E., Jr.: Head, neck, shoulder and arm syndrome followingcervical injury. The mechanism of injury and the symptoms and signsinvolved. J Internat Coll Surg 32:287-97, Sep 5915. Horwich, H.: The ocular effects of whiplash injury. Trans SectOphthalmol AMA, 1961, pp. 86-716. Schmorl, G., and Junghanns, H.: The human spine in health anddisease. Grune and Stratton, New York, 195917. On impact. 16-mm sound film. Aims Instructional Media Services,Inc., Hollywood, 195918. Fatal meeting. 16-mm. sound film. Aims Instructional Media Services,Inc., Hollywood, 196219. Whiplash. 16-mm. sound film. Aims Instructional Media Services,Inc., Hollywood, 1968

20. Cathie, A.: Testing for regional motion. DO 9:106-9, Jun 6921. Cailliet, R.: Neck and arm pain. F.A. Davis Co., Philadelphia, 196422. Brogdon, B.G., et al.: Whiplash. Avoiding a diagnostic backlash. Pa-tient Care 4:107-26, 15 Mar 7023. Bingham, R.: Whiplash injuries. Med Trial Tech Q 14:69-80, Jun 6824. Webber, T.D.: Diagnosis and modification of headache andshoulder-arm-hand syndrome. JAOA 72:697-710, Mar 7325. Shafer, N.:" Whiplash". 5 diagnostic traps. Consultant 12:21-3, Aug 7226. Daily, L.: Muscular and vitreal disturbances produced by traumaticvitreous rebound. South Med J 63:1197-8, Oct 7027. Flax, H.J., Fernandez, B., and Rodriguez-Ramon, A.: The "whiplash"injury. Bol Assoc Med PR 63:161-5, Jun 7128. Pang, L.Q.: The otological aspects of whiplash injuries. Laryngoscope81:1381-7, Sep 7129. Toglia, J.U., Rosenberg, P.E., and Ronis, M.L.: Posttraumatic dizzi-ness. Vestibular, audiologic, and medicolegal aspects. Arch Otolaryngol92:485-92, Nov 7030. Shapiro, S.L.: The otologic symptoms of cervical whiplash injuries.Eye Ear Nose Throat Mon 51:259-63, Jul 7231. Magoun, H.I.: Osteopathy in the cranial field. Ed. 2. Journal PrintingCo., Kirksville, Mo., 196632 Percy, E.G.: At the Montreal General Hospital. Extension injury to thecervical spine (Case P25). Can Med Assoc J 101:626-8, 15 Nov 6933. Hewitt, P.M.: Cervical spondylosis. OP 34:45-7, Jan 67. Reprintedfrom Br Osteopath J 3:2, 196634. Ruddy, T.J.: Seminar, Dallas, Texas, about 1971-7235. Mitchell, F., Sr.: AAO tutorial, Dallas, Texas, about 196536. Salta, H.S.: Modern scientific medical acupuncture. JAOA 72:685-96,Mar 7337. Tsumura, Y., and Hoshiga, T.: Subarachnoidal injection therapy inchronic cases of the so-called whiplash syndrome. Acts Anaesthesiol Scand15:61-4, Mar 7138. Tenicela, R., and Cook, D.R.: Treatment of whiplash injuries by nerveblock. South Med J 65:572-4, May 7239. Miyazaki, M., et al.: Treatment of whiplash injury in the field ofanesthesiology. Patho-anatomical considerations on the indication fornerve block. Jap J Anesthesiol 18:47-53, Jan 69. Cited by Tenicela andCook"40. Horwich, H., and Kasner, D.: The effect of whiplash injuries on ocularfunctions. South Med J 55:69-71, Jan 6241. Brown, W.L.: Whiplash injuries. Presentation at annual convention ofArizona Osteopathic Medical Association, Tucson, May 6-9, 197142. You, too, can be a whiplash victim. Moneysworth 2:1,8, 20 Mar 7243. Becker, R.E.: Personal communication44. Becker, R.E.: X ...whiplash injury. AAO Yearbook, 1961, pp. 90-8;reprinted AAO Yearbook, 1964, pp. 96-104.45. O'Neill, B., et al.: Automobile head restraints. Frequency of neckinjury claims in relation to the presence of head restraints. Am J PublicHealth 62:399-406, Mar 7246. Braunstein, P.W.: Forum. What injuries can automobile seat beltsproduce? Do these injuries militate against use of the belts? Mod Med38:146-7, 1 Jun 7047. Gissane, W.: Seat belts and head rests. Br Med J 2:288, 29 Apr 7248. Campbell, H.E.: Forum. What injuries can automobile seat belts pro-duce? Do these injuries militate against use of the belts? Mod Med 38:147, 1Jun 70

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49. Gikas, P.W.: Forum. What injuries can automobile seat belts produce?Do these injuries militate against use of the belts? Mod Med 38:146, 1 Jun7050. Smith, W.S., and Kaufer, H.: Patterns and mechanisms of lumbarinjuries associated with lap seat belts. J Bone Joint Surg (Am) 51:239-54,Mar 69Becker, R.E.: Whiplash injuries. AAO Yearbook, 1958, pp. 65-9; reprintedAAO Yearbook, 1964, pp. 91-5Brec k, LW., and Van Norman, R.W.: Medicolegal aspects of cervical spinesprains. Clin Orthop 74:124-8, Jan-Feb 71Buonocore, E., Hartman, J.T., and Nelson, C.L.: Cineradiogram of cervi-cal spine in diagnosis of soft-tissue injuries. JAMA 198:25-9, 3 Oct 66Editorial. Whiplash injury in infancy. Med J Aust 2:456, 28 Aug 71England, R.W.: The cervical spine. Some clinical and practical considera-tions. JAOA 71:129-46, Oct 71Guthkelch, A.N.: Infantile subdural haematoma and its relationship towhiplash injuries. Br Med j 2:430-1, 22 May 71Heilig, D.: "Whiplash" mechanics of injury; management of cervical anddorsal involvement. AAO Yearbook, 1965, vol. 1, pp. 52-9Koshino, K., et al.: Activated irregular spike and wave complex in traumat-ic cervical syndrome. Brain Nerve (Tokyo) 24:49-55, Jan 72Lalli, J.J.: Cervical vertebral syndromes. JAOA 72:121-8, Oct 72Lord, J.W., Jr., and Rosati, L.M.: Thoracic outlet syndromes. Clin Symp23:3-32, 1971Magoun, H. I.: Whiplash injury. A greater lesion complex. JAOA63:524-35, Feb 64Pauker, S.G. Grand rounds. Whiplash. N Engli Med 283:600-1, 10 Sep 70Perlmutter, I.: Common spinal injuries. Diagnosis & treatment. MedTimes 96:649-60, Jun 68Policoff, L.D.: Extra-articular musculoskeletal disorders of the upper ex-tremity. Am Fam Physician 4:93-103, Sep 71Stuck, R.M.: Paper read before Third International Congress of Neurolog-ical Surgery, Copenhagen, 1965; reported in Med World News 6:33-4, 24Sep 65Wiesinger, H.: Whiplash injuries. Ann Ophthalmol 4:357, May 72

Submitted for publication in June 1973. Updating, as necessary,has been done by the author.

This paper was submitted as partial fulfillment of the require-ments for fellowship in the American Academy of Osteopathy.It was presented at the AAO Conclave of Fellows during their an-nual convocation in Colorado Springs, May 24-26, 1973.

Dr. Harakal is chairman of the Departmentof Osteopathic Philosophy, Principles, andPractice at Texas College of OsteopathicMedicine, Fort Worth.Dr. Harakal, 4153 Travis at Fitzhugh, Dal-las, Texas 75204.

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an osteopathically integrated approach whiplash injuries

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