In the more than 25 years we have been helping patients with their chronic pain, we have seen many people with hyper-extended neck injuries, or, in simpler terms whiplash injury. We have also seen patients who suffered from long-term effects of their whiplash injury until such time as they were diagnosed with Whiplash Associated Disorders (WAD). As noted in many studies including that published in the journal Frontiers in neurology:
- “The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (WAD) for months if not years following the accident.”(1)
As noted, Whiplash associated disorders are a lingering and complex series of problems for patients who have suffered whiplash injury in the past and whose impact continues for years even decades after the initial injury. The complexity of pain issues these patients suffer from leaves many frustrated with their health care providers and leaves some fighting to prove that there is something really wrong with them. If one were to examine the research on whiplash related disorders, he/she would find that most of the new studies center around identifying those patients who cannot be helped or feel helpless.
Why the helplessness?
Some whiplash patients consider themselves “cursed.” We get a lot of whiplash related emails, mostly the person who sends in the email tells us about not only being rear-ended in a car accident once, but two, sometimes three times. It is easy to see why this person would consider themselves “cursed,” at the least “unlucky.” Worsening symptoms including dizziness, headaches, a severe and stabbing pain that starts in the neck and the base of the skull and radiates its way through the upper back, shoulders, arms and hands, and possibly a host of mystery ailments that seemingly have nothing to do with their neck injury.
In our office we have seen Whiplash related disorder be involved with not only the obvious symptoms of neck pain, stiffness and spasms, headaches, shoulder pain, and numbness or tingling sensation all the way into the fingers, but to an extent we see patients who may also report:
- Sleep problems
- Low back pain
- Noise Sensitivity
- Concentration difficulties
- Blurred vision
- Swallowing difficulty
- Cognitive impairment
- TMJ / Jaw pain
The helplessness of these patients can be best expressed by one person’s statement: “My problems are growing. I have pain all over.”
“I have pain all over.”
People who suffered from a whiplash injury, can and do have pain all over. In June 2019, doctors reported in the journal BioMed Central musculoskeletal disorders of this mysterious phenomena of “pain all over,” in whiplash patients. They wrote: “A considerable number of patients with whiplash-associated disorders (WAD) report variable and indefinite symptoms involving the whole body, despite there being no evidence of direct injuries to organs other than the neck.”(2)
Doctors in Norway wondered why nearly every whiplash patient (at least 96% of them), had other pain besides the pain caused by whiplash. In their study titled: Pain and pain tolerance in whiplash‐associated disorders, published in the European Pain Journal, (3) the doctors of the study made these observations:
- Individuals with whiplash associated disorders reported more additional causes of pain, more painful locations and higher pain intensity than individuals with chronic pain from other causes.
- Here is the breakdown:
- Both men and women with whiplash associated disorders were more likely to report pain in the neck, shoulder, back, head and jaw than individuals reporting chronic pain from other causes.
- Women with whiplash associated disorders also reported pain in the hip, arm, hand, stomach, chest and genitalia more often.
The fact that women report pain in the hip and genital area shows the extent of the problem of whiplash and why some doctors would find it challenging to connect these pain issues with a whiplash injury. The researchers in this study, as well as other studies touch on the worsening of symptoms being possibly related to depression and the patient’s fear of movement causing pain.
My MRI cannot confirm that I have whiplash associated disorders
If this has happened to you, you are not unique. While MRIs can show damage to the cervical spine and neck, it cannot tell whether or not your problems are being caused by what the MRI image shows. This was pointed out by a January 2022 paper (11) assessing the value of MRI in helping to diagnose whiplash associated disorders. The authors of this study wrote: “Many of these (WAD) patients receive treatment in primary care settings based upon clinical and diagnostic imaging findings. Despite the identification of different types of injuries in the whiplash patients, clinically significant relationships between injuries and chronic symptoms remains to be fully established.” The are some of the problems the radiologists looked for:
- Kyphosis. The cervical spine is either straight “military neck” or has begun to curve in the opposite, non-natural direction.
- Lateral atlas displacement
- Alar ligament signal changes (damage),
- Transverse ligament signal changes (damage),
- Lateral joint degeneration C0/C1,
- Lateral joint degeneration C1/C2,
- Reduced disc height
- Modic changes (bone marrow lesions),
- Uncovertebral joint degeneration, (the C3 to C7 group).
- Facet joint degeneration,
- Neural foraminal stenosis,
- Spinal canal stenosis and,
- Vertebral artery loop. Changes in the neck have caused the vertebral artery supplying blood to the brain to have a loop or strecth in it.
Despite seeing these damages, the radiologists could not determine if any of these injuries prevented the natural flow of cerebrospinal fluid (the fluid of the brain that provides protection and nutrients for the brain). A characteristic of whiplash associated disorder.
Do conservative care treatment cause Whiplash Associated Disorders?
There have been many papers over the years which questioned whether whiplash patients should receive early intensive care. This would include physical therapy, chiropractic care, and other treatments. Some papers found early care not to be of benefit, others found it detrimental. Let’s examine a paper that appeared in the journal Archives of physical medicine and rehabilitation. (4) It was presented by medical university researchers in Canada, Sweden and Denmark.
Here are highlights at a glance:
- This study set up to determine whether the results from previous research suggesting that early intensive health care delays recovery from whiplash-associated disorders (WADs) were confounded by expectations of recovery (doctors were confused that their early intervention did not help and made things possibly worse).
- “Individuals with high utilization health care had slower recovery independent of expectation of recovery and other confounders. Compared to individuals who reported low utilization of physician services, recovery was slower for those with high health care utilization regardless of the type of profession. “
- those who went to their doctor and then were referred to physiotherapy had significantly slower recovery.
- those who went to the doctor and were referred to the chiropractor had significantly slower recovery.
- those who went to the doctor and then to massage therapy had significantly slower recovery.
At the time of the accident or sports impact, the victim may have reported that they were not suffering from whiplash related symptoms, but then a day, two days or a week later, suddenly, they would start developing pain in their neck, shoulders and back. When it was reported to the doctor – intensive care was started. This may have included painkillers which have been shown to have caused delayed or inhibited healing on their own.
Waiting for the whiplash injury to develop
Research that was published in the medical journal Spine (5) examined 70 research studies related to treatment and long-term prognostic factors in neck pain and whiplash.Their evidence suggests that:
- Almost 50% of patients with Whiplash Associated Disorders will continue to report neck pain symptoms 1 year after their injuries.
- Greater initial pain, more symptoms (as those mentioned above), and greater initial disability or injury predicted slower recovery.
- Few factors related to the collision itself (for example, the direction of the collision, headrest type) were prognostic (able to predict the severity of symptoms the patient may suffer from); however, post-injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.
In another study from the University of Copenhagen from January 2020, (6) researchers documents the frequency of neck pain at 84% and frequency of headache at 60% in patients within 7 days following whiplash injury. At 12 months post-injury, 38% of patients with whiplash still experienced neck pain, while 38% of whiplash patients reported headache at the same time interval post-injury.
Some never recover
Research in the The Journal of manual & manipulative therapy records: “current data indicate that up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by their condition.”(7)
A November 2019 study (8) suggests: “Almost 40% of individuals with chronic whiplash-associated disorders report headache after 5 years, making it one of the most common persistent symptoms besides neck pain.”
Treating neck ligaments to restore neck stability
In our office, treating Whiplash associated disorders begins with the repair and strengthening of neck ligaments. Ligaments are the connective tissue that hold your cervical spine vertebrae in place and your neck in its correct anatomical alignment. It has long been suggested that damage to these strong connective bands of tissue may be THE cause of Whiplash associated disorders. Below I briefly dsicribe PRP and stem cell therapies. These treatments help address the problem of damaged ligaments. When your ligaments are damaged, discs slip and herniate.
In the BioMed Central musculoskeletal disorders (9), researchers wrote of their findings connecting damaged cervical ligaments to symptoms of Whiplash associated disorders.
- “Significant decreases in ligament strength were observed following whiplash, supporting the ligament-injury hypothesis of whiplash syndrome.”
- “whiplash loading causes decreased ligament strength.”
When your ligaments are weak, they can no longer hold the neck in proper alignment. When the neck is not in alignment the vertebrae can pinch nerves, constrict arteries, put pressure on your esophagus among other problems that may cause the myriad of symptoms described above.
Cervical neck ligament weakness causing loss of curvature of the cervical spine
In their April 2019 update, Cervical (Whiplash) Sprain in the publication StatPearls (10) from the National Center for Biotechnology Information, U.S. National Library of Medicine, Kara J. Bragg of the Mayo Clinic and Matthew Varacallo, Department of Orthopaedic Surgery, University of Kentucky School of Medicine wrote:
“(Whiplash) injury occurs in three stages with a rapid loss of lordosis. (Lordosis means an abnormal neck curvature. It can mean too much of a curve or that the curve is bent or pointed the wrong way, this is called reverse cervical lordosis.)
Both the upper and lower spines experience flexion (hypermobility) in stage one. In stage two the spine assumes an S-shape while it begins to extend and eventually straighten to make the neck lordotic again. The final phase shows the entire spine in extension (hyper-extended) with an intense sheering force that causes compression of the facet joint capsules.Studies with cadavers have shown the whiplash injury is the formation of the S-shaped curvature of the cervical spine which induced hyperextension on the lower end of the spine and flexion of the upper levels, which exceeds the physiologic limits of spinal mobility.”
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1 Laporte S, Wang D, Lecompte J, Blancho S, Sandoz B, Feydy A, Lindberg P, Adrian J, Chiarovano E, de Waele C, Vidal PP. An Attempt of Early Detection of Poor Outcome after Whiplash. Front Neurol. 2016 Oct 20;7:177. doi: 10.3389/fneur.2016.00177. PubMed PMID: 27812348; PubMed Central PMCID: PMC5072109.
2 Matsui T, Iwata M, Endo Y, Shitara N, Hojo S, Fukuoka H, Hara K, Kawaguchi H. Effect of intensive inpatient physical therapy on whole-body indefinite symptoms in patients with whiplash-associated disorders. BMC Musculoskelet Disord. 2019 Jun 5;20(1):251. doi: 10.1186/s12891-019-2621-1. PubMed PMID: 31164107; PubMed Central PMCID: PMC6549292.
3 Myrtveit SM, Skogen JC, Sivertsen B, et al. Pain and pain tolerance in whiplash-associated disorders: A population-based study. Eur J Pain. 2015 Nov 16. doi: 10.1002/ejp.819. [Epub ahead of print]
4. Skillgate E, Côté P, Cassidy JD, Boyle E, Carroll L, Holm LW. The effect of early intensive care on recovery from whiplash associated disorders – Results of a population based cohort study. Arch Phys Med Rehabil. 2016 Jan 22. pii: S0003-9993(16)00035-6. doi: 10.1016/j.apmr.2015.12.028. [Epub ahead of print]
5 Carroll LJ, Holm LW, Hogg-Johnson S, Cote P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008; 33 (Supp 4): S83–92.
6 Al-Khazali HM, Ashina H, Iljazi A, Lipton RB, Ashina M, Ashina S, Schytz HW. Neck pain and headache following whiplash injury: a systematic review and meta-analysis. Pain. 2020 Jan 25.
7 Sterling M. Whiplash-associated disorder: musculoskeletal pain and related clinical findings. Journal of Manual & Manipulative Therapy. 2011 Nov 1;19(4):194-200.
8 Landén Ludvigsson M, Peterson G, Widh S, Peolsson A. Exercise, headache, and factors associated with headache in chronic whiplash: Analysis of a randomized clinical trial. Medicine (Baltimore). 2019 Nov;98(48):e18130. doi: 10.1097/MD.0000000000018130. PMID: 31770245; PMCID: PMC6890366.
9 Tominaga Y, Ndu AB, Coe MP, Valenson AJ, Ivancic PC, Ito S, Rubin W, Panjabi MM. Neck ligament strength is decreased following whiplash trauma. BMC Musculoskelet Disord. 2006 Dec 21;7:103. doi: 10.1186/1471-2474-7-103. PMID: 17184536; PMCID: PMC1764743.
10 Bragg KJ, Varacallo M. Cervical (Whiplash) Sprain. [Updated 2019 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541016/
11 Uhrenholt L, Brix L, Wichmann TO, Pedersen M, Ringgaard S, Jensen TS. Advanced magnetic resonance imaging of chronic whiplash patients: a clinical practice-based feasibility study. Chiropractic & Manual Therapies. 2022 Dec;30(1):1-3.