Marc Darrow, MD, JD.
In the more than 27 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.
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:
- Fatigue
- Anxiety
- Sleep problems
- Low back pain
- Noise Sensitivity
- Concentration difficulties
- Blurred vision
- Swallowing difficulty
- Dizziness
- Cognitive impairment
- TMJ / Jaw pain
- Headache
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.
A June 2024 paper (13) added factors related to worsening headaches: “The risk of presenting with persistent headache attributed to a whiplash injury is increased when people present with higher neck pain intensity and pain catastrophizing soon after a whiplash injury.”
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 stretch 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.
Post-concussion and neck pain
In a May 2024 study (12) researchers found new or worsened neck pain is common after a concussion (as seen in more than 30% of patients), negatively influences recovery, and is associated higher in women and level of contact in sport. In this study varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as non-varsity sport athletes at military service academies were eligible for enrollment. A total of 2163 injuries were studied.
New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without neck pain.
Jaw pain and whiplash
Above I mentioned the patient who has “pain all over.” The cause of these pains can be related to spasms or ligament damage to the neck and not an injury to that specific area of the body. In February 2024, (14) researchers pointed out that jaw pain following whiplash trauma can result without direct injury to the jaw. “Pain development and maintenance in the jaw region during the period between 1 month and 2 years after whiplash trauma are primarily not related to the trauma itself, but more associated with physical symptoms and general mechanisms behind widespread pain.”
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. “
Specifically:
- 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.”
Nerve blocks for acute whiplash – the facet joint is the likely pain generator in whiplash in 50% of patients.
One of the challenges of MRI and diagnosis is determining where whiplash pain may be coming from. In a December 2021 paper, (16) researchers write: “Although diagnosis can be challenging, the consensus from the current literature suggests that the facet joint is the likely pain generator in whiplash in 50% of patients.” Further they offer characteristics of what doctors may look for in whiplash pain. They are:
- Older patients.
- Moderate/severe levels of a pre-injury neck disability, and symptoms of neural hyperexcitation (nerve pain) on the first examination.
In addressing the facet joints of the neck, the paper continues: “There is good literature to support the use of diagnostic and therapeutically targeted injections to identify and treat pain generators in WAD. There is also a corpus of evidence supporting the use of nerve ablation following a successful diagnostic nerve root block to achieve long-term pain relief. Despite an incidence of minor complications such as minor bleeding, both targeted injections and nerve ablations have been shown to be safe and clinically effective procedures.”
Repairing neck ligaments to restore neck stability
Research suggests that reversing 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.
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.
A March 2024 study (15) looked at three-dimensional (3D) SPACE MRI findings of the transverse ligament in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group to highlight possible injury of the transverse ligament in whiplash patients.
- In this study cervical spine MRI scans were obtained from 46 patients with WAD and 62 nontraumatic individuals.
The researchers found: “When comparing the whiplash-associated disorder (WAD) and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3 injury) and the number of degenerated cervical levels.” The researchers suggested “High-grade morphological changes in the transverse ligament can be detected in patients with whiplash-associated disorder through the use of 3D SPACE (MRI) sequences. . . Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning. ”
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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References:
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