There are many causes of neck pain but in today’s article, we are going to go through what some people call whiplash.
What is whiplash, is it just neck pain?
The first thing to know is that you cannot have whiplash. Wait, what did you say? Yes, you can’t, but you can have a whiplash associated disorder. Amazingly whiplash is the movement that your head and neck make, which gets its name from being like the motion of a whip. It is this motion that causes the injuries, which there are many that cause symptoms such as neck pain or headaches etc.
Here is a definition below:
“Acute whiplash injury follows sudden or excessive hyperextension (head goes backwards), hyperflexion (head goes forwards), or rotation of the neck and causes neck pain and other symptoms.”
“an acceleration-deceleration mechanism of energy transfer to the neck”
“from motor vehicle collisions, but can also occur during other mishaps”
“results in bony or soft-tissue injuries (whiplash-injury), which may, in turn, lead to a variety of clinical manifestations called Whiplash-Associated Disorders (WAD)”
So as you can see it is more the mechanism of the injury and is not exclusively isolated to car accidents.
Whiplash associated disorders are classified in terms of severity and the classification system used is the Quebec Task Force Classification:
Grade 0: No complaints about the neck. No physical sign(s).
Grade I: Neck complaint of pain, stiffness or tenderness only. No physical sign(s).
Grade II: Neck complaint AND musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness.
Grade III: Neck complaint AND neurological sign(s). Neurological signs include decreased range of motion and point tenderness.
Grade IV: Neck complaint AND fracture or dislocation.
What causes whiplash-associated disorders?
The most common and obvious is a car accident or road traffic collision but falling backwards is another example of how you can cause a WAD.
A car accident caused WAD is associated with more severe symptoms and rear-end collisions account for half of the cases (Bannister et al, 2009).
What occurs in the car accident?
It all happened so fast (a millisecond is a one-thousandth of a second).
0-50 milliseconds (ms): Cervical (neck) and thoracic spine (mid-back) straighten as car seat pushes the torso forwards.
50-75ms: Abnormal “S-shaped” cervical curve of lower segmental extension and upper flexion causing stretching, pinching and tearing of the facet joint capsules of the neck.
Just under 100ms: Maximal head and neck displacement: All cervical levels are fully extended.
(Elliott et al, 2009).
All of this happens far quicker than any muscular protection of the neck can occur! We just weren’t designed to move at these speeds as human beings (Panjabi et al 1998).
What injuries are sustained in a whiplash associated disorder?
Like we mentioned before the injuries are associated with whiplash, so what are the potential injures that can occur?
Facet Joint injury:
Facet joint Haemarthroses, which is bleeding in the facet joint, is often observed due to facet joint capsular tears. Articular cartilage damage of the joints can be observed and in more severe cases joint fractures and even ruptures of the capsule can occur. (Jonsson et al 1991).
Injuries to cervical facet capsular ligaments are common as ligaments main role is to stop excessive motion, which is what the whiplash causes (Stemper et al 2005).
It has been found that the upper neck is the worst culprit for facet joint pain with C2-3 facet joints causing 60% of joint pain but the next worst area is C5-6. (Lord et al 1996).
Dorsal Root Ganglion (DRG) and Nerve Root injury:
The dorsal root ganglion is the back area of the spinal cord where there is a cluster of neurons and the nerve roots are the nerves that leave the spinal cord and supply the peripheral nervous system. Both of these structures are in a location that is vulnerable to injury via excessive stretching during the rapid acceleration-deceleration movement from a rear or head-on accident. The side bending in the neck commonly caused by a side impact can also damage these structures (Taylor et al 1998).
Cervical disc injury has been found in 20% to 25% of people after whiplash, which correlates very well with their symptoms (Pettersson et al 1997). What is interesting is this an irritation of what already exists or does the whiplash cause it to occur. I would think the former due to the high incidence of disc prolapses found in non-symptomatic individuals on MRI scans.
The C5-6 level was found to be the most common level found with a disc injury (Ito et al 2004).
It is commonly believed that persistent symptoms following a whiplash often arise from ligament injury to the mid to lower aspect of the neck. Evidence has been found to show weakness and altered mechanical and structural properties of the neck ligaments including mechanoreceptors and pain nerve endings, which then leads to long term pain and problems (Tominaga et al 2006).
Upper cervical ligament injuries such as Alar and Transverse ligaments and even the Tectorial membrane have also been found to be injured from whiplash-associated disorders too. They have found more severe injury to the Alar ligaments when the head is turned on impact (Krakenes et al 2002).
Injury to the Sternocleidomastoid muscle particularly to the musculotendinous junction have been found in whiplash too (Brault et al 2000). Other muscle injuries to Semispinalis and Splenius Capitis and even the Upper Trapezius have been found from rear impacts (Vasavada et al 2007).
Except for neck pain, what are the other the signs and symptoms of a whiplash associated disorder?
The most common symptoms arising from whiplash are neck pain and headaches the pain can also commonly refer to the shoulder or arm.
Neck pain is present in 88% to 100% of cases and headaches are present in 54-66% of cases.
The next symptoms are less common but can occur in some cases:
Limited and reduced neck movement
Muscles spasm and active trigger points
Nausea (Feeling sick)
Tinnitus (Hearing noises)
Dysphagia (Trouble swallowing)
Paraesthesiae (Abnormal sensations such as pins and needles or numbness)
Temporomandibular joint pain (Jaw pain)
(NSW Government 2014)
What are the things to watch out for to indicate a much more severe injury?
Obviously, a head injury can occur in some accidents so look out for any altered levels of consciousness, midline neck tenderness and any wider spread weakness or abnormal sensations with exaggerated reflexes. Also, look out for speech issues, swallowing problems, tremors, abnormal muscle tone and visual issues. If these present then you need urgent medical attention.
Not all severe issues are to do with head injury though, so also watch out for the following:
There is a greater risk if the person is over 65 years of age
They have instant onset neck pain and they are unable to walk or sit
Their accident is related to diving or drowning
If they have a noticeably significant head or facial injury
The type of accident is relevant, for example, a fall from more than 1 metre or a side or head-on impact are more likely to have more severe problems.
If the person already has a rigid spinal disease like Ankylosing spondylitis
How do you diagnose a whiplash associated disorder?
Binder et al (2007) have found that the severity of the person’s symptoms may be very severe but commonly no specific abnormality can be found on both a detailed clinical or a radiological investigation. Our Physiotherapy assessments at our Stoke-on-Trent clinics can thoroughly assess you with questions about the accident, pain and symptoms, your previous medical history and more.
Other diagnostic elements include:
If we suspect a serious neck or head injury then you will need to visit Accident and Emergency.
If you are over 65 then we need to use the Canadian C-spine rule to judge whether we can assess your movements or if an X-ray of the cervical spine is required. (See Below):
We will look at your active range of motion as per the flow chart above.
So we can check this if you:
Had a simple rear-end motor vehicle collision.
Can sit and can walk afterwards.
If neck pain was not instant.
No midline neck tenderness.
As above if you can turn your head and neck to 45 degrees or more both ways then you don’t need an X-Ray.
We can see how the injury is affecting your daily life by using outcome measures such as the Neck Disability Index (NDI).
We can check for any neurological involvement as part of our assessment such as decreases in sensation, strength, or abnormal reflexes.
We will palpate the area to assess the sensitivity of the neck and surrounding areas.
Obviously, the neck is not always the only injury caused in a car accident so we can assess other problems if they are needed.
Psychological issues are common from whiplash so we can signpost you and offer some help on this side of things too.
All of this helps us to come up with a diagnosis of the specific nature of your whiplash-associated disorder, as well as rule out serious complications that need medical intervention. Once we know that you are safe for Physio then we can then formulate a treatment plan for you from there.
How do you treat a whiplash-associated disorder?
Pain and symptoms are a normal response to trauma to heal and protect the injury and it is normal to recover from whiplash-associated disorders within the first 2 to 3 months.
It is important to encourage early return to usual activities and get the area and body moving as a whole providing that these activities don’t aggravate symptoms. This is because it has been found that maintaining normal activities and staying active help recovery and conversely restricting your activity of may delay recovery so soft collars are not a great idea. Focus on progressions in small increments and small goals, not just full recovery (Cote et al 2016).
If needed then oral Paracetamol, Ibuprofen or even Codeine may be helpful to enable progress. Remember they enable movement, which helps recovery rather than directly influence recovery itself and you should try to not use them unnecessarily and for too long if possible. The guidelines from NSW Government (2014) are to limit their use for 3 weeks and no more.
Since some people can have post-traumatic stress disorder like issues with whiplash and these type of issues are linked to poor outcomes then this is certainly an area to look at in some cases. Using the Impact of Event Scale [IES]) it can highlight the need for a psychological referral with a score of more than 26 at six weeks post-injury (Cote et al 2016).
If neck pain from whiplash is above 5/10 and no progress is occurring at 3 weeks then Physiotherapy is recommended. APTA (2017) recommends that Physiotherapy should involve a multimodal treatment strategy, which means a combination of different approaches. These include manual therapy and exercises covering the following aspects:
Range of motion exercises:
Strengthening exercises for neck:
Strengthening exercises for shoulder girdle:
What are examples of manual therapies?
In cases with radiating symptoms down the arms then mechanical intermittent cervical traction can be useful and in all presentations of whiplash cervical and thoracic mobilisation and manipulations can be helpful too (APTA 2017).
If there is neck pain and headaches then a C1–2 sustained natural apophyseal glide (SNAG) technique can be done to help (APTA 2017).
Massage therapies such as sports massage can be useful for short term relief of pain, tenderness and spasm. This can be useful to help to enable exercise and movement for mechanical neck pain (Patel et al 2012).
In some cases, acupuncture can be used to reduce pain, once again to enable the return of function. In a study by Tobbackx et al (2013), they found a reduction in pain sensitivity in the neck with chronic whiplash. Also (APTA 2017) concurs that acupuncture can be used in chronic cases too.
If progress is poor by 12 weeks then a referral to a pain specialist is required (Willimas et al 2004).
How long does it take to recover from whiplash?
At 6 weeks after the injury, 40% of people should have some improvement and at 12 weeks 40% of people should be fully recovered. Sometimes things can take longer and it was found that 50% are fully recovered after 1 year (APTA 2017). Like with any injury full recovery is very subjective and depends on the needs of the person. A great example is a rugby player needs much more improvement to feel 100% for their sport than an elderly person would need to feel 100%.
So why do only 50% recover well?
It has been found that whiplash is far more complicated than other types of traumatic injury, it is not just neck pain! It has even been found that those that don’t do well have a high incidence of post-traumatic stress disorder and this negatively affects successful recovery.
What are some of the things to be aware of that may mean poor recovery?
Mindset: People with negative recovery expectations and believe that their accident severity was severe tend to not recover well from whiplash.
Pain level: People with very high pain intensity at the start tend to not recover well either.
Range of movement: If a person has poor neck mobility at the start along with sensitivity to cold then they tend to not recover well from whiplash.
(NSW Government 2014).
Bottom line is that Physiotherapy can help neck and shoulder pain with whiplash and I have personally seen thousands of whiplash patients over the years due to working with solicitors and medico-legal companies. We can assess and treat your whiplash-associated disorder at our Physiotherapy clinics in Stoke-on-Trent, Stafforshrie.
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.