Whiplash and Whiplash Associated Disorder

Whiplash has been the butt of many jokes, but to a person who suffers from it, it is no laughing matter. Each year, some two million Americans suffer from whiplash, most of them having been injured in a rear-end collision where the car they were riding in was stopped and hit by an inattentive driver. Severe whiplash can result in injury to the intervertebral joints, discs, ligaments, cervical muscles, and nerve roots. In severe cases, surgery may be necessary to repair damage to the spinal cord.

Animation courtesy of High Impact, Inc.

Between 15 percent and 40 percent of people who suffer whiplash will continue to have pain months after the injury occurred. There is an 18 percent chance that a whiplash victim will still be experiencing some symptoms after two years. In some people, this chronic pain can be traced to damage in the joints, discs, and ligaments of the neck. In many cases, however, no abnormality can be found to explain the persistent neck pain.

Whiplash is not a medical term. Doctors refer to it as neck sprain or neck strain or even more technically as cervical sprain or cervical strain (and sometimes “hyperextension”). Whiplash often involves pain and stiffness in the neck, but may also affect the surrounding muscles in your head, mid-back, chest, shoulders, and arms. Whiplash injuries can be mild or severe, temporary or permanent. Whiplash is often referred to as “soft tissue injuries,” as the damage is usually limited to the ligaments, muscles, and tendons of the neck and upper back and does not involve the fracture of any bones or vertebrae.

Whiplash occurs when the soft tissues (ligaments, muscles, and tendons) of the neck are injured by a sudden jerking or “whipping” of the head which strains the muscles and ligaments of the neck beyond their normal range of action. Whiplash injuries occur when there is a sudden backward movement of the neck (“hyperextension”) followed by a sudden forward movement of the neck (“hyperflexion”). The most common cause of whiplash is when you are in a car that is stopped and is rear-ended by another vehicle. Whiplash can also be caused by amusement park rides such as roller coasters, sports injuries, being punched or shaken, or falls from bicycles or other sources. Whiplash is often found in “shaken baby syndrome.”

Whiplash can take days, weeks, even months to develop. You may feel fine after an accident but slowly the typical symptoms of whiplash—such as neck pain and shoulder stiffness—may develop. Whiplash can be associated with other spinal conditions such as osteoarthritis (bone and joint pain) and premature disc degeneration (faster aging of the spine). The sooner the symptoms of whiplash appear, the more serious the injuries tend to be. Sometimes whiplash will appear in the first few days following the accident, go away, but then come back several days later. If this describes your situation, you should consult a doctor promptly.

Signs and symptoms of whiplash include:

  • Neck pain and stiffness

  • Headaches and dizziness (symptoms of a concussion)

  • Tenderness along the back of the neck

  • Muscle spasms in the side or back of the neck

  • Tingling, burning, or prickling sensations in the arms or legs (“paresthesia”)

  • Loss of function in the arms or legs

  • Pain and stiffness in the shoulder or between the shoulder blades

  • Back pain

  • Jaw pain (temporomandibular joint [TMJ] symptoms)

  • Ringing in the ears

  • Blurred vision

  • Difficulty concentrating

  • Memory problems

  • Irritability

  • Sleep disturbances

  • Fatigue

  • Nausea

  • Difficulty swallowing and chewing and hoarseness

Not too long ago, a person who suffered from whiplash was given a soft foam neck collar (brace) from the doctor and told to wear it for three to four weeks to immobilize the area. Today, doctors generally agree that immobilizing the area and the use of neck collars is not warranted, as immobilizing the neck for long periods of time can lead to decreased muscle bulk and strength and impair recovery. If a collar is prescribed for you, the doctor will usually want you to wear it no more than three hours at a time and only for the first few weeks after the injury. However, if you’re continually being awakened at night by whiplash pain, the doctor may have you wear a cervical collar to help you sleep.

Today, most doctors promote the use of pain relievers, muscle relaxants, stretching exercises, and/or physical therapy as appropriate treatment of whiplash. Early range of motion and exercises lead to a more rapid recovery than prolonged immobilization or use of a cervical collar. Nevertheless, if you experience pain when you move your head, or the pain involves your shoulders or arms, the doctor may prescribe a soft neck collar.

For many whiplash victims, if they follow the doctor’s advice and take the right medications and faithfully attend their physical therapy sessions, whiplash is resolved four to six weeks after the accident. But for some people, regardless of how intensive their physical therapy and their medications, whiplash results in long-term symptoms that can be extremely painful and disabling.

If you have been injured in a car accident (or other accident that has caused your head to snap forward and backward) and the back of your neck or your neck and shoulders are causing you pain, it is a good idea to seek immediate medical care to ensure that nothing more serious than whiplash is causing your pain. When you see the doctor, he or she will measure how far your neck can move in different directions and will also check to see whether any parts of your neck are especially tender to pressure. The doctor often will order x-rays of your neck and upper spine to see whether there has been any damage to the spine, such as fractures of the cervical vertebrae (the bones that make up the top part of your spine), dislocations, etc. Where more serious injuries are suspected, or you have not significantly recovered from your injuries in four to six weeks, the doctor may order a CT scan or an MRI to help assess the extent of your injuries and check for soft-tissue damage or pressure on the nerves.

In addition to whiplash, there is the more serious Whiplash-Associated Disorder (WAD). In the more severe and chronic case of “whiplash associated disorder,” symptoms can include those occurring in ordinary whiplash cases as well as the following:

  • Depression

  • Anger

  • Frustration

  • Anxiety

  • Stress

  • Drug dependency

  • Post-traumatic stress disorder (PTSD)

  • Sleep disturbance (insomnia)

  • Social isolation

Four grades of Whiplash-Associated Disorder were defined by the Qubec Task Force, commissioned by the public auto insurer in Quebec, Canada, which made specific recommendations on the prevention, diagnosis, and treatment of WAD. These four grades of Whiplash-Associated Disorder are:

  • Grade 0: no neck pain, stiffness, or any physical signs are noticed

  • Grade 1: complaints of neck pain, stiffness, or tenderness only, but no physical signs are noted by the examining physician

  • Grade 2: neck complaints and the examining physician finds decreased range of motion and point tenderness in the neck

  • Grade 3: decreased range of motion plus neurological signs such as decreased deep tendon reflexes, weakness, insomnia, and sensory deficits

  • Grade 4: neck complaints and fracture or dislocation, or injury to the spinal cord

For the immediate treatment of whiplash, doctors recommend that you should take either acetaminophen (Tylenol) for pain relief or an over-the-counter non-steroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve). For more serious whiplash injuries, the doctor may prescribe pain relievers containing codeine (such as Vicodin or Norco), as well as prescription muscle relaxants. To reduce the possible swelling (“inflammation”), in the first 24 hours following the accident you should apply cold to the back of your neck for 20 minutes every hour while you are awake and lying down. This should start as soon as possible after the accident. A package of frozen peas works nicely. The cold source should not be placed directly on the skin; rather it should be wrapped in a towel and applied to the source. A day or two after the accident, you should begin treating the back of the neck and shoulders with heat, such as a heating pad or a moist towel warmed in the microwave. For three to four weeks after the injury, you should avoid lifting or carrying anything heavy or participating in sports.

Once your pain is under control, the doctor will usually want you to regularly perform gentle stretching exercises to help restore your neck’s range of motion. These exercises generally involve rotating your head from side to side, and bending your neck forward, backward, and to the sides. You may also be referred to a physical therapist for treatment. The doctor may inject you with a corticosteroid medicine or lidocaine (a numbing medicine) into painful muscle areas to relieve the muscle spasms that can arise from a whiplash injury. This will make it easier for you to perform the stretching exercises necessary to recovery.

For most victims, the symptoms of whiplash usually subside for the most part in three to four weeks, although it may take up to three months to become completely symptom free. If symptoms continue or worsen after six to eight weeks, further x-rays or other diagnostic testing—such as a CT scan or an MRI—may be necessary to assess whether the person suffered a more severe injury than ordinary whiplash. Severe extension injuries like whiplash can damage the intervertebral discs, which may require surgical repair.

Rather than seeing a medical doctor, you may seek treatment by alternative health professionals. You may choose to see an osteopath (D.O.), who is a medical doctor who frequently corrects disorders of the system through manipulation of the spine.

Another option is to see a chiropractor. Research studies show that chiropractic care for neck pain is just as good as, but not better than, traditional physical therapy. Combining spinal manipulation with exercise provides more benefit. However, manipulation of the neck by a chiropractor carries with it the remote risk of a stroke or other injury.

Some people choose to be treated for their neck pain with acupuncture. In acupuncture, ultrafine needles are inserted in specific locations on your skin. However, research studies have been split fairly evenly as to whether acupuncture can help relieve persistent neck pain caused by strains.

Deep-tissue massage of the tight muscles in your neck may be helpful if you continue to have muscle spasms for more than a week or two. Before having the massage, you should relax the muscles in your neck first by taking a hot shower or bath, or by using a moist towel warmed in the microwave.

Your health care provider may recommend the use of a TENS unit. TENS stands for transcutaneous electrical nerve stimulation. A TENS unit sends a mild electric current to the skin, which decreases some types of pain by interfering with the transmission of the body’s pain signals. Treatment with a TENS unit can help relieve chronic neck pain, but only when combined with exercise. Ultrasound may also be used to treat your injury.

Although you can’t prevent a car from rear-ending you, you may be able to reduce the severity of whiplash by properly positioning the headrest of your seat. Some car manufacturers have begun to install various whiplash protection devices in their cars to reduce the risk for and severity of a whiplash injury in the form of “active head restraints” and “whiplash prevention systems.” However, the effectiveness of such measures has not yet been proved. One study found no difference in the severity of whiplash injuries, while one study in Trauma found that such systems can reduce the risk of neck injuries by up to 75 percent in a rear-end collision. In order for a headrest to give maximum protection, the head restraint should be positioned directly behind the head. If the head restraint is lowered below the level of the head, it could actually force the head into further hyperextension after an impact. The middle of the headrest should be even with the upper tips of your ears. You should wear your seat belt, although it does not seem to make a difference in getting whiplash.

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