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Pain in the neck, shoulders, head or the base of the skull that occurs after a motor vehicle accident is often called whiplash. Most patients with whiplash recover in a few weeks or at most, a few months, but 15 to 20% of people develop chronic pain. Whiplash is not a trivial problem, because once it has occurred, only 70% have recovered completely by one year and only 82% have recovered completely by two years. In addition to neck pain, there are many symptoms associated with the whiplash syndrome and include sleep problems, poor concentration and memory, blurry vision, ringing in the ears, fatigue, and weakness.
The treatment for whiplash syndromes depends on the stage and degree of the problem and which structures have been injured. In addition to soft tissue injury, pain that persists after four to six months is usually due to injury to the facet joints, one or more discs, or both. The diagnosis can usually be made by injections, MRI, and X-rays. Treatment is usually successful, but requires physical therapy, injections, and occasionally surgery.
Although long, the following is a review of whiplash.
The term, whiplash, is confusing because it is both a mechanism of injury and the symptoms caused by a car accident. It is due to a traumatic event that causes the head to move suddenly (whip) in one direction and then recoil in the other direction. The most common cause of whiplash is a motor vehicle accident in which one vehicle is struck from behind by another. However, it can occur when a car stops abruptly after striking a pole, a wall, or another car, and can also occur after a side impact.
Significant damage to ligaments, discs, and joints can occur even if the swings of extension and flexion are not excessive, but often the neck is forced to the extreme ends of normal range or beyond. Because the trauma is usually sudden, occupants of the car are not prepared for the impact. The muscles are relaxed, which allows more forces on the discs, ligaments and joints. Perhaps the most important fact about whiplash is that significant pain and structural damage can occur at crashes of low velocity.
Whiplash: The causes of the pain
The most common causes of persistent pain in whiplash are the facet joints and the discs. There is a poor correlation between the radiographic appearance of the joints and whether they are painful. Some joints which look bad are painless while other joints that look normal can be proven to be a source of pain. Only facet injections can determine whether the joint is painful.
In a research study by Drs. Bogduk and Aprill, in 23% of patients, facet joints alone were the cause of pain, in 20% of patients the discs alone were the cause of pain, and in 41% of patients both the facet joints and discs were contributing. They were not able to identify the source of the pain in only 17% of their patients.
Whiplash: Associated symptoms
There may be fatigue, dizziness, problems with vision, ringing in the ears, heaviness in the arms, and low back pain. There can be poor concentration or memory, change in emotions with irritability, depression or short temper, and sleep disturbance. Dizziness occurs in one-quarter to one-half of people with whiplash injury. Again, researchers are not sure of the cause. The most likely explanation is an injury to the part of the inner ear that regulates balance. Problems with memory and concentration can be due to the pain itself, depression, medications, or trauma to the brain. Visual disturbances occur in 10 to 30% of whiplash patients and blurred vision is the most common.
Most patients destined to recover completely will have done so by three to four months, after which the rate of recovery slows markedly. By two years, essentially all patients have reached their individual maximum improvement. About 18% continued to have significant pain two years after the accident! Patients who did not get well tended to be older, had pain which began sooner after the accident, and/or had their head rotated to either side at the time of impact. They also found that patients who, before the accident, had a history of neck pain, arthritis of the neck, or headaches did not do as well.
Neck Pain, Whiplash and the Legal System
The effects of lawsuits and the outcome of whiplash syndromes
In another study from 1993, Drs. Parinar and Raymakers re-evaluated patients they had seen previously for legal opinions, not for treatment, 8 years after the initial consultation. They concluded that lawsuits did not influence the timing or degree of recovery.
Several years ago we carefully analyzed a group of patients who were referred for treatment by their attorneys because they were not getting better. The patients were treated with strengthening exercises, body mechanics training, medications, spinal injections and occasionally psychotherapy. No patient needed surgery. Most of the patients did well with significant improvements in pain and function. Although most patients still had mild pain at the end of treatment, it was not enough to interfere with their daily lives. These very favorable results occurred although none of the lawsuits had been settled.