Why Do I Still Have Whiplash Pain After All These Months?
November 21, 2018 6:00 pm
Chronic whiplash…is this pain treatable? Why do you still have pain in your neck many months after a motor vehicle accident?
Whiplash is a term used to describe an injury to the neck that involves a rapid backward and forward movement with a great force, such as a car accident. Whiplash is the most common non-fatal injury associated with a motor vehicle accident. The medical injury name involving this force to your neck is called Whiplash Associated Disorder, or WAD. In Alberta there were 140,705 reported collisions in 2017. Of these collisions, 18,000 people reported injuries. Those who reported injuries showed that 3,000 were documented as severe. The cost of these motor vehicle accidents to Albertans is $718 million per year in indirect and direct costs. Whiplash injury classifies signs and symptoms on a grade point scale from 0 to 4.
The spectrum of symptoms following a WAD are vast and varied revealing the complexity and multifactorial cause of the condition. Reported symptoms include:
- Neck pain and stiffness
- Numbness and muscle weakness
- Widespread sensory hypersensitivity (from any of the sense organs: touch, smell, taste, sight and hearing)
- Cognitive interference
- Anxiety and depressive disorders
The good news is that most clients who experience a whiplash injury present with an uncomplicated clinical presentation of mild to moderate pain and disability. Local increased pain over the neck region and mild psychological distress following a motor vehicle accident will recover usually in the first 3 months. At the other end of the spectrum, about 25% of clients present with a complex clinical picture, and as many as 50% will continue to report persistent interference in daily quality of life, even 12 months after an accident has occurred.
Thinking about who may be at greatest risk for chronic neck pain, we come up with a list that intuitively would make us think that the reason the pain persists is the amount of damage there was to the neck, with the following proposed risk factors:
- Direction of the impact
- Awareness of collision
- Headrest type
- Older age
- Vehicle speed
- How much the neck angulates forward and backward
It might surprise you to know that all the items listed above have no effect on outcome of clients who will experience persistent pain. You must now be asking yourself what are the risk factors for developing chronic neck pain, and what can you do to ensure that you are not going to develop ongoing symptoms from a motor vehicle accident?
Factors that have been shown to increase a client’s risk of developing chronic symptoms are:
- Self-reported high pain levels and disability after the accident
- Increased post-traumatic stress levels
- Increased catastrophizing (predicting a negative outcome)
- Hypersensitivity to cold and touch
It’s important that you see a Physiotherapist as soon as possible after a motor vehicle accident who can consider all the features of this heterogeneous condition. A detailed assessment will determine the extent of your injuries, while a quick screening test is needed to identify possible risk factors, provide early education, pain management strategies and reduce stress with reassurance. Fifth Avenue Physio will create a tailored exercise program that focuses on your specific needs.
In the assessment of chronic WAD clients, we need to be comprehensive. A Physiotherapist’s approach to treating motor vehicle accident pain needs to operate within a Biopsychosocial Model. A detailed assessment of the biological and psychosocial factors are imperative to target the features specific to the client’s presentation.
Studies that have compared individuals who had chronic neck pain from both whiplash disorders from motor vehicle accidents and chronic neck pain from other conditions, like degeneration, show interesting differences with two very different presentations.
In the group of clients that were involved in a motor vehicle accident, neck muscle degeneration and structural changes were found. The muscle fibers were replaced by fat content, which started to occur in as little as a few weeks after the accident. This muscle degeneration was not found in the chronic neck pain clients. This suggests that the fatty type changes and fatty infiltration is unique to those clients who were involved in a motor vehicle accident. The problem with this fatty infiltration into the neck muscles is that they don’t work the same way as lean muscle. Fatty muscle tissue is weaker in strength and endurance than lean muscle tissue. When a muscle becomes dysfunctional, it changes the neurological input into your brain, which can result in more pain, less coordination and altered proprioception.
So what do we do with this information and can we get rid of these fatty changes? The answer is move more, exercise and get stronger. A small study that implemented very specific neck exercises for women with whiplash disorders showed a reduction in fat content in the neck muscles, and more importantly, a reduction in painful symptoms. This is hopeful news for clients with chronic neck pain that this problem of fatty deposits is fixable.
Many studies have been done to implement the facet joints as a driver for persistent whiplash associated pain. Facet joints are the hinge-like joints on each side (right and left) of your neck that link the cervical vertebrae together. Studies have revealed that these joints in your neck may be a contributor to the chronic pain symptoms associated with whiplash disorders and treating them with injections will effectively help 40% – 45% of clients to relieve their ongoing symptoms. Your Physiotherapist will do a specific clinic evaluation to determine if this may be an effective treatment to modify your symptoms.
Persistent pain and psychological sequelae are common after a motor vehicle accident. Few people would disagree that being in a motor vehicle accident can be highly stressful. What many may not realize is how the psychological distress impacts our pain symptoms and ability to fully recover from the accident.
A study by British researchers suggests that at least one third of all people involved in non-fatal accidents have post-traumatic stress disorder, persistent anxiety, depression and phobias one year after the accident. The study also suggests high levels of psychological distress even when the motor vehicle accident has medically not been serious. The assumption that clients who have more severe injuries are more likely to have higher levels of psychological distress is not true.
Fear of movement is fairly common after whiplash injuries. Some people respond to pain with anxiety and fear. They start to catastrophize about the pain and lack confidence and control about movement and start to expect negative outcomes. Before you know it they start to “protect” themselves and stop moving, fearful that certain movements “might” cause pain and are causing “damage”.
A study published in the Pain Journal in 2012 found that fear of movement can explain 20% – 40% of pain related disability. This study revealed that some but not all clients with whiplash disorder can be helped by Therapy to reduce fear avoidance beliefs and behaviors.
Having an understanding by using tools to measure a client’s psychological distress levels, catastrophizing and fear avoidance beliefs following a motor vehicle accident will target the specific dysfunctions and possible barriers to a full recovery.
Physiotherapy is a main treatment option for individuals who have whiplash disorder. It’s important that you see a Physiotherapist as quickly as possible after a motor vehicle accident. A thorough assessment will be performed of your cervical spine movement. Tools will be used to measure possible risk factors for developing chronic pain. The primary goal will be to get the initial pain under control. Different strategies may be used to help control the pain:
- Manual Therapy
- Intramuscular Stimulation (Dry Needling)
- Electrical Modalities
With the client and Therapist working together using a biopsychosocial model to target specific features of this multifactorial and complex condition, the goal is to fully eliminate the chronic symptoms of whiplash altogether. The goal is to not suffer with treatable accident related pain.
Visit Kelly’s bio page here: http://www.fifthavephysio.com/our-team/kelly-barrie/
Elliott JM, Courtney DM, Rademaker A, Pinto D, Sterling MM, Parrish TB. The rapid and progressive degeneration of the cervical multifidus in whiplash: an MRI study of fatty infiltration. https:// doi.org/10.1371/journal.pone.0021194 31
Smith AD, Jull G, Schneider GM, Frizzell B, Hooper RA, Sterling M. Modulation of cervical facet joint nociception and pain attenuates physical and psychological features of chronic whiplash: a prospective study. https://doi.org/10.1016/j.pmrj.2015.03.014 96
Walton D, Elliott J. An Integrated Model of Chronic Whiplash-Associated Disorder. https://www.jospt.org/doi/pdf/10.2519/jospt.2017.7455
Mayou R, Bryant B, Ehlers A. Prediction of Psychological Outcomes One Year After a Motor Vehicle Accident. https://doi.org/10.1176/appi.ajp.158.8.1231