Whiplash Associated Pain
Whiplash-associated disorders (WADs) are common, disabling, and costly conditions that occur usually as a consequence of a motor vehicle accident or crash (MVC). The most common symptom of whiplash is neck pain. In addition to neck pain, there may be pain in one or both arms, between the shoulder blades, the face and even the low back along with heaviness or tingling in the arms, dizziness, ringing in the ears, vision changes, fatigue, poor concentration or memory and difficulty sleeping. If pain does not get better after several months, patients often get depressed.
The most common cause of whiplash and WAD is a motor vehicle accident (MVA) in which one car (the struck vehicle) is hit from behind by another (the bullet vehicle). It is usually not possible to know the exact cause of neck pain in the days or weeks after a car accident. We know the muscles and ligaments get strained and are probably inflamed, but they usually heal within six to ten weeks. Pain that lasts longer is usually due to deeper problems such as injury to the disc or facet joint, or both.
Facet Joint Pain is the most common cause of chronic neck pain after a car accident. It may occur alone or along with disc pain. Facet joint pain is usually located to the right
or left of the center back of the neck. The area might be tender to the touch, and facet pain may be mistaken for muscle pain. We cannot tell if a facet joint hurts by how it looks on an X-ray or MRI scan. The only way to tell if the joint is a cause of pain is to perform an injection called “medial branch block (MBB),” which is discussed later.
Disc Injury can also cause chronic neck pain. The disc allows motion of the neck, but at the same time keeps the neck from moving too much. The outer wall of the disc (called the anulus) can be torn by a whiplash injury. This usually heals, but in some people, the disc does not heal. In that case, it might get weaker and hurts when stressed during normal activities. The pain comes from the nerve endings in the annulus. The disc is the major cause of chronic neck pain in about 25% of patients, and there can be both disc pain and facet pain in some people. Less often, a disc can herniate and push on a nerve. This usually causes more arm pain than neck pain.
Muscle Strain of the neck and upper back can cause acute pain. However, there is no evidence that neck muscles are a primary cause of chronic neck pain, although muscles can hurt if they are working too hard to protect injured discs, joints, or the nerves of the neck or there is something else wrong that sustains the muscle pain, such as poor posture and work habits.
Spinal nerves and the spinal cord can be compressed by a Herniated Disc or Bone Spur.This usually causes arm pain, but there can also be neck pain.
Symptoms of whiplash and WAD
Headache due to neck problems is called cervicogenic or neck-related headache. It may be due to injury to an upper cervical disc, facet joint or higher joints called the atlantooccipital or atlanto-axial joints. Cervicogenic headache can also make migraines worse. Arm pain and heaviness may be due to nerve compression from a herniated disc, which is easy for your health care professional to diagnose. More commonly, arm pain is “referred” from other parts of the neck. “Referred pain” is pain that is felt at a place away from the injured areas, but not due to pressure on a nerve.
Pain between the shoulder blades is usually a type of referred pain.
Low back pain is occasionally seen and is quite common after whiplash and may be due to injury to the discs, facet joints of the low back or sacroiliac joints.
Difficulties with concentration or memory can be due to pain itself, medications you are taking for the pain, depression or mild brain injury. You might also experience irritability and depression.
Sleep disturbance can be caused by pain or depression.
Other symptoms might include blurry vision, ringing in the ears, tingling in the face and fatigue.
In patients who do not get better after about 12 weeks, more detailed evaluation might be needed and some of the tests are described below:
X-raysare used right after injury if the health care professional suspects there may be a fracture or that the spine is not stable. X-rays also show disc height and bone spurs. Otherwise they are often used in patients who do not get significantly better by about 12 weeks. If an MRI is performed, X-ray examination is usually also done to look at the bone anatomy.
MRI scanis necessary if the health care professional suspects a disc herniation, disc injury or compression of a nerve or the spinal cord.
Medial branch block (MBB) is an injection done to determine whether a facet joint is contributing to neck pain.
Discography is an injection into the disc itself to determine if a disc may be contributing to the pain. Discography is only used for patients with severe pain that has not improved with good treatment, and for whom surgery is being considered.
Computed tomography (CT scan), usually combined with myelogram (dye or contrast injected into the spinal canal) can also be used to help diagnose neck pain that does not respond to treatment.
Electromyography and nerve conduction velocity (EMG/NCV) might be used if there is suspicion that a nerve is being trapped (such as in carpal tunnel syndrome) or there is nerve damage.
The treatment of whiplash in the first few weeks and months usually involves strength training and body mechanics instruction. Patients who do not get better after about 12 weeks require specialized treatment, based on the cause of the pain.
Strength training is necessary to develop sufficient muscle strength to be able to hold the head and neck in positions of good posture at rest and during activity. Strengthening the muscles will also improve their range of motion.
Body mechanics describes the interrelationship between the head, neck, upper body and low back during movement and at rest. Training in proper posture decreases the stress on muscles, discs and vertebrae, giving damaged tissue the chance to heal. Poor posture and body mechanics unbalances the spine and creates high stress on the neck, which may impede healing.
Medications are helpful for symptom control.They never solve the problem and should be used as just one part of a total treatment program. There is no best medicine for neck pain. The choice of medication depends on the type, severity and duration of the pain as well as the general medical condition of the patient. Types of medications that are most often prescribed for acute neck pain include antiinflammatory drugs and opioid (narcotic) pain relievers. Additionally, your health care professional may prescribe the use of muscle relaxants. For chronic and severe neck pain,the opioid analgesics and antidepressants are generally most helpful.
Spinal Injections can be helpful in carefully selected patients. Again, injections do not cure the problem and should be only one part of a comprehensive treatment program. Epidural injections into the spinal canal can provide short-term relief in cases of nerve compression with arm pain, but are rarely effective for pure disc pain without radiating