Treatment of Whiplash associated disorders
Ross Hauser, MD
Treatment of Whiplash associated disorders
At our center, we see many patients with chronic whiplash symptoms. They usually have taken a long medical journey bouncing from one clinician to another looking for answers to problems that seemingly evade all treatments. In this article, we will present our clinical findings and observations on how the treatment of cervical ligament damage may be the answer that has eluded them.
When we see a patient with chronic whiplash symptoms, we typically hear a story like this:
I had an x-ray and nothing “remarkable,” was seen.
I was in a car accident where I was rear-ended. Following the accident, I had severe pain in my neck. As the days passed the pain crept into my upper back and shoulders. I had an x-ray and nothing “remarkable,” was seen. As the pain progressed I was put on pain management and physical therapy. The physical therapy I did twice to three times a week. As the PT was not helping my pain management was expanded from over-the-counter pain medications to a recommendation to an epidural steroid injection.
The first epidural helped a lot but the pain started to come back.
The first epidural helped a lot but the pain started to come back. I was sent for a second epidural. That did not help at all. I was sent to an MRI where again, “nothing remarkable” was found that would be significant enough to cause my pain issues.
I was told that eventually, all these problems would go away. My problems are not going away.
As more time passed I was diagnosed with “whiplash associated disorder.” My symptoms now included dizziness, headaches, severe pain that starts in my neck and goes through my upper back, into my shoulder, down my arm, into my elbow, and hand. I have numbness as well. I was told that eventually, all these problems would go away. My problems are not going away, they are getting worse and making it difficult for me to go to work.
My MRI and x-ray did not show anything wrong.
I started to do a lot of research to see if I could help myself. My MRI and x-ray did not show anything wrong. I did see the research that said that I may have a problem with ligament sprains or tears in the neck. I was relieved in a way that my problems were “not in my mind.” I have also had a lot of negative thoughts that I would never get well. I take a lot of pain medications and do a lot of PT still. I do not have great expectations that these treatments will help me.
Whiplash associated disorders treatments. Why do patients have a poor expectation of recovery?
I am going to briefly touch on this now, Why do patients have a poor expectation of recovery? Below I will also discuss the aspect of Functional somatic syndromes and somatization.
Over the years we have received countless stories from people who have been “wandering,” for years looking for help for their whiplash-related problems. It is easy to see why they would have a poor expectation that anything would help them, especially when their treatments may be into the decades. These people’s stories go something like this:
I have had issues now for more than 35 years. Throughout the years I had many problems and visited many medical professionals and have been prescribed more medication than I can even remember at this point. When I see my doctor and they want to “try something new,” we have to dig deep into my files to see if I had tried this medication or a similar medication years ago.
I have been told I have post-concussion syndrome and Craniocervical instability. My doctors have not been able to help with symptoms of sensitivity to noise or sounds, sensitivity to light or vision abnormalities like double-vision, or objects in my vision range “jumps,” or bounces around.
A few years ago I was told that my whiplash injury had progressed in cervical canal stenosis and I this was causing compression on the spinal cord. A was told to consider a cervical spinal fusion, which I declined because my surgeon told me that I may not get good results.
Looking into the minds of automobile accident victims
In the August 2018 edition of The Clinical Journal of Pain, (1) researchers looked into the minds of automobile accident victims to help doctors determine which psychological factors are important in the development of chronic whiplash symptoms.
The patients studied were more likely to have:
- Poor expectations of recovery,
- Posttraumatic stress symptoms, (which may include severe anxiety, flashback to accident fears, anger, self-destructive behavior (drug or alcohol use), and isolation.
In this group is also the challenge of avoidance of treatment or what doctors term “passive coping.” The patient avoids trying to solve the problems they are facing, partly because they have a poor expectation of recovery.
From Ross Hauser, M.D. Early in my career, while my Prolotherapy practice was building, I did hundreds of expert medical reports, reviewing medical records of patients who were injured in car accidents. I did my best, to be honest, and render expert opinions about what I felt the injuries were due to and what was appropriate care for their injuries. Most patients, lawyers, and even doctors involved in both the healthcare aspect and legal aspect of whiplash injury often don’t understand some of the key concepts of whiplash that we will discuss below.
After reviewing all these cases, I personally believe the best treatment for whiplash injuries was to address the ligament problems in the cervical spine possibly damaged in the whiplash injury and the subsequent degenerative weakening of these ligaments that can cause a myriad of symptoms, some of which are described above.
Why the ligaments?
When a person has a whiplash injury, they suffer a very quick flexion and extension of the neck and that causes injuries to the cervical neck ligaments. It is these ligament injuries that cause long-term pain. Whiplash injury causes ligament injury, which causes joint instability, which causes the vertebrae to go out of alignment. In our office, we try to stimulate the ligaments to repair themselves. Specifically with Prolotherapy which involves the injection of a healing stimulating proliferant (dextrose) into the damaged ligaments. This causes the ligaments to tighten and strengthen, making for stability in the neck which stops muscle spasms and resolves the pain.
Our results of the treatment are published below.
The wrong or inappropriate treatments at the onset of whiplash. Unnecessary scans and images, the wrong specialist in many cases:
In March 2020 (2) a paper in the journal BioMed Central health services research explored the type of treatments whiplash victims received immediately following the injury event. What they found was doctors and patients did not have a good understanding of what type of treatments or testing they should have. Listen to what the researchers reported:
Unnecessary scans and images, the wrong specialist in many cases:
Individuals with whiplash-associated disorders claimed a range of health services. Radiology imaging use during the acute post-injury period, and physiotherapy and chiropractor service use during the chronic post-injury period appeared concordant with current whiplash-associated disorders management guidelines.
Conversely, low physiotherapy and chiropractic use during an acute post-injury period, and high radiology and medical specialists’ use during the chronic post-injury period appeared discordant with current guidelines.
Strategies are needed to help inform medical health professionals of the current guidelines to promote early access to health professionals likely to provide an active approach to treatment and to address unnecessary referral to radiology and medical specialists in individuals with ongoing whiplash-associated disorders.
What are we seeing in this image? Ligament damage in whiplash injury.
The caption reads: Ligament strain with cervical extension and flexion during whiplash injury. Hyperflexion stretches the posterior ligament complex wheras hyperextension causes strain (stretch) on the anterior intervertebral disc and anterior longitudinal ligament.
Physical therapy and exercise, researchers do not know if this is any good in alleviating whiplash symptoms.
Some people do get varying degrees of benefit from exercise and physical therapy for their whiplash-related symptoms. These are the people we usually do not see in our offices. We see the people who had less than hoped for success. In an August 2019 study led by The University of Queensland appearing in the Journal of Clinical Medicine, (3) doctors wrote:
“The results of this review found that the strongest (chronic neck pain) treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence.”
As we have suggested many times, exercise and physical therapy are examples of resistance. If the soft tissue of the neck, that is the ligaments and tendons are damaged or weakened, they cannot provide the sufficient resistance needed to strengthen muscles. A November 2018 study (4) from the Scientific Institute for Quality of Healthcare at Radboud University in the Netherlands does suggest, however, that physiotherapy care understanding in treating whiplash-related disorders has been improving.
“To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not.”
Let’s now look at an April 2021 study from The University of Sydney published in the journal Musculoskeletal Science and Practice. (5) What the study researchers are suggesting is that “there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not.” To try to answer this question the researchers took a closer look at patients who were classified as exercise responders and exercise non-responders. There were thirteen patients in this study. Seven patients went to see a physical therapist.
According to the researchers, “patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not.
Four themes were generated from patient and physiotherapist interviews, including:
(1) the therapeutic relationship, (the patient either believed the health care profession would help them or would not. Let’s point out again as mentioned at the onset of this article that many whiplash patients have a low expectation that treatments can help them.)
(2) exercise experiences and beliefs, (the patient either believes that exercise will help them or they have their doubts. Generally, if someone has initial good results they will continue on with the exercise. If they do not believe that the exercise will help them, then exercise will not help).
(3) self-efficacy and acceptance, (the patient does or does not think they can do the exercise. “This is too hard for me).
(4) physical and psychological determinants of responsiveness. (This is more complicated as many researchers are not even clear what physical and psychological determinants are concerning why someone will not try to exercise.)
The conclusion of this study was: “Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership, and rapport.”
In this video Danielle R. Steilen-Matias, MMS, PA-C, focuses on the injury to the cervical spine ligaments as the cause of degenerative disc disease in the cervical spine and the myriad of neurological and musculoskeletal conditions these injuries may cause.
A summary of the video is below:
- A patient that is suffering from whiplash-associated disorders may have suffered significant cervical spine ligament injury.
- This damage renders the neck “unstable.”
- The cervical spine ligaments are like rubber bands that wrap around the cervical vertebrae and hold the cervical spine in its proper place and in its proper alignment. If these ligaments “rubber bands,” have been stretched out or damaged or loosened, the cervical vertebrae are going to slide in and out of place and compress on nerves and blood vessels that can contribute to all the symptoms they face.
- Damaged ligaments can be the cause of muscle spasms and the patient’s failure to adequately respond to physical therapy.
- At 4:05 of the video, an example of a digital motion x-ray DMX evaluation is shown. The DMX is an x-ray movie that can illustrate how the vertebrae are moving and where they are moving and sliding too much. This allows us to pinpoint treatment.
“Whiplash causes you more pain than imaging studies can verify – doctors can become skeptical of your pain.”
It is a simple matter for someone to become skeptical of their doctors because their doctors are skeptical of them. This is a write-up in the medical publication STAT PEARLS, it is an excerpt from an online book titled: Cervical Sprain. (6) This information is offered by the United States, National Center for Biotechnology Information. Most importantly, it is an update from November 2020.
This is what doctors read:
“The term “whiplash” injury was first coined by Harold Crowe in 1928 to define acceleration-deceleration injuries occurring to the cervical spine or neck region. Later modified to an all-encompassing term known as whiplash-associated disorders (WAD), these clinical entities have been refined to describe any collection of neck-related symptoms following a motor vehicle accident (MVA).
The elusive difficulty that remains in describing these injuries is secondary to the fact that there is, by definition, no structural pathology identified following a comprehensive diagnostic workup.
Therefore, WADs remain a diagnosis of exclusion. Treatments include rest, analgesia, soft braces, and early physical therapy. The injury may be acute with full recovery or maybe chronic with residual long-term pain, disability, and health care resource utilization.
The so-called Whiplash profile is when patients with WAD record high scores on subscales of depression, somatization, and obsessive-compulsive behavior.”
Functional somatic syndromes and somatization
What is somatization? It is very likely for some of you, that as your challenges continue, a suggestion to counseling or psychiatric evaluation was made. The understanding was that no one could figure out why you have more symptoms and more pain than you should. You must be in a situation of functional somatic syndromes and somatization.
Somatization is a complex problem that can be simply described as the physical (pain manifestations) of psychological dysfunction. People who suffer from somatization have a deep suspicion of doctors.
In February 2016, a group of chiropractors published a paper in the journal Manual Therapy (7) on people who had either low back or neck pain or both. What they wanted to know was if psychosocial factors are associated with worse outcomes in patients with neck pain or low back pain.
In this study 326 patients with neck pain completed self-administered questionnaires at the study’s start. What these people were asked was that they assess their psychosocial factors:
- Were they in distress?
- Have depression?
- Have anxiety?
- and have somatization?
The patients received chiropractic treatment and were asked again to assess their symptoms at the second visit, and at one, three, six, and twelve months. Somatization scores are consistently associated with perceived recovery, functional status, and pain. Somatization was the only variable consistently found to be associated with diminished perceived recovery, a higher degree of neck or low back disability, and increased neck or low back pain.
Above I wrote: Over the years we have received countless stories from people who have been “wandering,” for years looking for help for their whiplash-related problems. It is easy to see why they would have a poor expectation that anything would help them, especially when their treatments may be into the decades.
Somatization in these people may be a sign of poor expectation more so than a psychiatric disorder.
People who have chronic pain for long-duration can shut themselves off emotionally if they feel that no one understands that they have more pain than they should.
In October 2020 this 2016 study from the chiropractors was cited by a team of Italian university research and medical hospital doctors writing in the journal Frontiers in Psychology. (8) The psychologists and allied health practitioners of this study investigated whether chronic pain patients with somatization reported higher alexithymic (isolation, the inability to make an emotional connection with others) traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life, and somatization.
- One hundred thirty-four chronic pain patients were evaluated for alexithymia (feelings of isolation and emotional detachment), somatization, distress, health-related quality of life, and pain.
Results: Patients with somatization (37.04%) reported significantly higher feelings of isolation and emotional detachment and difficulty in identifying feelings than those without somatization. The somatizer group had also a significantly higher disease duration, severity, and interference of pain, distress, and lower health-related quality of life than the non-somatizer group.
People who have chronic pain for long-duration can shut themselves off emotionally if they feel that no one understands that they have more pain than they should.
Another study: “Whiplash causes you more pain than imaging studies can verify – doctors can become skeptical of your pain.”
In the patient story related above, we found that an x-ray and MRI showed “nothing remarkable.” In other words, what the imaging studies revealed was “nothing here to see.” Most patients, lawyers and even doctors involved in both the healthcare aspect and legal aspect of whiplash injury often don’t understand some of the key concepts of whiplash. A lot of times MRI and x-rays show nothing. This, however, does not mean that there is nothing there. That is not solely our opinion.
In research published in the medical journal Spine (9) and reprinted in the Journal of Manipulative and Physiological Therapeutics, Linda J. Carroll, Ph.D., of the Department of Public Health Sciences, School of Public Health, University of Alberta lead a study from The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) came up with this conclusion in regard to patients suffering from whiplash-associated disorders (WAD).
In examining 226 articles related to treatment course and prognostic factors in neck pain and its associated disorders, the team discovered that the evidence suggests that:
- Approximately 50% of patients with WAD will report neck pain symptoms 1 year after their injuries.
- Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.
- Few factors related to the collision itself (for example, the direction of the collision, headrest type) were prognostic; however, post-injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.
Dr. Michele Sterling of the Centre for National Research on Disability and Rehabilitation Medicine, at The University of Queensland, interpreted these findings in The Journal of manual & manipulative therapy as:
“Whiplash-associated disorders are a common, disabling, and costly condition that occurs usually as a consequence of a motor vehicle crash. While the figures vary depending on the cohort studied, current data indicate that up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by their condition.”(10)
Whiplash caused hip pain, hand pain, stomach pain, and pain in the genitalia, especially in women. Clearly, there is something causing more pain for these people.
Writing in the European Pain Journal, (11) Norwegian doctors found that whiplash caused more pain in other regions of the body than other pain causes. For example, whiplash-associated disorders caused:
- greater intensity back pain than chronic back pain did,
- greater intensity shoulder pain than chronic shoulder pain did,
- even greater intensity neck pain than chronic neck pain not associated with whiplash.
- Women with whiplash-associated disorders also reported pain in the hip, arm, hand, stomach, chest, and genitalia more often than women with chronic pain originating in other joints.
With individuals with whiplash-associated disorders also reporting pain in a wide range of bodily locations, a higher number of painful locations and higher pain intensity than individuals with chronic pain from other causes AND no differences were not accounted for by differences in pain tolerance than with control subject. Clearly, there is something causing more pain for these people.
This theory was also supported by research from The University of Sydney in the medical journal Injury which looks at why some patients recover more quickly than others and why some patients remain with chronic problems.
Whiplash-associated disorders – the first step in treatment? Have doctors believe Whiplash-associated disorders are real. The second step: have them believe something more can be done.
In December 2017, doctors at the University of Queensland and Griffith University, in Australia published their findings on the Whiplash associated disorders patient experience with healthcare in the journal BMC Musculoskeletal Disorders. (12)
- Whiplash-associated disorders are the most common non-hospitalized injury resulting from a motor vehicle crash.
- (As mentioned above) Approximately 50% of individuals with WAD experience ongoing pain and disability.
- Results from intervention trials for individuals with chronic Whiplash associated disorders are equivocal and optimal treatment continues to be a challenge. (What the researchers are saying here is that treatment studies and outcomes are open to interpretation, and optimal treatment continues to be a challenge. They do not see a gold standard in conventional medicine).
These researchers were looking for hope. The main finding of this study was to see if the patients were actually benefiting from any treatment but did not know how to say so in the study questionnaire format.
- Twenty-seven individuals with chronic Whiplash-associated disorders participated in a one-on-one, semi-structured individual telephone interview.
- Two themes emerged that described the experience of living with chronic Whiplash-associated disorders.
- First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to find the right healthcare practitioner (HCP)’ to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems (These would be insurance coverage complexities).
- Second, participants described a journey of realization, and the trial and error used to establish self-management strategies to both prevent and relieve pain. (The patients took an active role in their own health care, possibly because of less than hoped-for results in their doctor-driven treatments).
- Participants described trying to understand the impact of their initial injury in relation to the gradual realization that there may be an ongoing residual deficit.
- Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies.
- Recovery from a whiplash injury is an adaptive process and more than the elimination of pain or disability, therefore, may be different from common clinical patient-reported outcomes.
- (In this statement the researchers are suggesting that people with whiplash-associated disorders, benefit when they come to terms that there is no likely curative treatment for them and that they would do better at managing their pain and disability. Obviously, this is not a statement we would agree with unless Comprehensive Prolotherapy failed).
- Early identification of patient understandings of pain, expectations of recovery, symptoms, and therapy may help merge patient and healthcare professional understandings. (The patient and doctor are not on the same page, and it would be helpful if the patient found a doctor who understood what they are going through). This was followed up by this statement: “acknowledgment and validation of the whiplash injury by health care professionals are seen by many as a necessary step in the recovery process.”
The problems of whiplash-associated disorder that you have to deal with every day and their links to cervical instability. Is cervical instability treatment the answer?
How an apparently simple cervical spine injury can alter your thinking and sensation of pain
Many patients tell us on their first visit that “they don’t think right,” “they have memory problems.” These are unfortunately common and typical symptoms of whiplash. Another problem is that their families and doctors may not understand these symptoms.
My doctors are trying to help me but we are not getting anywhere. The pain is spreading from my neck into the other joints. I have “everything,” forgetfulness, a brain fog, headaches, jaw pain, vision problems, hearing loss, and I don’t think straight.
A 2016 study (13) in the journal EBioMedicine helps to understand how an apparently simple cervical spine injury can alter your thinking and sensation of pain. Something we commonly see in our patients.
There is increasing evidence of central hyperexcitability (heightened sense of pain) in chronic whiplash-associated disorders. However, little is known about how an apparently simple cervical spine injury can induce changes in cerebral processes (simply that part of the brain involved in speech, thinking, and memory).
To assess how a “simple” whiplash injury could affect brain function, the researchers of this study looked at possible alterations of regional cerebral blood flow in chronic whiplash-associated disorders and to test if central hyperexcitability reflects changes in regional cerebral blood flow upon non-painful stimulation of the neck.
The researchers then stated: “to verify our hypothesis that the missing link in understanding the underlying pathophysiology could be the close interaction between the neck and midbrain structures.”
Alterations of regional cerebral blood flow were then explored in a case-control study where study participants were exposed to four different conditions, including rest and different levels of non-painful electrical stimulation of the neck.
- Regional cerebral blood flow was found to be elevated in patients with chronic whiplash-associated disorders in the posterior cingulate (The cingulate cortex is part of the limbic system, that part of the brain involved with emotion, learning, and memory) and precuneus, (that portion of the brain with helps regulate emotional and pain responses and judgment) decreased in the superior temporal (involved in the processing and understanding the sounds we hear as well as participating in emotional responses), parahippocampal (that part of the brain involved in “remembering,” the retrieval of memory,” and inferior frontal gyri (the ability to inhibit inappropriate responses (14)), the thalamus (the information hub where nerve messages pass to and from the many parts of the brain) and the insular cortex (where sensory perception and emotion are linked) when compared with regional cerebral blood flow in healthy controls.
What the researchers found was alterations in regions directly involved with pain perception and interoceptive processing indicate that chronic whiplash-associated disorders symptoms might be the consequence of a mismatch during the integration of information in brain regions involved in pain processing.
Vision problems are a whiplash associated disorder
We are going to start with an introductory video by Ross Hauser, MD. Below the video is a summary of the video with explanatory notes to help further and explain some of the concepts that Dr. Hauser is putting forth in explaining vision problems as they relate to people with neck pain, cervical instability, and whiplash-associated disorders.
Summary learning points
- Dr. Hauser emphasizes that to understand the impact on symptoms of cervical neck instability causes, including ultimately vision problems, you have to understand that the nerves that travel the spine are so intertwined with each other and through the cervical vertebrae that any compression to the nerves will cause far-reaching problems.
- At 1:30 of the video: Dr. Hauser talks about C1-C2 instability and its impact on the Vagus Nerve (Cranial Nerve X)
- When the Vagus nerve is injured by compression caused by instability at C1-C2, this can cause vasospasms (narrowing of the arteries and reduction of blood flow). If these vasospasms impact the ophthalmic artery, the artery that supplies blood to the eye and eye area including the orbit – this can lead to some of the symptoms are patients describe to us such as darkening, black spots, or grayness in the vision of one eye.
Impairments of the eye and head coordination in chronic whiplash-associated disorders.
Also of note is an April 2020 study in the journal Musculoskeletal Science and Practice. (15) Here the researchers made these observations:
- Difficulties with driving and changes in driving behavior are reported by subjects with chronic whiplash-associated disorders.
- Subjects with chronic whiplash-associated disorders presented delayed response time and time to reach the (test) targets with both eyes and head compared to a control group and tended to compensate for the lack of neck motion with increased eye motion.
- This study shows indications of impairments of the eye and head coordination in chronic whiplash-associated disorders.
Swaying, posture control, balance, jaw pain TMD, head tremors, ringing in the ears (tinnitus) are whiplash-associated disorders and they are all connected
The complexity of and the riddle of treatment of Whiplash Associated Disorders is on full display in these next three studies. Here we can also ask if it is muscle problems or a broader cervical instability that involve the cervical ligaments as well.
In the January 2019 issue of Archives of Oral Biology, (16) a group of physiologists from learning universities in Sweden and Saudi Arabia, examined a phenomenon of instant reduction in postural sway during quiet standing by using a dental appliance. When human beings stand still, we sway to keep from tipping over. However, if we sway too much we lose balance. People with whiplash-associated Disorders may sway too much and this is causing balance issues.
Here is the conclusion of this research and then we will explain it:
“The prompt reduction in standing postural sway from intervention by intraoral dental appliance i.e. improved standing balance, suggests a potent effect on the postural control system by modulation of the jaw sensorimotor system, probably involving reflex transmission. The result opens for new insight into mechanisms behind postural control and the pathophysiology of balance disorders and adds to the knowledge on the plasticity of the nervous system. It may help develop new procedures for assessment and management of impaired balance in WAD and non-trauma neck pain patients.”
The researchers present an exciting conclusion because they have recognized the need for postural stability in helping with balance issues in Whiplash-Associated Disorders and they found their answer in providing stabilization in the movement of the jaw. Now watch this:
A study from the University of Antwerp published in the journal Experimental Brain Research (17) looked at the Cervical dystonia patient’s inability to have posture control. Some patients with Cervical dystonia (head tilt, muscle spasms, and tremors), sway too much when they are standing and they sway too much when they are sitting. Excessive sway is caused by impaired cervical sensorimotor control (sense of position and place). The researchers found that as the sway worsens the patients lose their sense of position and place, and with it, their center of balance. Their entire body becomes unstable. A suggested fix the researchers recommend is for a look at the cervical area (cervical instability) and the potential that the problem of instability is coming from a weakened neck. They recommended: “Further research towards the potential value of postural control exercises is recommended.” When you exercise, you are attempting to stabilize cervical instability.
Here we have two studies. The first says that if you stabilize the jaw, you stabilize the head and neck. The sway goes away. The second study says, if you strengthen instability issues in the neck, you can reduce balance issues.
Dizziness, no dizziness, eyes opened, eyes closed swaying
An April 2021 study in the journal PLoS One (18) looked at the curios symptom of swaying and balance when dizziness is or is NOT present. What these researchers suggested was:
Reduced joint position sense was observed in people with whiplash-associated disorders compared to healthy controls when the head was repositioned to a neutral head position from rotation and extension or when the head was moved toward a 50-degree rotation from a neutral head position.
For an explanatory note, let’s stop here to discuss the Reduced joint position.
- Joint position sense is also referred to as proprioception, the sense that you are moving and how your body reacts to this movement. For example, you are walking up a flight of stairs. You know you are walking up a flight of stairs, your body then recognizes that you have to lift one foot then the other up each step to move up the staircase. You are constantly changing your body position in space. People will not get dizzy moving up the stairs because the body is compensating for the movement and its place in space.
- Dysfunction of Joint position sense or Proprioception can be caused by a problem in the proprioceptive sensory neurons. A neurological deficit, a common problem in whiplash-associated disorders.
The problem then of deficits in sensorimotor control
Explanatory note: Sensorimotor control is the decision making process of what to do next. You are standing on a street and a terrible wind kicks up and almost knocks you over. Your sensorimotor control then bases a movement decision on what is happening to you and helps position your body in its best defense to stand upright against the heavy wind.
Back to the research: The researchers found that people with whiplash associated disorders with dizziness had reduced joint position sense compared to people with whiplash associated disorders with NO dizziness when the head was repositioned to a neutral head position from rotation. Larger sway velocity and amplitude was found in people with whiplash associated disorders compared to healthy no symptom control people for both eyes open study and eyes closed conditions. The conclusion was: “The observed changes of joint position sense and standing balance confirms deficits in sensorimotor control (for example the heavy wind kicked up but because of position deficient your body could not balance itself when it should have been able to) in people with whiplash associated disorders and especially in those with whiplash associated disorders with dizziness.
We have a comprehensive article on Cervical disc disease and difficulty swallowing – cervicogenic dysphagia on this subject. To touch on this problem here within the context of whiplash associated disorder we will highlight a portion of that article:
- Cervical instability in the neck has been linked to swallowing difficulties, diagnosed as cervicogenic dysphagia.
- Cervical instability has been linked to cervical spine nerve compression which can be an “unseen” cause of swallowing difficulties.
- Cervicogenic dysphagia is not a problem treated in isolation, it is one of a myriad of symptoms related to neck pain and neck hypermobility and can be found in Whiplash Associated Disorders
When a patient comes into our clinic with problems of swallowing difficulties, the swallowing difficulties are usually not a problem in isolation. While patients may tell us of their swallowing difficulties, most come in with primary complaints of neck pain or neck instability, whiplash-associated disorders, or post-concussion syndrome. Swallowing difficulties may be accompanied by headaches, dizziness, hearing problems, severe muscle spasms in the neck, to name but just a few symptoms.
Swallowing difficulty involves the sensation that food is stuck in the throat or upper chest. This sensation may be perceived either high in the neck or lower down, behind the sternum, or breastbone. Swallowing difficulty can become a serious problem among the elderly. The symptoms the patients describe are usually extremely debilitating and the patient often tells us that they are at the “end of their rope.” A feeling of abandonment by the medical community is also a common complaint.
In research from August 2019, research lead by The University of Sydney noted in the journal Dysphagia. (19)
- Non-specific self-reports of dysphagia have been described in people with whiplash-associated disorders (WAD) following motor vehicle collision; however, incidence and mechanistic drivers remain poorly understood.
- Alterations in oropharyngeal dimensions (the narrowing of space of the pathways in the middle part of the throat) on magnetic resonance imaging (possibly caused by cervical neck instability), along with heightened levels of stress, pain, and changes in stress-dependent microRNA expression (the immune system’s inability to heal damage) have been also associated with WAD, suggesting multi-factorial issues may underpin any potential swallowing changes.
The researchers suggested treatment parameters to include:
- expanding oropharyngeal space
- peritraumatic miR-320a expression (addressing possible immune system involvement), and
- psychological distress.
Some doctors do not believe that voice and swallowing difficulties can be attributed to whiplash-associated disorders
In June 2020, in the journal Dysphagia, (20) doctors could not say whether voice and swallowing difficulties can be attributed to whiplash-associated disorders. Here is the research:
“Swallowing and voice complaints after a whiplash injury have been observed and reported in several studies; however, variability in study design complicates the current understanding of whether dysphagia and dysphonia should be recognized as potential adverse outcomes. A scoping review was conducted across six databases from 1950 to March 2019. A total of 18 studies were included for review. . . Incidence of swallow-related problems ranged from 2 to 29%, with unspecified complaints of “swallowing difficulty”, “dysphagia” and fatigue and pain whilst chewing reported. . . Four case studies presented post-whiplash voice complaints; two of which described the loss of pitch range. Others described hoarseness, loss of control, and weak phonation (the ability to make speech-like sounds.) Most studies only mentioned swallow- or voice-related deficits when reporting a wider set of post-injury symptomatology and six did not describe the outcome measure used to identify the swallow and voice-related problems reported. The existing literature is limited and of low quality, contributing to an unclear picture of the true incidence and underlying mechanisms of whiplash-related dysphagia and dysphonia.”
This is not to say that people with whiplash disorders do not “really,” suffer from voice and swallowing difficulties. The researchers are saying the evidence is unclear. Our clinical observations of nearly three decades tell us differently.
In a September 2019 study in the medical journal Pain (21), doctors at The University of Queensland and the Australian Catholic University investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Here is how the study went:
- 99 Patients used an electronic diary to record hourly ratings of:
- traumatic stress,
- and fear of pain symptoms over a day.
- Of note:
- Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain;
- current pain was not associated with previous traumatic stress.
- The relationship between traumatic stress and previous pain became negligible after controlling for the problem of Fear of Pain, except for traumatic stress symptoms of hyperarousal (over the sensation of pain) that were driven directly by pain.
- Overall, these results support a pain primacy model and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms.
- The results also confirm that traumatic stress symptoms of hyperarousal are central in this relationship.
- Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and Fear of Pain change over time, and whether previous experiences of traumatic stress influence these relationships.
It appears that this research suggests that the key is to control the fear of pain. One way to control that fear of pain is to heal the injuries and reduce pain.
Treatment of interest: Prolotherapy for cervical ligaments damage and cervical neck instability
The above research shows us where medicine is in regard to the difficult to treat patients with whiplash-associated disorders. Treat the depression, treat the fear, treat the anxiety, keep looking for answers. Prolotherapy doctors have known for a long time that the best way to treat these problems is to treat and stabilize the cervical neck ligaments.
In our opinion, prolonged symptoms of whiplash – neck pain, headaches, dizziness, burning or prickling sensations (paresthesias), back or shoulder pain, and difficulties with concentration and memory are usually not problems solely correlated with the cervical discs damaged in whiplash but a problem of damage to the cervical ligaments.
When ligaments are subjected to quick forces, as occurs in whiplash traumas, it does not take much to tear or overstretch them. All whiplash traumas have the potential to significantly injure cervical ligaments and cause neck instability.
Prolotherapy has a long history of being used for whiplash type soft tissue injuries of the neck. The emphasis of treatment is on the posterior ligamentous complex, as injury to these ligaments causes instability in the direction of flexion-extension, lateral flexion and axial rotation, which is increased when there is capsular ligament disruption. Another interesting fact is that when there is an injury to a particular capsular ligament, for example at C5-C6, it produces a significant increase in relative motion at the next superior vertebrae, in this case C4-C5, as well as at the level of injury. Cervical instability should be understood as a progressive disorder that involves destructive joint forces and motions caused by wandering vertebrae. In the neck, cervical instability will cause disc degeneration in the unstable segments and then the instability and degeneration will move to the next level.
In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine
- In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
- At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
- At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina are now opening normally during motion
If it is not a problem of discs, but ligaments, a cervical fusion is the wrong treatment for whiplash
Research has shown that in a small percentage of patients with whiplash-associated disorders, cervical fusion can be successful. Dr. Bo Nystrom, a surgeon whose work we often cite, published a study in 2016 that suggested fusion may be of benefit in a group of carefully qualified patients whose problems came from segmental mobility issues, that is, functional problems in the disc. (22) Even so, this is a small group of patients, and success was 2 out of 3 achieving pain relief. One out of three did not, and had unsuccessful surgery.
We like to see patients before the cervical neck fusion surgery when the problems of a failed surgery compound a pre-existing problem. Unfortunately, we do not always see the patient first and see them after a cage, screws, and other fusion materials are already in place and the pain remains.
RESEARCH: Fusion creates the same problem it is trying to fix in whiplash patients
Another problem that can manifest in fusion patients looking for relief from their prolonged whiplash syndrome is that the fusion may mimic the problems the fusion was trying to fix. It is interesting that doctors from the University of Pittsburgh writing in the medical publication The Spine Journal discussed similar characteristics between whiplash and patients who underwent a cervical fusion. What they found was that when the head moves, up, down, side to side, or during rotation, the forces of motion come into play throughout the cervical spine.
Patients who have limited range of motion from a whiplash injury and patients who underwent cervical spinal fusion exhibited the same problems, not only reduced range of motion but increased segmental instability (meaning that the vertebrae above and below the fusion and near the points of injury in whiplash were under stress to help provide movement and neck stability).
The medical advice: “the clinician may advise the patient to avoid end range of motion positions to lessen the demand on the discs.”(23) Please refer to my article Cervical pain, adjacent segment disease following neck surgery for a more detailed understanding of this problem.
So surgery to help patients with whiplash injury, the cervical fusion, in this case, and for many patients, does not alleviate the problems of pain-free neck movement. In fact, it contributes to it.
Researchers want answers for perplexing and challenging whiplash patients
Most head traumas and whiplash injuries result in flexion and rotatory stress onto the upper cervical vertebrae, which disrupts the capsular ligaments (cervical facet joints).
There are four basic mechanisms of neck injuries:
- flexion (head snaps forward),
- extension (head snaps backward),
- rotation (head snaps top left or right or both) and
- compression (impact).
Most often head and neck trauma contain all four mechanisms. Any trauma that involves a rotatory component of the neck will then by definition injure the capsular ligaments.
Doctors in Belgium writing in the Journal of Manipulative and Physiological Therapeutics acknowledge that difficulty in diagnosing cervical neck injury lies in the fact that major injury to the cervical spine may only produce minor symptoms in some patients, whereas minor injury may produce more severe symptoms in others. Here is what they wrote in regard to MRI, CT Scans, and X-rays.
“There seems to be no correlation between the amount of hypermobility or subluxation and the presence of clinical signs or neurological signs. The clinical signs can vary from relatively diffuse complaints, no symptoms, and signs to serious ones.
Radiology does not seem to be a reliable diagnostic mechanism in relation to upper-cervical instability. Conventional X-rays fail to give adequate information about atlanto-axial stability. CT-scan and MRI can visualize much more because of the direct sagittal projection (basically a cross-section view) but neither is an absolute standard. Furthermore, in relation to upper-cervical hypermobility, the validity of radiology is under debate.”(24)
Dr. Bengt H Johansson in the medical journal Pain Research and Management wrote: Damage to cervical ligaments from whiplash trauma has been well studied, yet these injuries are still often difficult to diagnose and treat. Standard x-rays often do not reveal the present injury to the cervical spine and as a consequence, these injuries go unreported and patients are left without proper treatment for their condition.
“Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint [CCJ] complex). Studies indicate that injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headaches, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light, and pronounced fatigue.”(25)
Cervical ligaments and chronic whiplash-associated disorders – the answer is in the examination
Here is a study from the journal Traffic Injury Prevention: What the doctors were looking for was how the placement of the head at the time of impact affected long-term symptoms. In other words – how stretched were the neck ligaments at the time of impact – and how much more did they get stretched during the impact. The key here is the injury to the ligaments and future impact on neck instability.
The doctors then came up with a model that would predict ligament damage. Here is what they concluded:
- Higher potential for injury when the head was turned (ligaments will be stretched in head turned position). This time of impact position could lead to a higher potential for whiplash injury by as much as 50%.(26)
This is agreed to and embellished in a paper from Fort Lewis College and Colorado State University researchers who suggested doctors can be misled in their diagnosis and treatment by not fully understanding the complexities of the range of motion in the neck. To find the cause of cervical instability – doctors need to increase the physical examination of the neck ligaments. (27)
Chronic post-whiplash symptoms: Treatment options
Ross Hauser, MD and Brian Hutcheson, DC discuss treatment options for chronic post-whiplash symptoms.
Summary edited transcript of this video:
It is very common that people can suffer from whiplash-associated disorder after they have had a car accident years later. They have a lot of pain, may be in agony, and out of desperation may consider a surgical option.
- About 50% of people that suffer some kind of whiplash suffer from some kind of chronic pain.
- Why these people suffer from chronic pain obviously means that something is not being treated. In many cases, these can be the cervical spine ligaments. In a whiplash injury, when there is the rapid deceleration that causes the head to snap in abnormal motion there is always the chance for chronic neck instability but it goes undiagnosed. So these people may go through Physical Therapy to get some stability restored through the activation of the muscles but this may be short-term. A year or more later they are still hurting.
Still hurting another MRI
- Now, these people get another MRI. This MRI may show a disc herniation because of abnormal wear and tear, so then the surgeon recommends that we have to clean up that disc herniation or offer a fusion to hold the bones in place. This surgery may solve one of the problems but it is also creating another problem because when you fuse those two bones together or separate them with rods and metal, there is no mobility at all so when we have instability we don’t want you to be immobile we just want to restore the normal integrity so that joint can return to its normal function. So we would suggest is some, that they consider conservative care options that they may not have explored including Prolotherapy. We do understand that some people may need surgery and many will have good outcomes. These are not the people we see in our office.
An examination of the alar ligaments as the cause of upper cervical stability. Are doctors missing something?
A January 2020 study in the Journal of Biomechanics (28) comes from the Department of Orthopaedic Surgery at the University of Pittsburgh. The focus of this research is to determine the biomechanical contribution of the alar ligaments to upper cervical stability. In simplest terms, the alar ligaments connect the skull to the axis (c2 vertebrae). The researchers took 8 cadaveric C0-C3 specimens and ran them through a series of physical tests.
Let’s let the researchers of this study take over from here:
“Acute and chronic whiplash-associated disorders pose a significant healthcare burden due to chronic pain, which is associated with upper cervical instability resulting from the ligamentous injury. No standard measure exists for diagnosing alar ligament injury and imaging findings vary widely. Multiple physical examination maneuvers are used to diagnose alar ligament injury including the C2 Spinous Kick, Flexion-Rotation, and Bending-Rotation tests.”
Intact, unilateral, and bilateral alar ligament injury states were tested.
- Unilateral alar ligament injury led to significant increases in lateral bending, axial rotation, and flexion-extension compared with intact specimens.
- The C2 Spinous Kick Test showed the largest percentage change, and the Bending-Rotation Test towards the side of injury significantly increased axial rotation by the largest absolute magnitude. Overall, quantifiable changes to motion measured during simulated physical examinations were found, but the ability of a clinician to feel these changes remains unknown.
Let’s explain this: The Alar ligaments when damaged on one side or both, allowed significant hyper-rotations and cervical hypermobility. This was confirmed by physical examination. The problem is during the physical examination, “the ability of a clinician to feel these changes remains unknown.”
In this illustration, the vertebral artery is clearly seen weaving its way through C1-C2. If the C1-C2 are moving and hypermobile, they could press on and compress the vertebral artery. This could cause the sensation of lightheadedness and feeling faint. This is seen in the x-ray below.
Digital motion X-Ray C1 – C2
The digital motion x-ray is explained and demonstrated below
- Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
- The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
- This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.
Evidence closing in on untreated ligament injury as the cause of whiplash-associated pain
In research from December 2016, (29) doctors in Sweden used nerve blocks in Chronic Whiplash-Associated Disorders looking for evidence that the problems related to whiplash were coming from cervical vertebrae facet joints – a sign of ligament instability. They tested the C2-C7 joints and begin with a bupivacaine-based nerve block and for control also tested with saline.
The results showed that:
- 29% of patients had pain relief with the nerve block
- 60% did not respond,
- and 11% placebo responders. (Saline injections do work)
The doctors concluded: A substantial amount of patients with Chronic Whiplash-Associated Disorders have persistent pain emanating from cervical zygapophyseal joints.
It can be suggested then that 3 out of 10 patients who would normally be sent to fusion surgery, would be sent to unnecessary surgery.
Whiplash injury successfully treated with prolotherapy: a case report with long-term follow-up
A September 2020 study in the journal Regenerative Medicine (30) presented successful treatment of severe, longstanding, treatment-resistant Whiplash-Associated Disorders with Prolotherapy.
- The chronic whiplash-associated disorder can develop after flexion/extension injuries and may be refractory (difficult or non-responsive) to standard-of-care therapies.
- In this paper, doctors presented the case of successful treatment of severe, longstanding, treatment-resistant whiplash-associated disorder with Prolotherapy. Prolotherapy is a regenerative injection technique that stimulates the repair of injured tissue. In this case, the soft tissue surrounding the cervical spine.
- Four monthly sessions of fluoroscopically guided Prolotherapy with phenol (an organic compound typically given in cases of spasticity)-glycerin-glucose.
- Pain, disability, pain interference, depression, anxiety, sleep, and quality of life information were taken for the purpose of numerical scoring.
- Results: Significant improvement was achieved and maintained through 18 months after treatment in all assessed pain and functional measures.
- Conclusion: Regenerative medicine, including Prolotherapy, may be an appropriate treatment option for carefully selected patients with whiplash-associated disorder.
Patient outcomes and case histories following Prolotherapy injections for whiplash have a decades long history. George Hackett MD, a pioneer in the treatment of Prolotherapy published findings in 1960 (31) and 1962 (32). In these papers Dr. Hackett and his colleagues reported treating patients with whiplash injuries and noted more than 85% of patients had cervical ligament injury-related symptoms, including those with headache or whiplash associated disorder These patients upon completion of treatment reported they had minor to no residual pain or related symptoms after Prolotherapy. In a 1963 study published in the medical journal Headache (33) Dr. Hackett was a co-author on this paper lead by Daniel Kayfetz DO. Here, even back in 1963, almost 60 years ago, the familiar problems of patients suffering from whiplash injury were noted. Also noted is how much current treatment strategies failed. Has much changes in 60 years? I invite you the reader of whiplash sufferer to decide.
“Headache occurs frequently as an annoying and often disabling symptom following a so-called whiplash injury . It may persist either as an intermittent pain or constant pain even for years after the injury. Many of the long-term headache sufferers have accepted accepted the gamut of treatments (ranging from medications, analgesics, muscle relaxants, sedatives, antidepressants, vasodilator or vasoconstrictor, anti-serotonins, glucocorticoids) through a variety of forms of physical therapy, neck braces and collars, local anesthetic infiltration, various nerve blocks, occasional rizotomy (surgery to kill nerves and prevent them from sending pain signals to the brain), cervical laminectomy, intervertebral disc excursions, posterior fusions and now interior fusions.
When the patient does not improve following these forms of therapy and many do not, then (he/she) is tagged as having a functional overlay or compensation neurosis, terms frequently effective in stifling further evaluation of treatment. We feel quite strongly that the patient’s failure to respond to the physicians honest therapeutic efforts should make the physician question the efficacy of this form of treatment and not the patient’s integrity.”
In this study 206 patients were treated with Prolotherapy for their whiplash related headaches. Outcome results showed that in 79% of patients, prolotherapy completely relieved their headaches.
Caring Medical Published Research
This is also confirmed in our own published research spearheaded by Danielle R. Steilen-Matias, PA-C. In this research that appeared in The Open Orthopaedics Journal, we showed that conventional treatments for chronic neck pain remain debatable, primarily because most treatments have had limited success because they did not address the cervical ligaments.
Multiple studies have implicated the cervical facet joint and its capsule as a primary anatomical site of injury during whiplash exposure to the neck. Others have shown that injury to the cervical facet joints and capsular ligaments is the most common cause of pain in post-whiplash patients.
In our study, we were able to conclude and document Prolotherapy injections to be an effective treatment for chronic neck pain and cervical instability due to whiplash, especially when due to ligament laxity in the cervical joints. (34)
In 1984, doctors at the University of Iowa produced a study that is often cited in medical research even today. Here the researchers examined the relative motion between various vertebrae of multi-level cervical ligamentous spinal segments. They found that when there is an injury to a particular capsular ligament, say at C5-C6, it produces a significant increase in relative motion at the next superior vertebrae, in this case, C4-C5, as well as at the level of injury. (35)
In over two decades of experience specializing in cervical spine cases and reviewing the medical research on whiplash and cervical spine instability, we developed Caring Cervical Realignment Therapy (CCRT). For patients who are struggling with post-traumatic injuries to the neck and have been trying everything from rest to physical therapy to medications and even surgery, CCRT makes the most sense for long-term relief of pain and symptoms, as well as restoring the normal curve to the spine!
In other words, injury or ligament damage instability, at one level of the cervical neck impacts the whole neck and the whole body.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding Whiplash associated disorders, Craniocervical Instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain. . . Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated August 3, 2021