Treatment of Whiplash associated disorders

Ross Hauser, MD

Treatment of Whiplash-associated disorders

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.

Still hurting another MRI

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 for 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, and 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.

I was in a car accident and was diagnosed with whiplash. My cardiologist says I am fine. 

I was in a car accident and was diagnosed with whiplash. I started to have pain in my neck, shoulder, and arm. I then started having symptoms of dizziness, sweating, palpitations, and headaches at times. Sometimes when I turn my neck I feel pain in my chest. I have been diagnosed with anxiety, depression, high blood pressure, tachycardia, Premature Ventricular Contractions, and Premature atrial contractions, but yet my cardiologist is fine. I take the medication prescribed and still have symptoms. I have been to all specialists in every field. Had all my blood done and everything came back normal. I personally think it has to do with the car accident I was in which gave me whiplash and damaged a nerve. Please see my article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?

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.

Summary learning points of this article:

Part 1: Whiplash causes you more pain than imaging studies can verify – doctors can become skeptical of your pain

Part 2: The wrong or inappropriate treatments at the onset of whiplash. Unnecessary scans and images, the wrong specialist in many cases. 

Part 3: The many symptoms of Whiplash-Associated Disorders

Part 4: Conventional Treatments 

Part 5: Cerebrospinal fluid (CSF) flow and whiplash.

Part 6: Cervical Instability and Whiplash Associated Disorders.

Whiplash-associated disorders treatments. Why do patients have poor expectations of recovery?

Whiplash associated disorders treatments. Why do patients have a poor expectation of recovery?

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 in 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 that “jump,” or bounce around.

A few years ago I was told that my whiplash injury had progressed into cervical canal stenosis and that 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, (1researchers 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:

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.

A November 2022 editorial in the journal Frontiers in pain research (2) followed with this assessment: “After a whiplash injury, approximately 50% of patients develop a chronic whiplash-associated disorder, with around 16% reporting ongoing severe pain-related disability. Despite decades of research, current guideline-based treatments such as education, advice, and exercise, typically demonstrate modest effects. This may reflect our incomplete understanding of WAD’s complex and heterogenous mechanisms, which span contributions from musculoskeletal, neurological, inflammatory, and psychological factors.

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,” or “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, brain fog,  headaches, jaw pain, vision problems, hearing loss, and I don’t think straight.

A 2016 study (3) 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.

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.

“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. (4) 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.”

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 aspects 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 (5) 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 courses and prognostic factors in neck pain and its associated disorders, the team discovered that the evidence suggests that:

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.”(6)

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, (7Norwegian doctors found that whiplash caused more pain in other regions of the body than other pain causes. For example, whiplash-associated disorders caused:

With individuals with whiplash-associated disorders also reported 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 the 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.

Functional somatic syndromes and somatization in Whiplash Associated Disorders

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 (8) 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:

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 in 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 a 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. (48) 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.

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 a long duration can shut themselves off emotionally if they feel that no one understands that they have more pain than they should.

Part 2: The wrong or inappropriate treatments at the onset of whiplash. Unnecessary scans and images, the wrong specialist in many cases:

Patients generally see multiple health providers, literally numbering 25, 50, or even 100 such providers, over a period of years. The patients present with a myriad of changing symptoms and signs, yet they have no clear pathology on conventional cervical X-rays, CT scanning, or recumbent MRI scanning. With an inability to “localize” the diagnosis of the whiplash injury effects to one specific spinal, cranial, or central nervous system locus coeruleus where the stress hormone and neurotransmitter are produced noradrenaline, ineffective treatment modalities are instituted, essentially based on guesswork.

The symptoms worsen and become impossibly debilitating, and the patient, having failed dozens of attempts at treatment, proceeds to lose their job, education, and romantic relationship. Eventually, the patient is labeled as hypochondriacal, depressed, malingering, and even accused of fraudulently attempting to “win the lottery” in a personal injury automobile collision lawsuit.

This tragic but unnecessary turn of events occurs because of a fundamental misunderstanding of the underlying mechanisms of a whiplash injury (whether occurring in high velocity or so-called “low velocity” impacts), the biomechanics of the upper cervical spine, and the neurological consequences of these phenomena. In fact, the explanation of all of this is not all that complicated and logically flows from basic observations. The clinical entity of concern has recently been characterized as “craniocervical syndrome” (CCS), a form of whiplash-associated disorder (WAD).

“Doctors and patients did not have a good understanding of what type of treatments or testing they should have for understanding whiplash-associated disorder symptoms.”

In March 2020 (9) 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 referrals to radiology and medical specialists in individuals with ongoing whiplash-associated disorders.

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.

Earlier, in December 2017, the same researchers published their findings on the Whiplash-associated disorders patients experience with healthcare in the journal BMC Musculoskeletal Disorders(10)

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.



Part 3: Symptoms


In this article, we spoke about the worsening of symptoms in whiplash-associated disorders. In the image below we see x-rays showing the C1 space compressed with head protraction, the head moved forward.  When this person maintains a neutral position (A) the C1 space shown by the arrow is very open, but because of their hypermobility and instability, when they jut their chin forward (head forward) the C1 space is almost completely closed off. This narrowing of the C1 space was compressing and stretching their C1 nerve, resulting in severe headaches and eye pain.

Are headaches the key in whiplash associated disorder?

This research was built on an August 2022 study that isolated the role of headaches following whiplash. Writing in the journal Pain Medicine (11). Here researchers explored headaches as having a possible role in psychosocial factors contributing to the presence of headaches or worsening of headaches after a whiplash trauma. The researchers found: “The level of neck pain intensity and disability, kinesiophobia, catastrophizing, and anxiety were all greater in people with acute WAD who presented with a headache compared to those without headache.”

In this study forty-seven people with acute WAD were recruited; 28 with headaches, and 19 without. The researchers found patients with neck pain intensity, pain catastrophizing, kinesiophobia, and anxiety state were higher in those with headaches when compared to those without. In addition, high levels of neck pain, moderate levels of neck disability, moderate levels of pain catastrophizing, and moderate and severe levels of kinesiophobia were related to the presence of headaches.

So what is being said is that fear of movement and pain catastrophizing were significant factors in causing headaches in people with more neck pain than controls. But where do these psychological; factors come from?

Symptoms and headaches

These modalities are neither directed towards nor effective in treating the associated neurologic disorders nor migraine headaches. Please see my related articles: Cervicogenic headaches: Migraines, tension headaches, and cervical spine instability and Vestibular migraines and spontaneous vertigo – Migraine Associated Vertigo. Below I discuss the headache connection to worsening whiplash symptoms.

During the extremes of cervical flexion or extension, as in a whiplash injury or traumatic force on the head or neck, significant damage can occur to the upper cervical ligaments and can even result in complete tears of the transverse and alar ligaments. Competent (strong) transverse and alar ligaments are needed to limit backward movement of the odontoid process (or dens, the bony protrusion of the C2 or axis).

In the image below the caption reads: Because the Dens takes up one-third of the spinal canal space, the spinal column is narrowest at the C1-C2. If the C2 is wandering the Dens can compress on the spinal cord.

the Dens can compress on the spinal cord in whiplash

If the odontoid process (the Dens) moves even a few millimeters backward, it will compress the upper cervical spinal cord and cause nerve conduction block and even spinal cord nerve damage. Any type of excessive atlas or axis motion can cause significant symptoms all over the body. For many people, fortunately, most cervical ligament injuries are partial or incomplete. Thus, the vast majority of atlantoaxial subluxations can be treated with conservative means by a skilled chiropractor, osteopathic physician, physical therapist, or another skilled manual therapist.

If these treatments do not resolve symptoms, then the Prolotherapy injections discussed below could be recommended.

There are various diagnostic criteria, depending on the training of the clinician, to figure out what constitutes a simple subluxation and when the upper cervical spine is unstable. Fielding and Hawkins’ four-part classification scheme for evaluating rotatory displacement is as follows:

Type 1 and 2 atlantoaxial rotary displacements can be treated conservatively by mobilization, manipulation, or other manual medicine techniques. Prolotherapy injections can also be utilized and are very effective for many patients.

Generally, type 3 and type 4 are considered highly unstable, and surgical consultation for possible fusion is warranted. Anytime there are symptoms of progressive neurological dysfunction, including upper motor neuron signs such as extremely hypertonic reflexes, clonus, abnormal reflexes such as Babinski sign (patient does not respond to stimulation in the sole of the foot), spasticity or signs of myelopathy, an orthopedic or neurosurgery consult should be made. Generally, symptoms such as severe pain and/or radicular pain down the arm can be treated conservatively unless radiographic analysis reveals an extremely unstable spine. In that case, fusion surgery is going to be needed.

“Atlas Orthogonal” specialists

Modern chiropractic treatment is directed towards treating spinal disorders, partly because they cause pain and partly because they cause neurologic dysfunction. This is true of specialists who direct their treatment modalities to C1-C2 instability, for example, “Atlas Orthogonal” specialists.

Orthogonal is defined as work with angles, Atlas Orthogonal means the work to restore the head to a proper 90-degree angle by realigning the atlas (C1) without the modern and traditional chiropractic methods of cracking the cervical spine. These more subtle adjustments are considered by some to be more effective.

However, as the treatment mechanism involves a variety of methods to realign the spine (including using computer-guided power manipulation, manual manipulation, distraction, and modalities) as opposed to repairing the underlying pathology, although often feeling better during the course of three-week treatments, a significant group of these patients go on to experience a recrudescence of their symptoms, sometimes progressively worse. The use of home traction and a hard collar is similarly transiently effective. 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.

Craniocervical syndrome

The clinical entity of concern has recently been characterized as “craniocervical syndrome” (CCS), a form of whiplash-associated disorder (WAD). Symptoms generally have their onset within a day or so of the car crash. An essential condition of craniocervical syndrome is neck pain and new onset intractable cervicogenic migraine headaches. Only 15% of these patients report prior migraines; however, the post-whiplash migraines are far worse in intensity. These post-whiplash migraines typically occur daily, rise up to an intensity of 10+/10, last much of the day, require a dark, quiet room, are refractory to medical or procedural migraine treatments, and are extremely debilitating.

Most patients also report the phenomenon of “brain fog” – neurocognitive dysfunction, independent from migraine headaches. Conflated with the diagnosis of permanent traumatic brain injury (TBI), patients with post-whiplash brain fog complain of short-term memory loss, the requirement of constant reminder list generation, loss of train of conversational thought, word-finding anomia, calculation deficits, and subtle complex three-dimensional visualization difficulties, among many other subtle complaints. The fascinating clinical observation is that this phenomenon is reversible, as discussed below.

A myriad of other complaints are noted – some bordering on bizarre, yet clinically confirmed. These include ataxia, fine motor coordination issues, myelopathy, varying weakness, sexual dysfunction, visual disturbances, diplopia, autonomic dysfunction including postural orthostatic tachycardia syndrome (POTS), hyperhidrosis, syncope, nocturnal repeated myoclonic jerking (initially mistaken for seizures – then mistakenly diagnosed as “pseudo-seizures,” a psychiatric phenomenon), sleep disturbance, depression, and many others.

A clinician in any field, presented with this picture, a patient with normal imaging studies, and non-focal or multi-focal complaints varying in space and time, really does have little to go on. The whiplash is labeled as a soft-tissue injury and a rational treatment plan cannot be formulated.

Forward Head Posture and greater error in sensorimotor control

Whiplash Associated Disorders: Forward head posture stretches spinal cord and vagus nerve

Whiplash Associated Disorders: Forward head posture stretches spinal cord and vagus nerve

An October 2022 paper in the European spine journal (12) investigated and compared sensorimotor integration (the ability to sense and gather information and act on it, for example, you are hungry, you see food, you eat), sensorimotor control (to eat, you need to be able to bring the food to your mouth), and cognitive-motor dual-task during walking (the ability to walk and perform cognitive functions, like reading a street sign or a sign for a garage sale), in persons with chronic whiplash associated disorder as compared between chronic idiopathic neck pain and normal healthy controls.

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 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

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. (13) Here the researchers made these observations:

Loud noises

Another ear symptom that can occur post-whiplash is sensitivity to loud noises. This occurs because the tensor tympani (one of the muscles involved in proper Eustachian tube functioning) innervated by the trigeminal nerve is not functioning properly. It is attached to the stapes (inner ear bone) and helps maintain the ossicles in the proper position to protect the inner ear from excessive sound levels.

Swaying, posture control, balance, jaw pain TMD, head tremors, and ringing in the ears (tinnitus) are whiplash-associated disorders and they are all connected

People with whiplash-associated disorders are known to have deficits in gaze stability (eyes move with head movement) and head-eye coordination. It is well-documented that ocular reflexes are distorted in people with whiplash-associated disorders. It follows that ocular movements in people with whiplash injuries are not coordinated with head movements compared to normal controls, even producing nystagmus. It is felt that these changes in cervico-ocular coordination may underlie clinical symptoms reported by people with whiplash-associated disorders that involve visual deficits and changes in function during cervical rotation such as postural control and balance. As has already been delineated, the symptoms of whiplash-associated disorders in large measure are from upper cervical instability. Upper cervical instability causes most or all of these balance and vision findings as it relates to the ocular reflexes in whiplash-associated disorders patients.

The complexity of and the riddle of treatment of Whiplash Associated Disorders is on full display in these next studies. Here we can also ask if it is muscle problems or a broader cervical instability that involve the cervical ligaments as well.

An August 2023 paper in the journal Medicina (50) makes it clear that the relationship between whiplash and TMJ is unclear. In looking at previously published literature, the researchers summarized the clinical evidence of any trauma related cause and effect relationship between whiplash and TMDs. What they found was “An accurate screening of the previous literature showed that a true relationship between WADs and TMDs is still unclear. Although an association is most likely, it is unknown whether its strength is clinically significant.”

In the January 2019 issue of Archives of Oral Biology, (14) 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 new insight into mechanisms behind postural control and the pathophysiology of balance disorders and adds to the knowledge of 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 (15looked 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 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 (16) 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.

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.

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.

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 were 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 confirm 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.

Odd and unusual movement disorders are commonly reported after a whiplash injury.

Odd and unusual movement disorders are commonly reported after a whiplash injury. In a landmark study from 1989 (17) researchers found that in a group of whiplash patients, 18 out of 20 patients with persistent symptoms (post-whiplash syndrome) had oculomotor dysfunction (movement disorder of the eyes). The eye findings include saccadic eye movements (sudden quick symmetric) such as nystagmus. What was interesting about this analysis was when asymptomatic post-whiplash patients were compared to a normal (non-injured) control, there was no difference in oculomotor dysfunction. The authors concluded that “It seems that patients with soft-tissue injury have a localized lesion of the brain stem or an afferent proprioceptive dysfunction of the cervical spine.” These results could be explained by those who do not resolve their symptoms after whiplash still have ongoing cervical ligament injury.

What are we seeing in this image?

The caption reads Ligament-muscular reflex in upper cervical instability. Damage to the upper cervical ligaments initiates dramatic nerve input to the suboccipital muscles to tense, tighten, and temporarily “stabilize” the upper cervical spine.

What makes a study a landmark study is that its relevance is still found among modern researchers. Such is the case of a 2012 study citing the above research (18) which highlighted a strong relationship between eye and neck muscle activation in pain-free subjects that could suggest that whiplash-associated disorders may disrupt the intricate coordination between eye and neck movement. This is what the researchers noted:

Electromyographic activity (EMG) of muscles that rotate the cervical spine to the right (left sternocleidomastoid, right obliquus capitis inferior (OI), right splenius capitis (SC) and right multifidus (MF)) was recorded in nine people with chronic whiplash-associated disorders. Cervical rotation was performed with five gaze conditions involving different gaze directions relative to cervical rotation. The relationship between eye position/movement and neck muscle activity was contrasted with previous observations from pain-free controls.

Our explanatory note: The researchers are following a path that muscle activity in routine rotation of the neck is somehow disturbed and this may explain visual deficits. In our illustration explained above we suggest that this is a problem of damaged ligaments putting stress on the muscles to provide stability. The muscles of the neck are designed to move the neck quickly as needed for safety; they are not intended to stabilize the spine. Neck stability is provided by the ligaments primarily.

Three main differences the researchers observed were in whiplash-associated disorders patients.

First, the superficial muscle splenius capitis was active in both directions of cervical rotation in contrast to activity only with right rotation in pain-free controls.

Second, the activity of the right obliquus capitis inferior and right multifidus varied between directions of cervical rotation, unlike the non-direction-specific activity in controls.

Third, the effect of horizontal gaze direction on neck muscle EMG was augmented compared to controls. These observations provide evidence of redistribution of activity between neck muscles during cervical rotation and increased interaction between eye and neck muscle activity in people with WAD. These changes in cervico-ocular coordination may underlie clinical symptoms reported by people with WAD that involve visual deficits and changes in function during cervical rotation such as postural control.

Swallowing difficulties

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:

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 instabilitywhiplash-associated disorders, or post-concussion syndrome. Swallowing difficulties may be accompanied by headaches, dizziness, hearing problems, and severe muscle spasms in the neckto 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 led by The University of Sydney noted in the journal Dysphagia. (19)

The researchers suggested treatment parameters to include:

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)  research led again by University of Sydney 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.

Post-Traumatic stress 

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:

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.

The association between sleep problems and recovery outcomes in patients with chronic Whiplash-Associated Disorders.

association between sleeping problems and recovery outcomes in patients with chronic Whiplash-Associated Disorders

The association between sleep problems and recovery outcomes in patients with chronic Whiplash-Associated Disorders

Many people contact with a myriad of symptoms. When they have listed all their symptoms wishing for better sleep. Here are some examples, these emails have been edited for clarity purposes.

One person’s story

I have neck pain and back pain, disrupted sleep and altered Circadian rhythm sleep disorders, brain fog, and debilitating fatigue. I also suffer from gastroparesis, reduced organ function, difficulty swallowing, and mast cell activation syndrome. I would like to be able to sleep eight hours and wake feeling rested) and be able to eat without digestive aids.

Another person’s story

I have poor cervical and lumbar posture, digestive disorders, SIBO: Small intestinal bacterial overgrowth, GERD, slow motility, constipation, food sensitives, and difficulty swallowing. I do not sleep well. I would like to be able to sleep more than four hours without waking and be able to eat certain foods and have normal bowel movements.

An October 2022 paper in The Clinical Journal of Pain (22) looked at the association between sleeping problems and recovery outcomes in patients with chronic Whiplash-Associated Disorders.

In this paper, one hundred sixty-five people (63% female) with chronic whiplash-associated disorders and not taking medications for sleep disturbance completed questionnaires evaluating sleep disturbance, pain intensity, pain interference, disability, physical and mental health quality of life, stress, anxiety, depression, pain catastrophizing, and post-traumatic stress severity.

The researchers found: “Greater sleep disturbance was associated with increased duration of symptoms, higher levels of pain and disability, higher levels of emotional distress and pain catastrophizing, and functional impairment (reduced health-related quality of life). Mediation analyses demonstrated that sleep disturbance influenced chronic pain intensity and interference through both direct and indirect associations (lack of sleep can directly cause symptoms and indirectly cause symptoms. If lack of sleep causes anxiety and anxiety causes pain catastrophizing, lack of sleep indirectly causes pain catastrophizing) inclusive of stress, anxiety, and pain catastrophizing. Similarly, sleep disturbance was associated with higher levels of disability and poor health-related quality of life. . . ”

Part 4: Conventional Treatments 

Conventional treatments for whiplash are generally directed toward the symptoms themselves, not the underlying pathologic process.

Conventional treatments, therefore, are generally directed toward the symptoms themselves, not the underlying pathologic process. Epidural steroid injections, facet injections, and trigger point injections are administered to treat pain, which, in a sense, is the final common pathway of the whiplash effect. Physical therapy is directed towards muscle strengthening and improving range of motion – again, an end result of the whiplash effect. All of these modalities are generally transiently effective in pain relief, which can last a few days to weeks.

Researchers do not know if physical therapy and exercise are helpful in alleviating whiplash symptoms in some patients.

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, (23) 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 (24) 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. A September 2020 paper from the same researchers indicated that about half of patients found that exercise had somewhat improved their condition. (25)

Researchers not sure physical therapy and exercise helps whiplash

Researchers are not sure physical therapy and exercise helps whiplash

“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. (26) 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.”

“Contrary to our expectations, three out of four participants were nearly pain-free at the end of the aerobic exercise intervention”

A September 2022 paper in the journal Disability and Rehabilitation (27) examined the effectiveness of aerobic versus strengthening exercise therapy in individuals with chronic whiplash-associated disorder. Prior to this study the researchers had suspected aerobic exercise would not help. Here are their findings in a small group of patients:

Change in muscle 

A September 2022 study in the journal BioMed Central musculoskeletal disorders (28) looked at muscle fat infiltration in neck muscles. When fat infiltrates muscle the muscle becomes weaker and prone to causing neck instability. In patients with more severe pain, the researchers found changes in muscle on the neck side of worse pain.

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. (29) 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.”(30Please 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.

Part 5: Should we include cerebrospinal fluid (CSF) flow measurements in whiplash examination

Let’s briefly discuss cerebrospinal fluid (CSF) flow. In my article Cervical Spine Instability, fluid build-up and intracranial hypertension, I write about the many patients we see with intracranial hypertension (one cause is the backup of cerebrospinal fluid into the brain). Symptoms include those common in whiplash-associated disorders, dizzinessheadachevision problems such as sensitivity to light, tinnitus or ringing in the ears, neck pain, and tremors. These are the types of people we see at our clinic – layers of symptoms, and no real understanding of the underlying possible diagnosis. The condition causes moderate to severe headaches that often originate behind the eye and are worse with eye movements because the condition can cause swelling in the optic nerve and even blindness.

In the image below the caption reads: “Brain venous sinus outflow obstruction. This condition is called venous dysgemia which can lead to intracranial hypertension and result in brain cortex hypoperfusion (reduced blood flow) fusion and resultant cortex hypoperfusion (reduced blood flow to the brain) and  brain cell death or brain atrophy.” Compare these symptoms to that of the whiplash patient.

Brain venous sinus outflow obstruction

In January 2022, researchers wrote in the journal Chiropractic and Manual Therapies (31) about the difficulties in treating the whiplash patient and how much more challenging this can be by relying on MRI interpretation. Here is what they wrote: “Despite the identification of different types of injuries in the whiplash patients, clinically significant relationships between injuries and chronic symptoms remain to be fully established. (In other words, the identification of the injury may not help in identifying what is causing the patient’s symptoms).” This study then investigated magnetic resonance imaging (MRI) techniques including measurements of cerebrospinal fluid (CSF) flow as (a new understanding tool) in helping the whiplash patient’s symptoms.

Here are the conclusions: “This clinical practice-based feasibility study of 20 chronic whiplash patients and 18 age and gender-matched healthy controls examined the cervical spine morphology, (MRI type diffusion-weighted imaging)  and CSF flow characteristics using advanced MRI techniques. Although no significant differences between the two groups could be established using the advanced MRI protocols, (the MRI) did visualize CSF flow within the spinal canal, which may be a relevant attribution to future cranio-cervical imaging studies.”

What is being said is that the MRI could not distinguish certain disorders between whiplash patients and health controls however, it was able to see CSF flow problems, and this ” may be a relevant attribution to future cranio-cervical imaging studies,” or something doctors should look for.

Treatment of CSF leak as the cause of whiplash-related disorders is controversial

Among Japanese doctors the diagnosis of CSF hypovolemia or traumatic CSF leak as the cause of whiplash-related disorders is controversial. Not for the diagnosis but because of the reliance on an epidural blood patch.

A 2018 paper in the journal Advances in Orthopedics (32) wrote: “In Japan, some physicians have insisted that the cause of CSF hypovolemia is traumatic CSF leak, and they call this syndrome traumatic CSF hypovolemia. CSF hypovolemia syndrome exhibits a variety of symptoms such as neck pain, visual deficit, double vision, dizziness, nausea, vomiting, ringing in the ears, hearing loss, and headaches. These symptoms resemble those of a whiplash injury, and some of them occur sporadically as traumatic cervical syndrome.  . . However, (research) reported that traumatic CSF leak was not observed on CT myelography findings in patients with whiplash-associated disorder, in whom CSF leak was suspected when comparing the vesicular radioisotope cisternography (RIC) accumulation (test to determine leaks). An epidural blood patch (EBP) is the therapy of choice in patients with chronic WAD with a suspected CSF leak. Treatment for traumatic cervical spine syndrome should be uniform and logically based on medical science, and invasive treatment such as EBP should be carefully performed only in selected patients. The association of a CSF leak with chronic WAD has never been established, although its symptoms may be reduced following treatment.” 

If cerebrospinal fluid flow is resisted too much, it backs up in the brain in a condition known as hydrocephalus. The resistance to CSF flow has been implicated in various conditions. Sometimes the blockage of CSF flow is so bad that a shunt has to be placed in the brain’s lateral ventricle. This type of drain is known as an extraventricular drain. We now have the technology to measure the resistance to CSF flow, as well as CSF volume, and flow in the brain and in the cervical region. When the volume of CSF increases due to obstruction of CSF flow or absorption, the intracranial pressure (ICP) increases. This can cause headaches, vomiting, fatigue, back pain, and visual disturbances. These are symptoms that occur in many of the conditions discussed with cervical instability including post-concussion syndrome (PCS) and whiplash-associated disorders (WAD).

Whiplash and cerebrospinal fluid leak – the dizziness and vertigo reported were presumed to be derived from the severe damage especially to the cerebellum and the brain stem, caused by the downward sagging of the brain structures.

A 2007 paper (33) from the Mayo Clinic College of Medicine wrote: “Some patients have a characteristic constellation of vague neurological symptoms, often including headache, posterior neck discomfort, dizziness, nausea, and sometimes visual changes. Recently presented research has noted that some patients who have a whiplash-associated disorder have imaging findings consistent with a low-pressure cerebrospinal fluid leak.” Please see my article Cervical Spine Instability, Vein Blockage, fluid build-up, and intracranial hypertension.

In 2008, doctors at the Department of Neurology, Juntendo University School of Medicine in Japan (34)  described two patients with cerebrospinal fluid (CSF) leakage after whiplash injuries, mainly complaining of dizziness and vertigo. After automobile rear-end collisions with whiplash injuries but without head trauma, both patients immediately suffered from headache, vertigo, dizziness, nausea, neck pain, and cervico-brachialgia (arm pain related to the neck). Neurological examinations were normal in both patients, except for neck tenderness.

Tests revealed definite CSF leakages at the cervicothoracic (C7-T1) junction in one of the patients and at the lumbar portion in the other. The magnetic resonance (MR) images depicted downward displacement of the cerebellar tonsils and the brain stem, and narrowing of the lateral ventricles, presenting an acquired Arnold-Chiari malformation.

The patients were consequently diagnosed as having intracranial hypotension (or CSF hypovolemia) syndrome and underwent several epidural blood patch (EBP) therapies. Transiently their various symptoms improved, but were soon exacerbated once more and have continued until the present. . . The most striking finding was that of optokinetic nystagmus (involuntary, rapid, and repetitive movement of the eyes). . . In conclusion, the dizziness and vertigo in the currently reported CSF hypovolemic patients were presumed to be derived from the severe damage, especially to the cerebellum and the brain stem, caused by the downward sagging of the brain structures.

Part 6: Cervical Instability and Whiplash Associated Disorders

In the image below: Long-term effects of untreated neck injury from whiplash. Cervical instability is always a progressive disorder; treatments should be instituted before the cervical spine has advanced degeneration.

The learning points of this image are:

Most head traumas and whiplash injuries result in flexion and rotatory stress onto the upper cervical vertebrae, which disrupts the capsular ligaments (facet joints). There are four basic mechanisms of neck injuries – flexion, extension, rotation, and compression. 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. With frontal head trauma, the head rotates abruptly upon impact against a hard object (like hitting your head on a cabinet). This sudden twist of your head injures the capsular (and other) ligaments of C1-C2. Capsular ligament injury is felt to be the culprit in cervical instability due to whiplash injury.

An examination of the alar ligaments is the cause of upper cervical stability. Are doctors missing something?

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 aspects 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 neck 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.

A January 2020 study in the Journal of Biomechanics (35) 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.

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 a sensation of lightheadedness and feeling faint. This is seen in the x-ray below.

In this x-ray, when the patient looks down, a 6 mm space opens between the C1-c2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed.

In this x-ray, when the patient looks down, a 6 mm space opens between the C1-c2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed.



What are we seeing in this image? Ligament damage in whiplash injury.

The caption reads Ligament strain with cervical extension and flexion during a whiplash injury. Hyperflexion stretches the posterior ligament complex whereas hyperextension causes strain (stretch) on the anterior intervertebral disc and anterior longitudinal ligament.

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.


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:

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, and 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 painheadaches, 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

Cervical ligaments and chronic whiplash-associated disorders – the answer is in the examination

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:

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.”(36)

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 cervicoencephalic syndrome, as evidenced by headaches, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light, and pronounced fatigue.”(37)

Damage to cervical ligaments from whiplash trauma has been well studied, yet these injuries are still often missed. The primary reason is that the cervical ligaments do not show up well on MRIs or CT scans, and you cannot see ligaments on X-rays. The effects of ligament damage can show up on motion X-rays, CT scans, and MRIs, but these are often not ordered. The late-term symptoms include chronic neck pain, migraines, dizziness, vertigo, paresthesias, and a host of other symptoms reminiscent of craniocervical or Barré-Liéou Syndrome. This is, of course, suggestive that this and other cervical sympathetic syndromes have a common link of cervical instability from injury to the posterior ligament complex, especially the capsular ligaments.

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 the future impact on neck instability.

The doctors then came up with a model that would predict ligament damage. Here is what they concluded:

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. (39)

Digital motion X-Ray C1 – C2

The digital motion X-ray is explained and demonstrated below.

In my article Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability, I discuss DMX and compare it to standard digital imaging in varying cervical spine instability issues including whiplash.

Please see our article on treatments for Atlas displacement c1 forward misalignment.

Whiplash injuries sustained can be documented with motion imaging

When a person has had a motor vehicle accident and sustained some ligament injuries, it is important to find out where exactly they hurt and what motions actually increase the pain. This can then be correlated with the actual trauma, but more important the injuries sustained can be documented with motion imaging, as the exact same motion can be done and the bones visualized. As the head and neck are hyper flexed quickly during whiplash, as already discussed, there is an abnormal S-shaped curve in which the primary motion of the vertebrae in the lower cervical spine is a posterior retraction (pulled in further) relative to their inferior adjacent vertebrae (the lower vertebra is pushed back further than the vertebra above it). This retraction component of the whiplash kinematics has been reported to be the dominant mode of loading this joint.(39) During whiplash there is vertebral retraction where the facet joint undergoes shear (simply the vertebrae are being pulled one way while body motion continues the other way) as the inferior facet of the top vertebrae (the back, bottom of the vertebrae) translates posteriorly (moves back) relative to the superior facet (the vertebrae underneath’s top forward part closer to the spinal cord) and the facet capsular ligament undergoes excessive stretching and thus is at risk for injury.

Studies have shown that with this retraction motion of the facet joint of about 1/8th of an inch, microscopic damage can be seen (but no visible tissue damage seen) and at 1/5th of an inch of stretch there is tissue failure. (40) Not only can this be seen on motion x-ray as facet gapping, the amount of retraction or laxity can be measured.

In the image below we see gapping and its result of narrowing of the neural foramina – resulting in impinged, pinched nerves. Gapping displays instability and “floating” or “wandering” vertebrae.

Spinal motion MRI is getting better known, but it is only available in flexion and extension. Flexion and extension MRI have been shown in multiple studies to find ligamentous abnormalities when static X-ray or MRI did not. Functional CT scan to document instability is typically reserved for the evaluation of rotatory instability of the upper cervical spine. Its use is limited because motion X-ray and MRI scanning can adequately document the other instabilities without the large radiation exposure from CT scanning.

Evidence closing in on untreated ligament injury as the cause of whiplash-associated pain

In research from December 2016, (41) 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:

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

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Our research documents our experience with our patients.

A September 2020 study in the journal Regenerative Medicine (42) presented successful treatment of severe, longstanding, treatment-resistant Whiplash-Associated Disorders with Prolotherapy.

Learning points

Archival research

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 (43) and 1962 (44). 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 disorders. 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 (45) Dr. Hackett was a co-author of this paper led by Daniel Kayfetz DO. Here, even back in 1963, 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 changed 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 intermittent pain or constant pain even for years after the injury. Many long-term headache sufferers have accepted the gamut of treatments (ranging from medications, analgesics, muscle relaxants, sedatives, antidepressants, vasodilators or vasoconstrictors, anti-serotonins, glucocorticoids) through a variety of forms of physical therapy, neck braces and collars, local anesthetic infiltration, various nerve blocks, occasional rhizotomy (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 physician’s 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 that Prolotherapy injections are an effective treatment for chronic neck pain and cervical instability due to whiplash, especially when due to ligament laxity in the cervical joints. (46)

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. (47)

With 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?

Whiplash occurs when the neck suffers a “hyperflexion-hyperextension” injury, often after a rear-end collision or other car accident. Anyone that has ever been rear-ended knows that a lot of force is placed on your neck when your head moves forward and then backward after the car has been hit. Research shows that when the head is rotated, there is a significant increase in the amount of force placed on the neck during whiplash injuries. By simply having your head turned to the side, a significant increase in force is placed on the facet joints in your neck, which can predispose you to more ligament injuries and subsequent symptoms. Common symptoms of whiplash-associated disorder include neck pain, headache, dizziness, vertigo, crepitation in the neck, fatigue, irritability, tinnitus, nausea/vomiting, cognitive impairment, anxiety, lightheadedness, and memory problems. The facet joints in the cervical spine can be easily injured easily with rotational forces, such as the whiplash scenarios explained above.

The premise of this article is that chronic pain and the unusual symptoms that sometimes come with it, including dizziness, mental exhaustion, vertigo, dysesthesias, tingling, weakness, and a host of others, are due to neck instability from cervical ligament damage. Perhaps no other disorder confirms this premise more than all the people we know including myself who continue to have symptoms after whiplash injury. In 1977, my dad and I were stopped in a Chevy Chevette to turn left when a pick-up truck going about 40 miles an hour rear-ended us. Neither one of us had a seat belt on. Neither of us started getting Prolotherapy on our necks until the early 1990s. Needless to say, there was a lot of degeneration in both of our necks that had set in by then. I am glad to say that Prolotherapy has helped both of us.

I 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, our staff wants 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. Please visit the Hauser Neck Center Patient Candidate Form

More reading:

Dynamic Structural Medicine Ross Hauser MD Review of Treatments for Cervical Spine Instability

How neck pain and cervical spine instability cause nausea, gastroparesis and other digestive problems

Vagus nerve compression in the neck: Symptoms and treatments

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This article was updated March 21, 2023




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