Pain in the neck, shoulders, head or the base of the skull that occurs after a motor vehicle accident is often called “whiplash.” It’s a common term that most patients hear following a car accident. Most patients with whiplash recover in a few weeks or at most, a few months. However, 15 to 20% of people develop chronic pain. Whiplash is not a trivial problem, because once it has occurred, only 70% have recovered completely by one year and only 82% have recovered completely by two years. In addition to neck pain, there are many symptoms associated with the whiplash syndrome and include sleep problems, poor concentration and memory, blurry vision, ringing in the ears, fatigue, and weakness.
The diagnosis can usually be made by injections, MRI, and X-rays. Treatment is usually successful, but may require physical therapy, injections, and occasionally surgery. The treatment for whiplash syndromes depends on the stage and degree of the problem and which structures have been injured. Treatment can vary from chiropractic care, physical therapy, orthopedic intervention and more. In addition to soft tissue injury, pain that persists after four to six months is usually due to injury to the facet joints, one or more discs, or both.
The term acceleration deceleration injury is confusing to many. This is because it is both a mechanism of injury and the symptoms caused by a car collision. It is due to a traumatic event that causes the head to move suddenly in a whipping motion in one direction and then recoil in the other direction. The most common cause of acceleration deceleration injury is a motor vehicle collision in which one vehicle is struck from behind by another. However, it can occur when a car stops abruptly after striking a pole, a wall, or another car, and can also occur after a side impact.
Significant damage to ligaments, discs, and joints can occur even if the swings of extension and flexion are not excessive, but often the cervical spine is forced to the extreme ends of normal range or beyond. Because the trauma is usually sudden, occupants of the car are not prepared for the impact. The muscles are relaxed, which allows more forces on the discs, ligaments and joints. Perhaps the most important fact about acceleration deceleration injury is that significant ache and structural damage can occur even in low velocity crashes.
It is the patient with constant pain without any other specific findings on examination or specialized tests that presents the most difficult problems for the patient himself or herself, the doctors, and the legal system in personal injury. In the first few weeks to months after motor vehicle accident, it is often impossible to determine the exact cause or causes of the pain associated with the injury. The symptoms and signs are not sufficiently specific in the case. In almost every instance, the muscles and ligaments have been strained and may be inflamed, painful, and tender. However after about three months, primary muscle or other soft tissue injuries usually have healed.
The most common causes of persistent pain in whiplash are the facet joints and the discs. There is a poor correlation between the radiographic appearance of the joints and whether they are painful. Some joints which look bad are painless while other joints that look normal can be proven to be a source of pain. Only facet injections can determine whether the joint is painful. In a research study by Drs. Bogduk and Aprill, in 23% of patients, facet joints alone were the cause of pain, in 20% of patients the discs alone were the cause of pain, and in 41% of patients both the facet joints and discs were contributing. They were not able to identify the source of the pain in only 17% of their patients.
Many whiplash patients have symptoms which seem unexplainable, such as headaches, pain in the shoulders, between the shoulder blades, or in one or both arms. These symptoms can significantly impact activities of daily living. There may be fatigue, dizziness, problems with vision, ringing in the ears, heaviness in the arms, and low back pain. There can be poor concentration or memory, change in emotions with irritability, depression or short temper, and sleep disturbance. Dizziness occurs in one-quarter to one-half of people with whiplash injury. Again, researchers are not sure of the cause. The most likely explanation is an injury to the part of the inner ear that regulates balance. Problems with memory and concentration can be due to the pain itself, depression, medications, or trauma to the brain. Visual disturbances occur in 10 to 30% of whiplash patients and blurred vision is the most common.
Fortunately, most people who suffer cervical spine ache after an acceleration deceleration injury will recover by six months. However, a small percentage of people continue to have ache. Most patients destined to recover completely will have done so by three to four months, after which the rate of recovery slows markedly. By two years, essentially all patients have reached their individual maximum improvement. About 18% continued to have significant ache two years after the collision! Patients who did not get well tended to be older, had ache which began sooner after the collision, and/or had their head rotated to either side at the time of impact. They also found that patients who, before the collision, had a history of cervical spine ache; arthritis of the cervical spine, or headaches did not do as well.
Common sense would tell us the greater the pain and impairment, the larger the legal settlement or award might be. Rarely, patients may exaggerate their symptoms or be faking. However, a bigger question is whether the potential for money from a legal settlement can unconsciously prolong or worsen the pain. This is called “secondary gain” and it is unconscious, not fraudulent. The science shows that personal injury litigation does not adversely affect outcome. In 1983, Drs. Norris and Watt reviewed 61 patients who were treated for whiplash injuries, 41 of whom had personal injury lawsuits. They found no change in symptoms after claims were settled. About ten years later, long after litigation had settled, only 12% had completely recovered, and 48% had pain which interfered with normal daily life. In another study from 1993, Drs. Parinar and Raymakers re-evaluated patients they had seen previously for legal opinions, not for treatment, 8 years after the initial consultation. They concluded that lawsuits did not influence the timing or degree of recovery.
Several years ago a group of patients were analyzed. This was a group of patients who were referred for treatment by their attorneys because they were not getting better. The patients were treated with strengthening exercises, body mechanics training, medications, spinal injections and occasionally psychotherapy. No patient needed surgery in this case. Most of the patients did well with significant improvements in pain and function. Although most patients still had mild pain at the end of treatment, it was not enough to interfere with their activities of daily living. These very favorable results occurred although none of the lawsuits had even been settled.
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