From: J Pain. 2012 Jan 24. [Epub ahead of print]

A controlled experimental study was performed to examine the efficacy of the endogenous pain inhibitory systems and whether this (mal)functioning is associated with symptom increases following exercise in patients with chronic whiplash associated disorders. In addition, 2 types of exercise were compared. Twenty-two women with chronic whiplash associated disorders and 22 healthy controls performed a submaximal and a self-paced, physiologically limited exercise test on a cycle ergometer with cardiorespiratory monitoring on 2 separate occasions. Pain pressure thresholds, health status, and activity levels were assessed in response to the 2 exercise bouts.

In chronic whiplash associated disorders, pain pressure thresholds decreased following submaximal exercise, whereas they increased in healthy subjects. The same effect was established in response to the self-paced, physiologically limited exercise, with exception of the pain pressure thresholds at the calf which increased. A worsening of the chronic whiplash associated disorders symptom complex was reported post-exercise. Fewer symptoms were reported in response to the self-paced, physiologically limited exercise.

These observations suggest abnormal central pain processing during exercise in patients with chronic whiplash associated disorders. Submaximal exercise triggers post-exertional malaise, while a self-paced and physiologically limited exercise will trigger less severe symptoms, and therefore seems more appropriate for chronic whiplash associated disorders patients.

The results from this exercise study suggest impaired endogenous pain inhibition during exercise in people with chronic whiplash associated disorders. This finding highlights the fact that one should be cautious when evaluating and recommending exercise in people with chronic whiplash associated disorders, and that the use of more individual, targeted exercise therapies is recommended.

From: Eur Spine J. 2012 Jan 24. [Epub ahead of print]

Chronic radicular symptoms have been documented in whiplash patients, potentially caused by cervical neural tissue compression during an automobile rear crash. The goals of this study were to determine neural space narrowing of the lower cervical spine during simulated rear crashes with whiplash protection system and active head restraint and to compare these data to those obtained with no head restraint. We extrapolated our results to determine the potential for cord, ganglion, and nerve root compression.

The model, consisting of a human neck specimen within a BioRID II crash dummy, was subjected to simulated rear crashes in a whiplash protection system seat (n = 6, peak 12.0 g and ΔV 11.4 kph) or active head restraint seat and subsequently with no head restraint (n = 6, peak 11.0 g and ΔV 10.2 kph with AHR; peak 11.5 g and ΔV 10.7 kph with no head restraint). Cervical canal and foraminal narrowing were computed and average peak values statistically compared (P < 0.05) between whiplash protection system, active head restraint, and no head restraint.

Average peak canal and foramen narrowing could not be statistically differentiated between whiplash protection system, active head restraint, or no head restraint. Peak narrowing with whiplash protection system or active head restraint was 2.7 mm for canal diameter and 1.6 mm, 2.7 mm, and 5.9 mm(2) for foraminal width, height and area, respectively.

While lower cervical spine cord compression during a rear crash is unlikely in those with normal canal diameters, these results demonstrated foraminal kinematics sufficient to compress spinal ganglia and nerve roots. Future anti-whiplash systems designed to reduce cervical neural space narrowing may lead to reduced radicular symptoms in whiplash patients.

A simple and proven method of improving head restraints for whiplash protection that is user friendly and effective - proven in crash test results and highly recommended by heath care professionals is the add on headrest

From: Coll Antropol. 2011 Sep;35 Suppl 2:187-90

The predominance in performing surgery of major spine injuries by neurosurgeons usually has the consequence of treating all types of spine injuries by neurosurgeons – neurotraumatologists. In the neurosurgical wards of Clinical Hospital Rijeka, the authors take care of the majority of these patients, following both the major, as well as minor whiplash injuries of the neck. The article overviews patients admitted in the one year period (October 1st 2009-October 1st 2010) where 1077 cases of neck injuries were analyzed. Vast majority of these injuries were due to traffic accidents (over 94%), and only a small proportion were serious injuries that needed a surgical approach decompression and stabilization (c1%). The authors analyzed minor neck injuries thoroughly both because of the increasing number of whiplash neck injuries and because more complicated diagnostic and therapeutic protocols occupy too much time in the ambulatory practice of neurotraumatologists each year thus representing a growing financial burden to the health organizations and to the society as a whole.

The results proved that the majority of the injured are male (over 60%), young and active (almost two thirds 21-40 years of age), had commonly sustained a Quebec Task Force (QTF) injury of grades 2 and 3 (almost 90%), and, if properly treated, recovered completely after a mean therapy period of ten weeks. Only a minority complained of prolonged residual symptoms, some of them connected with medico-legal issues (less than 20%). The results shown are in contrast with the general opinion that malingerers in search of financial compensation prevail in these cases, and leads to the conclusion that minor neck injuries (including whiplash) as well as Whiplash Associated Disorder are real traumatological entities, that have to be seriously dealt with.

From: J Orthop Surg (Hong Kong). 2011 Dec;19(3):317-21

Neck pain is the most frequent injury sustained by motor vehicle occupants in the USA. In developed countries, claims for whiplash injury cost billions of dollars each year. Neck pain after motor vehicle injury may involve the intervertebral discs, facet joints, and the spinal cord, and is associated with atypical manifestations of carpal tunnel syndrome.

No theory for whiplash based on physical damage has been widely accepted. The prevalence of neck pain in uninjured controls is similar. Changes in the incidence of whiplash has been noted after legislative changes. Such observations have led to the proposal of alternative theories implicating psychosocial factors in neck pain after motor vehicle collisions.

Non-physical factors attributing to the development of whiplash include compensation, litigation and legislation, blame, post-traumatic stress, and symptom expectation. Many related studies have been retrospective, have used insurance data that may be unreliable, have used secondary outcomes measures (return to work or case closure), and were prone to selection bias by only including patients seeking compensation.

The authors identified possible psychosocial predictors of neck pain in patients with acute injuries following motor vehicle trauma.

The higher rate of neck pain in females after motor vehicle collisions has been reported. Lower education levels have also been associated with neck pain. This may be due to differences in coping skills or physical activities, which may reflect differences in the background prevalence of neck pain, rather than differences resulting from the injury. In other words, neck pain may be more common in people with lower education (owing to employment factors), even without involvement in a motor vehicle accident. The lack of uninjured controls limited the ability to explore this further.

Neck pain has been associated with the use of a lawyer, but 2 systematic reviews of whiplash injury provide different conclusions regarding the role of legal/compensation involvement. Insurance and compensation systems have a large impact on recovery from acute whiplash injuries, based on findings of the Quebec Task Force on Whiplash-Associated Disorders. Nonetheless, these studies were limited by small sample sizes, poor followup, lack of statistical analysis, recourse to indirect outcomes (such as return to work), retrospective and before-and-after timelines, and varying definitions of legal and compensation involvement.

The association between legal involvement and increased reporting of symptoms after traumatic injury has been attributed to coaching by lawyers, symptom magnification for secondary gain, and stresses related to the adversarial legal system. Such stresses include the need for repeated presentations for examination, dealing with administrative complexities, uncertainty regarding the outcome of the claim, challenges to the patient’s veracity, and court appearances. Although it is possible that patients with neck pain were more likely to engage the services of a lawyer, the lack of any association with physical factors makes the consideration of non-physical predictors such as legal involvement reasonable. Blaming others for an injury has been associated with increased reporting of symptoms, and these patients may be more likely to consult a lawyer. Nonetheless, the multiple regression analysis showed that the use of a lawyer was a stronger predictor than blame. Studies have reported no significant association between neck pain and injury severity or vehicular damage.

This study strengthened theories purporting a greater role for psychosocial factors over physical factors in neck pain after motor vehicle trauma. This has implications for treatment, as most treatments are directed at the physical cause. It also has implications for the insurance industry in relation to liability and the role of the accident in the development of neck pain after these injuries, particularly as the processes involved in claiming compensation may have a role in the development of clinical symptoms.

Source: Predictors of neck pain after motor vehicle collisions: a prospective survey

From: Exp Brain Res. 2011 Dec 17. [Epub ahead of print]

People with whiplash associated disorders not only suffer from neck/head pain, but commonly report deficits in eye movement control. Recent work has highlighted a strong relationship between eye and neck muscle activation in pain-free subjects. It is possible that whiplash associated disorders may disrupt the intricate coordination between eye and neck movement. Electromyographic activity (EMG) of muscles that rotate the cervical spine to the right (left sternocleidomastoid, right obliquus capitis inferior, right splenius capitis and right multifidus) 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. Three main differences were observed in whiplash associated disorders. First, the superficial muscle right splenius capitis was active with both directions of cervical rotation in contrast to activity only with right rotation in pain-free controls. Second, activity of 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 whiplash associated disorders. 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.

From: Am J Phys Med Rehabil. 2011 Dec 14. [Epub ahead of print]

This study aimed to determine differences in sleep quality between patients with mechanical neck pain, patients with whiplash pain, and healthy controls and to determine the relationship between the intensity of ongoing pain, disability, and sleep quality.

Nineteen patients with mechanical neck pain (4 men, 15 women; age, 40 ± 16 yrs), 22 with whiplash (4 men, 18 women; age, 38 ± 15 yrs), and 18 comparable controls (4 men, 14 women; age, 41 ± 13 yrs) completed the Pittsburgh Sleep Quality Index to assess sleep quality. A numerical pain rate scale (0-10) and the Neck Disability Index (0-50) were collected for assessing neck pain and disability.

Significant differences in sleep quality, sleep latency, sleep efficiency, sleep disturbances, use of sleeping medication, daytime dysfunction, and total Pittsburgh Sleep Quality Index score but not for sleep duration were found; patients with mechanical neck pain and whiplash pain exhibited higher scores in all components compared with healthy controls. Seventeen (77%) patients with whiplash and 13 (68%) with mechanical neck pain reported poor sleep quality (Pittsburgh Sleep Quality Index score, >8). Significant positive correlations between mean intensity of ongoing pain with sleep quality; sleep duration; sleep efficiency and total Pittsburgh Sleep Quality Index score were found in patients with whiplash pain; the higher the intensity of ongoing pain, the worse the sleep quality.

Sleep disturbances are a common finding in individuals with neck pain and are associated with the intensity of ongoing pain in whiplash. It seems essential to address the ongoing cycle of pain and sleep disturbances as an integral part of the treatment of patients with neck pain.

From: Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S280-5.

The aim of this study was to illustrate and discuss educational and learning perspectives in the rehabilitation of patients with acute whiplash associated disorders. Whiplash associated disorders is a major problem for the individual and the society. Several treatment options have been studied without giving convincing results for lessening the transition to chronicity. Current management of acute whiplash associated disorders include among other things advice of exercise and educational activities.

A literature search on the PubMed database was conducted with additional topic discussions with the research colleagues at a symposium. These resulted the present state-of-the-art review. There are several possible cognitive factors and behavioral learning processes such as self-efficacy, fear of movement and (re)injury, and catastrophizing that are important to focus on in decreasing acute whiplash associated disorders to becoming a chronic condition. Learning based on behavioral medicine approach in physiotherapy framework has gained evidence in other musculoskeletal pain conditions.

Exercise, education, and learning with a behavioral medicine approach should be focused on in the future studies of acute whiplash associated disorders management.

From: BMC Musculoskelet Disord. 2011 Dec 2;12(1):274. [Epub ahead of print]

Most studies suggest that patients with Whiplash Associated Disorders report chronic neck symptoms one year after the injury. The main problems in whiplash patients with chronic neck pain are cervical dysfunction and abnormal sensory processing, reduced neck mobility and stability, impaired cervicocephalic kinaesthetic sense, in addition to local and possibly generalised pain. Cervical dysfunction is characterised by reduced function of the deep stabilising muscles of the neck.

Besides chronic neck pain, patients with whiplash associated disorders may suffer from physical inactivity as a consequence of prolonged pain. This influences physical function and general health and can result in a poor quality of life. In addition, whiplash associated disorders patients may develop chronic pain followed by sensitisation of the nervous system, a lowering of the threshold for different sensory inputs (pressure, cold, warm, vibration and electrical impulses). This can be caused by an impaired central pain inhibition – a cortical reorganisation. Besides central sensitisation, the group with whiplash associated disorders may have poorer coping strategies and cognitive functions, compared with patients with chronic neck pain in general.

Studies have shown that physical training, including specific exercises targeting the deep postural muscles of the cervical spine, is effective in reducing neck pain for patients with chronic neck pain, albeit there is a variability in the response to training with not every patient showing a major change. Physical behavioural-graded activity is a treatment approach with a focus on increasing general physical fitness, reducing fear of movement and increasing psychological function. There is insufficient evidence for the long-term effect of treatment of physical and cognitive behavioural-graded activity, especially in chronic neck pain patients. Educational sessions, where the focus is on understanding complex chronic pain mechanisms and development of appropriate pain coping and/or cognitive behavioural strategies, have shown reduced general pain.

A review indicated that interventions with a combination of cognitive, behavioural therapy with physiotherapy including neck exercises is effective in the management of whiplash associated disorders patients with chronic neck pain, as also recommended by the Dutch clinical guidelines for whiplash associated disorders. However, the conclusions regarding the guidelines are largely based on studies performed on patients with either acute or sub-acute whiplash associated disorders. A more strict conclusion was drawn for whiplash associated disorders patients with chronic pain in the Bone and Joint Decade 2000-2010 Task Force, stating, that ‘because of conflicting evidence and few high-quality studies, no firm conclusions could be drawn about the most effective non-invasive interventions for patients with chronic whiplash associated disorders”. The concept of combined treatment for whiplash associated disorders patients with chronic pain has been used in a former randomised controlled trial. The results indicated that a combination of non-specific aerobic exercises and advice containing standardised pain education and reassurance and encouragement to resume light activity, produced better outcomes than advice alone for patients with whiplash associated disorders 3 months after the accident. The patients showed improvements in pain intensity, pain bothersomeness and functions in daily activities in the group receiving exercise and advice, compared with advice alone. However, the improvements were small and only apparent in the short term.

This project is formulated on the expectation that rehabilitation of whiplash associated disorders patients with chronic neck pain must target cervical dysfunctions, training of physical function and the understanding and management of chronic pain in a combined therapy approach. Each single intervention is based upon former studies that have shown effectiveness. This study is the first to also include the long-term effect of the combined approach in patients with chronic neck pain after whiplash trauma. The conceptual model in this study is based upon the hypothesis that training (including both individually-guided specific neck exercises and graded aerobic training) and education in pain management (based on a cognitive behavioural approach) is better for increasing the patients’ physical quality of life, compared with education in pain management alone. Increasing the physical quality of life includes increasing the general physical function and level of physical activity, decreasing fear of movement, reducing post-traumatic stress symptoms, reducing neck pain and increasing neck function. The effect is anticipated to be found immediately after the treatment (i.e. 4 months; short-term effect) as well as after one year (longterm effect).

The trial is registered in www.ClinicalTrials.gov identifier NCT01431261

From: Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S275-9

Narrative review of the literature and commentary to discuss from an epidemiological and sociological perspective whether the early clinical management of whiplash associated disorders can lead to iatrogenic disability. There is a lack of evidence supporting the effectiveness of early rehabilitation care for whiplash associated disorders. The authors describe the epidemiological evidence on the effectiveness of early rehabilitation on health outcomes for patients with whiplash associated disorders and analyze from a sociological perspective how the medicalization of this condition may have contributed to increasing its burden on disability.

The evidence from randomized clinical trials suggests that education, exercise, and mobilization are effective modalities to treat whiplash associated disorders. However, the evidence from large population-based cohort studies and a pragmatic randomized trial suggests that too much health care and rehabilitation too early after the injury can be associated with delayed recovery and the development of chronic pain and disability. These findings suggest that clinicians may be inadvertently contributing to the development of iatrogenic disability. The epidemiological evidence is supported by the sociological concepts of medicalization, iatrogenesis, and moral hazard. The current evidence suggests that too much health care too early after the injury is associated with delayed recovery. Clinicians need to be educated about the risk of iatrogenic disability.

From: Swed Dent J. 2011;35(3):123-31

Chronic Whiplash Associated Disorders present with frequent pain in the neck, head and shoulder regions but the presence of frequent jaw-face pain is unclear. The aim of the study was to investigate the frequency of jaw-face pain, pain in other regions, and general symptoms in chronic whiplash associated disorders patients.

Fifty whiplash patients and 50 healthy age and gender matched controls were examined by questionnaire for pain in the jaw-face, pain in other regions and other symptoms. In contrast to healthy, a majority of the whiplash associated disorders patients (88%) reported frequent pain in the jaw-face, in addition to frequent pain in the neck (100%), shoulders (94%), head (90%) and back (72%). The whiplash associated disorders patients also reported stiffness and numbness in the jaw-face region, and frequent general symptoms such as balance problems, stress and sleep disturbances.

The result suggests that frequent pain in the jaw-face can be part of the spectrum of symptoms in chronic whiplash associated disorders. The finding of self-reported numbness in the jaw-face indicates disturbed trigeminal nerve function and merits further investigation. The authors conclude that assessment of whiplash associated disorders should include pain in the jaw-face region. A multidisciplinary rehabilitation program including dentists, preferably specialized in the area of orofacial pain, should be advocated after whiplash injury.