#whiplash #whiplashrecovery #chronicpain #physiotherapy # nervoussystem
Whiplash injuries are one of the most complex things for a physio to treat….and sometimes one of the most frustrating because they don’t quite obey the normal rules for soft tissue injuries! You’ve got insurance claims in the mix, emotional response to the accident adding in a psychological/trauma element to the pain and the whole thing gets a bit messy for use simplicity-loving physio folk.
Whiplashes have also been much mis-understood because of their complexity. I remember a period when we used to talk of ‘compensationitis’, a smart-ass term that used to be bandied about (wink, wink) when people were engaging with a solicitor at the same time as seeking treatment for the whiplash. There was definitely an industry that grew out of people seeking compensation for whiplash injuries, and because they were so hard to objectively quantify, lots of artful dodgers got away with ( and still do) getting large sums for non-existent injuries. Plenty of solicitors made a killing on this too. All the while, genuine cases were tarred with the same brush, even though the injuries often remained to some extent after the case was settled. And don't worry, clinicians can tell who is genuine or not.
So, as I said, it’s complex. Recovery is also complex but the more you understand, the easier it is and this blog is here to help.
WHEN DID WHIPLASH INJURIES BECOME A THING?
Let’s have a little look back at the history of them. They first got described from crash-test pilots somewhere in the middle of the 20th century after test collisions. As more and more people drove cars, whiplash injuries started to be seen in people after road traffic accidents (called RTAs in medical terms). When people started to adhere to wearing seatbelts ( somewhere in the 1970s), they got even more common, even though fatalities reduced. This is because the force of the collision was now on the neck and head, which were catapulted forward or sideways as the torso remained in situ by the belt.
By their nature, whiplash injuries are an acceleration-deceleration injury: you head gets flung forward ( or sideways) by a sudden impact, it comes to a sudden stop, then gets flung backwards to hit off the head-rest, and then forwards again. The two sides of your neck move differently because one is held back more by the seat belt on your shoulder. Sometimes, one side of your lower back ( the one not held in fully by the seatbelt) , also gets jarred, sometimes your jaw and even your inner ear gets a jangle. All of this is not unusual.
WHY DON’T I FEEL PAIN STRAIGHT AWAY?
Typically, you’ll feel fine physically when you get out of the car, not a lot of pain and just a bit ‘shook’. Most often, the pain hits the following day. This is not because you’ve spotted your chance to make millions and have reconsidered your options, it’s because the inflammatory effect on your body has taken place, and it can ramp up further in the days after. It’s the same process for delayed onset muscle soreness ( DOMS) after heavy exercise: you typically feel sore muscles about two days later.
Typically , in a whiplash situation, you end up with strained muscles and ligaments, and your nerves get stretched as well ( more about nerves later). The problem is, a bit like DOMS, it’s not just one large tear, which is relatively straight forward for the body to heal - it’s hundreds of micro-tears, which is harder for the body to heal. This is why whiplashes take a bit longer to recover. It’s also why, so far anyways, MRIs don’t show up the injury. X rays also don’t show anything, unless you’ve been unfortunate enough to break a bone, which is most uncommon. These investigations pick up large scale injuries in your anatomy, and not the smaller scale ones. So you might have all this pain and nothing to show for it on investigations. This is why whiplash injuries were so easy to fake for the artful dodgers. Hopefully, investigations will improve in time, but so far we don’t have a good objective way of showing the extent of the injury.
But remember, they DO heal, they just take longer than a typical simple muscle tear.
WHY DO SOME PEOPLE FARE WORSE THAN OTHERS?
- For a start, some people and more flexible and bendy than others. Think of a dry twig and a fresh one: which is easier to snap? The more flexible your body, the easier it is to absorb the impact. Typically, a child in the same car-crash situation will fare much better, because their bodies are more flexible and can ‘go’ with being flung forward. Adults are naturally stiffer, and so suffer more soft-tissue injuries injuries in the same crash.
- In my experience, heavier individuals fare better too. Again, think of the mechanics of it: when you give it a sharp shove, an item with more weight will not move as much compared to something light. Ditto with people: light people get bandied around more than heavier, and often ( not always) have more impactful injuries.
- There is the impact of psychological trauma: it has long been proven that a traumatic situation ( the crash) creates greater trauma in someone who has no control over the situation, compared to someone who HAS. So if you were the driver, and you were able to swerve to avoid most of the crash, you will have felt some degree of personal control over what happened. But if you were the passenger, you had no control OR if you were stopped in traffic and saw the vehicle coming towards you without you being able to do anything about it, then the psychological impact will be more traumatic.
- People’s ability to withstand trauma is different because we are all at different trauma thresholds. If you’ve had previous psychological trauma in your life, then you are more easily traumatized by a RTA than someone who has never had a trauma in their lives…stands to reason.
- On the same note, if you are naturally of an anxious disposition, the effects of the RTA are likely to feel more distressing and anxiety-provoking than someone who is horizontal about life.
So you are starting to see how the same crash can affect two people in the same vehicle very differently.
THE MECHANISM OF THE CRASH CAN IMPACT THE EXTENT OF THE INJURY
- What’s important is the relative difference in speed between the 2 moving vehicles because that determines the extent of sudden deceleration. So a car going at 50K per hour into the back of a car travelling 20K/hour will have roughly the same impact as a car at 30k/hour crashing into a stationary vehicle. This is why slow crashes can still cause damage and why people find it so hard to understand. It was only a tip, right?
- A heavier vehicle crashing into a lighter one will cause more damage
- It seems that side-on crashes or ones involving a twisting motion cause more of an injury than straight rear-end collisions, in the same way that twisting injuries cause worse bone fractures or ligament injury: our bodies are not as good at twisting as they are at going forwards.
WHAT ABOUT THE NERVOUS SYSTEM?
Ok, let’s talk about nerves and where the nervous system comes into the picture. While nerves are semi-elastic and can stretch a bit, they also pass through more rigid structures like fascia and ligaments, so they can get injured at the interfaces. Again, there are no easily-available investigations to show up micro-tears. Now, when nerves get injured they HURT and it’s a different quality of pain to muscles. Think tooth-ache: this is what nerve pain feels like and a lot of people who have whiplash pain describe a dragging kind of pain, similar to tooth ache. So from what I have seen clinically over the years, there seems to be an aspect of nerve pain to whiplashes, which could be another reason why they take longer to heal. It's also the reason why you might have pins and needles and other 'wierd' sensations that might otherwise make no sense.
But even IF the nervous system doesn’t actually get injured and it’s just micro-tears of muscles/ligaments/fascia, if someone is in pain for more than a few weeks, then the nervous system starts to get sensitized. By this, I mean that from all the pain chemicals in your body, your nerves get more sensitive and it becomes much easier to provoke pain - in other words, pain creates more likelihood of pain. Fun, eh? This would certainly explain why people can have a manageable amount of pain for the first weeks after a whiplash, but then as sleep gets disturbed, and more anxiety creeps in about jobs/not being able to do sports etc. etc. they enter a ‘fight or flight’ state, and the pain can ramp up a few months down the line. In my clinical experience, keeping the nervous system out of the ‘fight or flight’ state and preventing this second wave of pain is the key to maintaining control over your recovery from whiplash injuries.
LETS TALK ABOUT WHAT TO DO IN THE EARLY STAGES:
1) If you or anyone you know has a minor car crash, ice your neck and the area between your shoulders and neck hourly for the first 2-3 days WHETHER OR NOT YOU THINK YOU ARE INJURED. This reduces the potential of tiny bleeds and subsequent inflammation. Remember, there is usually no pain for the first day or two until inflammation sets in.
2) Go to your GP for an assessment
3) Take pain medication to reduce your pain, as per GP advice. Remember, pain creates the conditions for more pain, so you need to make sure in the early weeks that you are getting enough sleep and that your pain is reasonable. Even if it means taking heavier pain medication at night.
4) Keep your neck moving. Years ago, the treatment was to give people neck collars for their pain, which was lovely, but those same people were still wearing them 3 or 4 years later because they got dependent on them! Their muscles got weak and their joints got stiff and there was longer term problems. Movement is better, even if it is gentle. Go to a physio for advice on exercises and pain relief. You will also need advice on strengthening further down the line.
5) Keep your neck free from draughts ( cold creates muscle tension, which adds to pain) and put heat packs on it for comfort.
6) If you feel in any way traumatized or anxious by what happened e.g. flashbacks, panic attacks, feeling unable to cope, distressed by the pain….. get some psychological help : it will help you in the long run. You may also benefit from anxiolytics ( anxiety medication) if this is a huge factor, so talk to your GP about this.
7) Keep your head steady: Getting anxious or distressed by the pain is adding stress chemicals into the equation, which sensitises your nerves and will make your pain worse. You need to do a bit of work around this. See psychological plan below.
8) Have a relaxation plan for your nervous system. Pain puts your body into a ‘fight or flight’ state, and you need a plan to do some parasympathetic activities that turn down the dimmer switch on your nervous system. See my blog on relaxation here. This is about PHYSIOLOGICAL RELAXATION and not just scrolling the internet or watching football.
9) Try things like acupuncture, reflexology, massage and anything thing else that makes you feel better. Be aware that while something might help for a while, you may need to change it and try something else after a while. Don’t be surprised if massage doesn’t help in the early stages when things are inflamed. I’ve often made people worse with manual treatment in the early stages ( eek!).
10) There are treatments available for concussion and inner ear disturbance with vestibular physiotherapists. Talk to your GP about any lingering dizziness after a few months and get referred to one.
PSYCHOLOGICAL PLAN( bear in mind I’m a physio, not a psychologist)
1) Get your expectations right: some people recover if a few weeks, lucky them. Some people take a number of months or even longer : this is not unusual. It’s best to expect some level of pain for at least a few months, with the hope that you might be one of the lucky ones but expecting that you might not be.
2) Do everything in your power to keep your pain under control ( see my steps above) because feeling more control of the situation reduces the distress around it.
3) Get sleep , even if it means taking medication temporarily ( your GP needs to decide on this). If you don’t get sleep, your mood will be low.
4) Expect an up-down nature to recovery: some days you’ll have less pain than others. Don’t get too over analytical about it, but again keep to the 10 steps above. Recovery doesn’t happen in a smooth upward curve: it happens in stops and starts. When the good days overall start to outnumber the bad, you’ll know you are on the road to recovery. Even then, you’ll get some blips….expect them! Having an unexpected bad few days does NOT mean that you are not recovering.
5) This is the most challenging bit: try not to let your mood go up and down with the pain: don’t be elated on the good days, just enjoy them and look on them as an indication of what you’ll have in the future. Don’t get overly depressed and distressed on the bad pain days…better ones are coming. Overall, keep your emotions about the pain in check: This is HARD TO DO, but you can do it. See more on relaxation techniques below.
6) Do something that makes you smile or laugh or feel some joy every day: it secretes ‘happy’ hormones, which dim the ‘fight or flight’ switch on your sensitive nervous system. This is not just woo-woo hocus-pocus stuff, it is a chemical reality.
7) Keep as active as you can within the limits of your pain: if you can maintain social activities or change them a bit as required, but keep up social contacts.
8) Try not to slip into victim mode… because it ramps up the pain. Being simplistic, the more anger/blame/feeling hard done by you feel, the worse it is for your nervous system. If you don’t believe me, go have a full-on angry or feeling-sorry-for-myself day, and see what it does to your pain. Again, it’s because these ‘hot’ emotions create hormonal effects on your body and hence your nervous system. While it is normal to feel them, don’t get swamped in it. Keep your goals on the bigger picture, which is recovery . Keep to your recovery plan. And remember, life isn’t fair.
9) Don’t expect people to understand. Most people have never had a whiplash injury. Anyone who has had one, will understand. Unfortunately, pain is not visible, like a broken leg in a cast, and what people don’t see, they don’t understand. Grow and thick skin and keep to your recovery plan.
10) You may suffer from fatigue – go read my blog on fatigue here.
THE LEGAL SIDE ( bear in mind, I’m not legally trained!)
Over the years, I’ve seen many of my patients sue for injuries sustained in a RTA. The majority had no intention of doing this until they really felt that their life had been disrupted enough and that the costs of treatment had given them no choice. But sometimes, people get subsumed by the process, which can be lengthy and draining.
If your plan is to sue, make sure you keep it from wearing you out. You need to separate two important processes: the need to sue for fair compensation and your own plan to get better. DO NOT MIX THEM UP. Get your solicitor to do the legal side of things and stay out of it as much as you can. Getting too emotionally involved and anxious over the legal process is (you’ve guessed it)…bad for your nervous system and ramps up your pain. Oh, and grow a thick skin. People might judge you, let them.
On an aside, you might wonder how we can tell if someone is exaggerating their pain for legal gain : 2 simple things:
the objective tests don't match up with the symptoms they describe
the more detailed the questions about their symptoms, the more vague they get in responding. When you are genuine, you can answer any number of detailed questions about your pain and be able to give responses that make sense.
I hope my 2 x 10 step programme to recovery helps you. If you want to hear more from me, sign up for my monthly educational emails ( with summer breaks!).
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