Consultant Trauma Surgeon
Mr. Peyton has over 40 years experience as a general/trauma surgeon, with a particular interest in trauma and laparoscopic techniques. He is an ATLS® instructor and educator
He is also a world renowned expert on whiplash, and is the author of the book 'Whiplash' which is considered the definitive guide to the causes of whiplash, whiplash injuries and whiplash treatment.
20 Frequently Asked Questions on Whiplash
The following questions and answers are an abridged and condensed version of an audio recording Mr. Peyton produced to answer the most common questions he is asked at his clinics by whiplash sufferers.
The full 45 minute audiobook can be purchased for £4.95 from our online shop, and comes with a free PDF fact sheet containing advice on the legal aspects of whiplash, including advice on whether or not you need a solicitor, who pays any legal fees and what the next steps in the legal process are.
This audiobook can be easily downloaded to your mp3 player/phone allowing you to listen in your car or on the train.
Contents
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Introduction
- What is whiplash?
- What causes it?
- Why are the symptoms not just in the neck and back?
- Why did my symptoms take some time to develop?
- Is the damage permanent and will the symptoms get worse with time?
- Will I develop arthritis in the joints?
- Do I need to go to hospital or to see my family practitioner?
- Do I need x-rays or a scan?
- What treatment should I expect?
- Should I use a collar for support?
- Do I need physiotherapy?
- What exercises should I undertake?
- Why do I continue to feel upset, angry and fed up?
- When can I go back to work and what activities should I avoid?
- Will sport make matters worse?
- When should I resume driving?
- Do I need to see a Specialist?
- What if I have had a bad neck and back before?
- My doctor says I have a degenerative change in my spine. What is it?
- Will my back remain permanently weakened?
Introduction
Whiplash injuries are caused by damage to the soft tissues of the neck and back. The most usual cause is a road traffic accident but similar symptoms may arise following a fall or a sports injury.
In the developed world, it is estimated that one in 200 of the population will suffer whiplash injuries in a given year and, over a lifetime, the likelihood of an individual being hurt in this manner is approximately one in three.
Although there is great individual variation in the levels of symptoms, most people will get better in a relatively short space of time with appropriate management. This book is written to provide to clear, up-to-date and expert advice, based on the 20 most commonly asked questions about whiplash injuries. Of prime importance is the restoration of mobility at the earliest possible opportunity, and accordingly detailed advice is given on simple, self-help exercises which are fundamental to a speedy recovery.
1. What is whiplash?
Whiplash is a term applied to injuries primarily to the neck but also to the back. It is usually the result of a road traffic accident although it can occur in other accidents such as during sport or after a fall. It affects the muscles, ligaments, nerves and joints of the spine and occasionally there may be some damage to the bones of the vertebrae.
2. What causes it?
The damage is caused by sudden movements of the head, neck and body as the result of an impact from behind, from in front or from the side. The net result is that the soft tissues are stretched quickly beyond their normal range, perhaps several times in one episode and possibly torn. Subsequent bruising and swelling leads to increasing pain and stiffness.
In a road traffic accident whiplash can occur even when there is little damage to the vehicle, especially if the collision is from behind and without warning.
3. Why are the symptoms not just in the neck and back?
The main symptoms from a whiplash injury are pain and restriction of movement in the neck and the back. However, the nerves of the spine travel to all parts of the body. Any damage or inflammation to them can result in symptoms being felt in other areas. This is called referred pain. It may involve symptoms varying from pins and needles in the arms and the legs to actual pain involving these areas. Pain may also be felt in the jaws or up into the back of the head to give posterior headaches. Occasionally, there may be dizziness and abnormal ringing in the ears (tinnitus). This may originate from the neck or in some cases be due to a direct blow to the head for instance if the head hits the steering wheel, the roof, the door or the headrest.
4. Why did my symptoms take some time to develop?
Initially after any injury there may be a period of numbness caused by the shock of the incident. You may feel tense and angry, which are perfectly normal reactions. This bodily response is meant to help you escape from an area of danger, dulls pain and therefore you may not actually feel the onset of symptoms for several hours.
Further, with any tissue that has been injured, there may be some tears or bleeding and these areas may swell over 24 to 48 hours. This thickens the muscle and the ligaments rendering them more painful and stiff. Therefore, these symptoms may develop over the first few days, taking even up to one week to reach their peak. It is also quite possible that there could be an increase in existing pain and discomfort when full activities are resumed, for instance on return to work or during leisure and sports.
On the other hand, any significant symptoms developing after one month are unlikely to be directly connected to the incident. Symptoms which develop after a few days usually clear up more quickly than those that develop immediately, particularly if the pain and stiffness is directly related to the neck and back and does not radiate into the arms or legs.
5. Is the damage permanent and will the symptoms get worse with time?
The vast majority of whiplash cases start to clear after a few weeks and usually settle in three to six months. In about one in ten of the most serious incidents, some symptoms may continue into the longer term but even then it may be more of a nuisance than actually disabling and can be controlled with exercise and simple pain killers.
Unless there has been a fracture it is most unlikely that the level of symptoms will increase over time. Conversely improvement can continue to occur over protracted time periods, even up to three to five years.
6. Will I develop arthritis in the joints?
Following a whiplash injury to the neck or back where there has been no direct damage to any of the joints of the shoulder, arms or legs the development of arthritis is not an issue. As regards the neck and back, x-rays may reveal that there has been pre-existing degenerative change, normal with age, although it has not given rise to any symptoms prior to the accident. As a result of the incident, symptoms may start to develop in these areas and they can be prolonged.
However, in numerous studies, it has never been shown that the whiplash injury of itself can either cause or accelerate the development of arthritis in the spine. Over the years, any pre-existing degenerative change may increase and symptoms progress or new ones develop, but this is due to the natural ageing process and not related to the accident.
7. Do I need to go to hospital or to see my family practitioner?
If, after a severe accident, you are having a lot of pain it is advisable initially to visit an Accident and Emergency Department, otherwise your family practitioner is well able to advise you in these matters. This is particularly important if you are experiencing severe pain due to muscle spasms and especially if the pain is spreading into your arms or your legs. A visit is also indicated if you have been knocked unconscious, have severe headaches or nausea or other symptoms such as dizziness, ringing in the ears or difficulty with balance and walking. You may also need help from the doctor if you are having any psychological symptoms such as nervousness and irritability, problems with sleep, tiredness or depression.
8. Do I need x-rays or a scan?
Under normal circumstances this is not necessary. However, with severe symptoms it is best to see your doctor who may organise an x-ray to assess whether there has been any damage to the bones of the neck in the accident and to identify any pre-existing abnormalities in the neck such as degenerative change, which occurs with age and may tend to prolong the symptoms. The doctor may organise x-rays particularly if the pain radiates into the arms or the legs.
However the diagnosis of whiplash does not require an x-ray and your doctor will make it on the basis of listening to your history, taking note of your symptoms and his physical examination. Scans such as a CT or MRI are not normally indicated unless in the very rare situation that, because of prolonged and continuing severe symptoms, other methods of treatment such as injection or surgery may be required.
9. What treatment should I expect?
Initial management may be rest for the first couple of days, supplemented by pain killers and perhaps some muscle relaxants. It has been well shown that early exercise is important in getting back to normal movement and therefore your doctor may give you advice on the sort of exercises to undertake or refer you to a physiotherapist. Some hospitals have special classes run by their physiotherapy department in order to teach exercises which would be of benefit. If you require a course of physiotherapy this is usually organised via these classes or independently by your own family practitioner. The important message is to try and maintain as near normal activity as possible, even though it may be somewhat uncomfortable to begin with. In the initial phase, for the first day, or so heat application is not recommended.
Indeed, pain and stiffness may be eased by the application of something cold such as a packet of frozen peas for about twenty minutes at a time, several times a day. This tends to keep any swelling and bleeding to a minimum. After the first few days heat may be effective. This can be achieved by using a rolled up towel to support the neck in bed, with the towel heated around a hot water boiler or radiator prior to application. This may help to relieve spasm. Coupled with the use of the towel, it is also advisable to use a maximum of one low pillow, so that the head is maintained in a neutral position and not pushed forward or to the side.
The most commonly used pain killer is Paracetamol. Your doctor may prescribe anti-inflammatory tablets such as Ibuprofen which is also available over the counter in chemists. For the first few days these should be taken on a regular basis, in order to avoid the pain “breaking through”. Any medication has side affects and anti-inflammatory drugs in particular may have adverse effects on the stomach, sometimes causing pain and indigestion, and are contra-indicated in those with certain allergies such as asthma. Therefore it is best to consult a doctor or your pharmacist before taking them.
Occasionally a doctor may prescribe muscle relaxants in order to ease spasm. These also can have side effects of tiredness, fatigue and sleepiness and some can become addictive in the long term. They are not advisable beyond the first few days.
10. Should I use a collar for support?
Nowadays it is most unusual to be given a collar. While it may rest the neck it also tends to let it stiffen and get into disuse. This leads to increasing weakness of the neck muscles which need to be powerful to support the head. Therefore, occasionally a soft collar may be prescribed for one to two days to give comfort more than support for the head but should be discarded at the earliest possible opportunity. The best management is full mobilisation as soon as possible with graded exercises carried out to the limits of discomfort. These should be gradually increased until a full range is achieved.
11. Do I need physiotherapy?
Most patients can carry out the exercises to their neck and back themselves without any particular difficulty. They are quite simple and do not require a high level of physical fitness. If, however, the symptoms persist over the first two to three weeks, with muscle spasm and radiation to the arms and legs, then it is advisable to obtain the assistance of a physiotherapist. As well as active exercises they have other types of treatment such as ultrasound, heat and in some cases traction. These sessions can give a lot of ease but are only of use if between sessions you continue with an active exercise programme.
12. What exercises should I undertake?
Here are some basic exercises you could undertake to assist your neck and back. You should start slowly, not to the limits of pain but to the limits of tolerance, so you will experience some discomfort. You must try to increase your range of movement from day to day, leading to a progressive stretching of the muscles so that they regain their normal range as quickly as possible. After the first few days, during which time the use of heat may be contraindicated, undertaking these exercises after a warm shower or particularly a relaxing bath may help the process. You should develop an exercise programme that is best suited to yourself and undertake it at least four times a day, more often if possible. Each movement should be repeated 10 times in one session.
To begin these exercises, the basic position is to hold yourself as erect as possible. The best way to accomplish this is to stand with your back against a wall, making contact with the heels, pelvis, shoulders and the back of the head. This ensures a good posture, which is very important to achieve as early as possible after the incident. Later, these exercises may be performed away from the wall. In the case of neck exercises, these may be undertaken in a seated position and some of the back exercises by lying face down on the floor. Nevertheless, from time to time it is advisable to check against the wall so that the exercises are being performed correctly and good posture is maintained.
Neck excercises
- Flexion and extension. Forward flexion of the neck should be gradually increased until the chin can touch the breastbone. Extension exercises require you to be away from a wall, putting your head backwards in the position of "sniffing the morning air".
- Rotation. With the shoulders square against the wall look straight ahead, turn slowly to either side keeping the eyes level in a horizontal plane, attempting to look over each shoulder in turn purely by rotating the neck. You should be able to achieve a movement of at least two thirds of the rotation between looking fully forward and looking over the shoulder.
- Lateral flexion. Looking straight forward, bend the head to either side so that the ear approaches the top of the shoulder. It is important that you do not hunch the shoulders for this exercise but rather keep them level.
- Shoulder elevation. Standing square, shrug the shoulders as far upwards as you can, without bending the head. Let them down again slowly, to your resting position.
- Chin thrust. Looking straight ahead with your shoulders against the wall push your chin forward as far as it will go and then pull it straight back into your neck as far as possible.
- Pendulum movement. Starting with the head in neutral position looking forward, imagine you are being held by the nose and swing your chin from side to side as a pendulum movement, without moving the shoulders.
Back exercises
- Forward flexion. Standing against the wall place the palms of your hands on the front of your thighs and bend forward running your hands down your thighs past the knees as far as they will go.
- Lateral flexion. Place the palms of your hands on your outer thighs below the hips, with your arms straight. Bend to either side running the hand on that side down the outer aspect of the thigh towards the knee as far as it will go. Repeat on the other side.
- Rotation. Stretch the hands out in front. Keep the pelvis in a fixed position and rotate the shoulders and arms from side to side, turning from the waist.
- Extension. Move away from the wall and put your hands behind you on the small of your back. Lean backwards as far as possible, keeping your knees straight. An alternative to this action, if there is no shoulder pain, is to lie on your stomach and push upwards, first with your elbows and then with your hands, raising your shoulders but keep your pelvis against the floor.
13. Why do I continue to feel upset, angry and fed up?
Being involved in an accident is not a pleasant experience for anyone especially if it was not your fault and it occurred so quickly that you did not even realise what was happening. It is natural to feel annoyed, angry, frustrated or distressed. This may manifest itself by either irritability, displayed perhaps as a short temper, by difficulty in concentration, getting to sleep or waking early. Tiredness may lead to nervousness and a feeling of exhaustion simply because of the amount of emotional energy expended or as a consequence of lack of sleep. You are basically reacting to the situation, trying to come to terms with what has happened.
This is well known to doctors and is called an "adjustment reaction". You can be assured that, unless you have had any pre-existing psychiatric illness, the condition is self limiting, even though it may be prolonged until after most of the symptoms have disappeared. It could be prolonged for instance by not going back to work as soon as possible, or not resuming normal leisure and sporting activities even if these may cause some discomfort. The best management therefore is not by medication but by getting back to normal activity at the earliest possible opportunity.
14. When can I go back to work and what activities should I avoid?
This depends on the level of symptoms and the nature of the work you undertake. If your normal job requires a lot of manual work then a discussion with the employer may help you to ease back into your normal job over a space of weeks. It is best if this is a gradual increase from day to day and not as far as possible taking on a lesser job for a prolonged period of time or expecting work colleagues to undertake your duties for you. You should avoid activities which cause a lot of pain but some discomfort is to be expected as you gradually increase your activity. The best advice as before is to go back to normal activities in the shortest possible time.
Sedentary workers, for instance a secretary, may find difficulties after prolonged sitting at a desk or using a computer. Discomfort may be eased by frequent short breaks from the desk undertaking regular stretching movements and exercise especially when the neck and back begin to feel stiff. Problems may also be eased by an assessment of the work station ensuring that computers etc are at the optimal position. Seating should have good lumbar support. Some find difficulty after prolonged driving. Attention to the positioning of the driving seat, proper use of the headrest and the lumbar support will be of benefit as well as breaking up the journey frequently, and getting out of the car whenever possible to do some stretching exercises.
15. Will sport make matters worse?
Some sports provide excellent exercise, taken in moderation. Others which require a lot of bursts of activity, may be counter productive. Swimming for instance may be excellent for the lower back but if the tendency is to keep the head out of the water then this can put an excess strain on the neck causing pain in the neck shoulders and arms. Therefore, any return to swimming should be gradual although beginning as soon as possible. Sport will not lead to any further damage and will be of benefit provided the return is sensibly graduated with reasonable limits of discomfort.
16. When should I resume driving?
After such an upsetting experience, many find it difficult to get back into a car, particularly as a passenger since they feel they have little control. Passengers may find themselves very tense and have heated discussions with the driver as regards speed or closeness to other vehicles. Drivers may tend to travel more slowly and be overly vigilant of other road users for instance vehicles coming from behind when their car is stationary or other vehicles approaching from a side road, wondering whether or not it is going to stop especially if that has been the nature of the initial incident. You may also find yourself particularly nervous around the same location as the previous incident.
All this is due to the brain trying to protect you from what it sees as a dangerous situation. Your brain is very alert at all times and takes in a lot of information although it filters what it passes to your consciousness. As an obvious example, you will remember when you started to drive how alert you were to everything that was going on both outside and inside the car and yet with experience you manage to focus on what was necessary for driving and could actually discuss other unrelated issues at the same time. Following the accident the brain re-evaluates what is important since it has been attacked and therefore brings to your consciousness very quickly anything that is perceived as a danger.
This is a learned response and over time the system at the base of the brain will start to suppress these over-reactions once experience shows that no further harm occurs. Obviously this is much slower to settle if there have been previous similar incidents. Most people therefore will readjust quite quickly and the best advice is to resume driving at the earliest possible opportunity and not to put it off because of initial nervousness. It may be supportive to ask a friend to come with you when you first venture out.
17. Do I need to see a Specialist?
Under normal circumstances a specialist has nothing to add to the management of the physical symptoms or the psychological upset which may occur. If, as is rare, your symptoms continue to a significant degree over the long term and particularly if they spread into your arms or your legs, then your doctor may seek an opinion from an Orthopaedic Specialist. At that time, the Specialist may determine that scans are appropriate in order to see if there is any underlying pressure on the nerves to your arms and legs which may be helped by more specialised treatments. Initially they will wish you to have some physiotherapy. If the pain continues then they may suggest local injections to try and stop inflammation in the area or in a few cases surgery to relieve pressure from something pressing on a nerve such as a slipped disc. If the Orthopaedic Surgeon does not feel that surgery would be of benefit, he may suggest being seen by a Pain Specialist. Occasionally, the nerves become damaged in such a way that they react abnormally and do not heal fully, leaving abnormal sensations of pain. The Pain Specialists may try other therapies such a tens machine which continually stimulates nerves in such a way that it blocks some of the pain. Direct injections around the nerve root with steroids may be suggested or occasionally, particularly in the upper limbs, injections into the veins of the arms. They may also use other more powerful pain killers along with anti-depressant medications. These are not being used to treat depression but they do, in fact, have other effects on damaged nerves which may help them to return to their normal function or at least stop them creating the continual sensation of pain.
Some patients find it very difficult to get over the psychological effects of the incident, particularly if they have a past history of nervous ailments. The doctor may then seek the help of a psychiatrist who following assessment, may recommend medications or various forms of counselling.
One of the commonest nervous reactions is panic attacks. These are rare but can be very disabling. The sufferer will suddenly become very upset, often in a crowded situation. They feel their heart beating rapidly, start to sweat, may perhaps feel faint and have an overwhelming desire to leave the situation they find themselves in and get home. Initially these may be helped by the family practitioner with tablets called Betablockers which block the chemical in the blood which causes the pounding and the sweating. However, if the situation persists then the GP may suggest a period of counselling to help resolve them.
18. What if I have had a bad neck and back before?
The effect of previous symptoms very much depends on the nature of the problem. Everyone at some time will have had pain in the neck and back for which they may or may not have seen a doctor. However, if these episodes were short lived and not in the recent past then they will not have any particular bearing on the whiplash injury. However, if there have been persistent problems with the neck or back prior to the incident and especially if you are known to have problems with your discs or other arthritic changes in the neck and back, then these may well be markedly accentuated by the incident.
Nevertheless, the symptoms should start to settle down after the first few weeks and hopefully, in the majority of cases, revert to the state they were in prior to the accident. However, sometimes symptoms may be prolonged and, although they do settle somewhat, you may be left with symptoms on a slightly greater level than they were prior to the accident. In occasional cases persistent problems can be quite severe and it is in those circumstances that the family practitioner may well seek specialist advice and scans may be indicated.
19. My doctor says I have a degenerative change in my spine. What is it?
Degenerative change in the spine really is an indication of the ageing process. As we get older the discs and ligaments which used to be so supple gradually harden up and this can be seen on x-ray. The discs in the back, of which there is one between every vertebrae, normally act as shock absorbers. Over time, these begin to wear out and flatten causing them to bulge. The outer layers of the bulge may become calcified and visible on x-ray. These changes are referred to by your doctor as degenerative change or arthritis of the spine and they simply indicate the process of ageing which unfortunately happens to us all.
These changes may be present even without any symptoms. However, they do mean that the spine is less able to recover after trauma. These changes may begin as early as twenties and thirties although start in different people at different times. In a back which does have underlying degenerative change, recovery may therefore be protracted and some symptoms may persist into the long term.
There are other forms of arthritis which may effect the spine, again making it less resilient to trauma. Such conditions include rheumatoid arthritis, the skin disease psoriasis and a particular disease of the spine known as ankylosing spondylitis which starts in the teenage years. The usual management of these conditions is by exercise and perhaps some anti-inflammatory medication. Very occasionally if the degenerative change is such that there is pressure on the spine, an operation may be indicated, for instance to relieve the condition known as sciatica whereby the pain from the back spreads down the back of the leg due to pressure on the roots of the sciatic nerve.
Occasionally, x-rays of the spine may reveal abnormalities of the bones or ligaments which have either been present since birth (congenital), or developed during growth up to young adulthood (developmental). These do represent a weakness which may not have given any problems before the trauma of an accident. Again, symptoms may be prolonged, but usually do settle.
20. Will my back remain permanently weakened?
If symptoms settle as would normally be expected over a number of months, perhaps up to one year, then there is no evidence to suggest that there should be any residual weakness of any sort, or liability of the back to suddenly "give way" again. Even if you have had a previous incident hurting the neck or back, no long term consequences should occur and the second (or even the third!) incident should not exacerbate matters. However, if there have been continuing symptoms from one accident and then there is a second accident, symptoms can be markedly exacerbated, whether or not there are any degenerative changes on x-ray.
Fortunately, this is quite rare and over the long term there is no evidence that the level of symptoms would increase over time. No matter what has happened before, you should make it your goal to get back to your pre-incident state as soon as possible keeping as active and supple as you can by gradually stepping up the amount of exercise you perform. Recovery from a whiplash injury, in most cases, is as much to do with the motivation of the individual as with any specific treatment from a doctor or physiotherapist.
