Whiplash-Associated Disorders

By Diana L. Thompson
[Somatic Research]

Clients who complain about a combination of headaches and chronic musculoskeletal pain are five times more likely than those without complaints to have been involved in a motor vehicle collision (MVC).1 Persons experiencing pain after an MVC have an increased risk for chronic recurring pain from different anatomical sites,2 possibly reflecting central nervous system sensitization.3

While the validity of whiplash-associated disorders (WAD) are frequently questioned due to litigation and the prevalence of psychiatric disorders,4 compelling evidence is accumulating that underscores the complexity and severity of WAD in comparison to other mechanical neck disorders (MND).5

A fundamental component of a therapist’s intake is to investigate potential origins of symptoms, especially when presented with complex, unexplained conditions. Connecting the dots to previous MVCs can be a significant element of treatment. Help clients understand the complexity of whiplash injuries, no matter how minor the original trauma, and the prevalence of chronic WAD and its many faces. This may abate the frustration of poor health in the absence of visible or explainable injury and move the client toward a path to recovery.

How Prevalent is WAD?

According to the latest National Highway Traffic Safety Administration Research Notes, there were 5.5 million motor vehicle crashes reported in 2009, resulting in 1.5 million injuries and nearly 31,000 fatalities.6 This statistic accounts for reported injuries, collisions severe enough to generate traffic reports that document visible trauma, or injuries severe enough for a hospital visit.

Countless low-impact, rear-end collisions go unreported due to minor car damage and no immediate trauma. Days later, many of these drivers and passengers find their way into massage and bodywork clinics complaining of a stiff and sore neck, or other symptoms they thought would just go away. If weeks go by before seeking care, the pain has typically crept into their low back, and is often combined with an unrelenting headache. Months later, numbness and tingling in the arms and hands may become problematic; by then the car crash is a distant memory.

Of those who experience pain after car crashes, 15–40 percent develop chronic pain.7 Nearly one in four peripheral nerve syndromes are caused by motor vehicle collisions; 90 percent occur in drivers who had their hands on the wheel at the time of the collision.8 While 43 percent develop symptoms within one day of the MVC, many of these conditions, such as carpal tunnel syndrome or brachial plexus syndrome, do not materialize for weeks, months, or years.9 Many clients seek care under the pretext of other seemingly unrelated conditions; WAD is more prevalent than we may think.

Mechanisms of Injury

Despite a large number of rear-end collisions and a high frequency of whiplash injuries reported, the mechanisms of whiplash injuries are not completely understood. One of the reasons is that the injury is not necessarily accompanied by obvious tissue damage detectable by X-ray or MRI.10 Understanding the biomechanics of whiplash can help elucidate the mechanisms of injury.

Whiplash injuries are generally considered to be a soft-tissue injury of the neck with symptoms such as neck pain and stiffness, shoulder weakness, dizziness, headache, and memory loss.11 There are two components to the trauma: muscle damage and ligament damage. Both occur primarily in the hyperextension phase of whiplash. In a rear-end collision, the first action is hyperextension. Unless stopped by a well-positioned headrest, the head has a long way to go before colliding with the back of the seat. As the head goes into hyperextension by forcefully contracting, the anterior neck muscles react to the rapid overstretching. The overstretching of the sternocleidomastoid, longus capitus and coli, and scalenes, combined with forceful contractions in the same muscles, result in muscle strain injuries.

Ligamentous lesions are best explained through the shearing forces. As the lower neck begins to extend, the neck assumes an S-shaped curve. Gradually, the upper neck is forced to flex, which results in the loss of cervical lordosis.12 The rapid hyperextension/hyperflexion, especially when combined with rotation (looking into the rearview mirror upon impact), results in compressing and shearing forces strong enough to tear facet capsules, annular fibers of vertebral discs, capsular ligaments, and nerve roots, and can cause vertebral fractures and vertebral artery lesions.13 It is the trauma to the paravertebral ligaments, discs, and nerves that results in cognitive and neurological dysfunction and primarily contributes to chronic pain.14

To illustrate the point, I’d like to share a story. Chiropractor Dan Murphy spoke at a whiplash seminar that I attended recently in Seattle. He told the story of a patient who had been complaining of severe headaches since an MVC. He placed the X-ray of the patient’s head on the overhead projector, showing a pen lodged in the man’s brain. The man’s head was slung so far forward that the pen in his shirt pocket went right up his nose and embedded in his brain. And it occurred so quickly that he was completely unaware of what had happened. I no longer question the magnitude of an overstretching injury resulting from a car collision.

Brain trauma is another component of WAD, and not just from pens. Overstretching of the neck that occurs during whiplash places extreme traction forces on the spinal cord. These forces can cause contusions at the base of the brain, as the spinal cord is stretched beyond capacity and the brain is pulled into the foramen magnum. Concussions can also occur as the head is whipped from hyperextension into hyperflexion. Inertia—the principle that an object in motion will remain in motion until acted on by another force—explains the brain’s collision with the skull as the head changes direction before the brain catches up with the shift. In other words, you can get a concussion without the head hitting anything inside the car.

Temporomandibular joint disorder (TMJ) is a common concomitant dysfunction of a whiplash injury, also explained through the principles of inertia.15 The jaw is moving through space with the head, but as the head reverses direction, the jaw continues to move forward. The force with which the jaw catches up with the head, due to the stretch reflex and magnification of acceleration, can crack teeth, tear masseters and pterygoids, and dislocate jaws.

Other factors potentially increase the severity of a whiplash injury, such as the size and speed of the vehicles (bigger cars hit harder), the acceleration over time, or G-force, as well as the friction created by road conditions (wet roads allow for greater acceleration). Gather this information to better understand the mechanisms in play that may have complicated the client’s injury. It is important to understand that energy can be transformed into several things during a car crash: noise, tire marks, car damage, or physical injury. Less car damage can mean more physical injury; things are not always what they appear on the surface. While the presence of any of these things may increase the odds of acute injury, none of them influence the chances of suffering from chronic WAD.16

Today’s car manufacturers are making strides in decreasing the risk of injury, but there are still issues.17 Safety and comfort features can have contradictory results. Seat belts have decreased death rates but increased soft-tissue trauma; by stabilizing the body, they increase the movement of the neck and head. Shoulder harnesses increase trunk torsion as one shoulder is stabilized and the other rotates around the strap. This can result in thoracic trauma and explain the increasing occurrence of shoulder surgeries. Visceral lesions can be caused by submarining: the seat belt slips over the iliac crest and penetrates the abdomen. Air bags save lives, but can cause head injuries as the head bounces on the air bag, especially with shorter people. Comfortable car seats are springy, resulting in knee injuries as hyperextension loads the springs and catapults the person up and forward, throwing knees into the dash and steering column. Seats that recline can put the headrest too far away to be helpful.18

How Complicated is WAD?

Symptoms associated with WAD vary: changes in vision, dizziness, fatigue, headaches, numbness and tingling in extremities, poor health, poor posture, sleep disturbances, stiffness, vertigo, and can include back, jaw, or neck pain.19 Many sufferers are depressed, fearful, and frustrated, not understanding the origin of their poor health.20 Clients can exhibit acute inflammatory trauma, neurological and cognitive conditions, psychological distress, and functional limitations.

Soft-tissue trauma is likely present. This can include muscle, tendon, ligament, and fascia lesions, and bone fractures. The overstretching trauma will directly affect the neck, shoulders, and viscera, and likely affect the entire spine, nervous system and fascial system. Fractures of the vertebral bodies are possible due to compressive forces. If the head is rotated on impact, fractures can be found at the transverse processes due to shearing forces.

Neurological lesions are indicated at the brain stem and nerve roots, and can affect the spinal cord directly. Cognitive dysfunction is unsettling for the client, resulting in short-term memory lapses, difficulty concentrating, and confusion.21 Sensorimotor dysfunction can cause poor proprioception, leading to poor posture, jerky movements, and unsteady gait.22 Simple actions seem impossible. One might be mistaken for being drunk or accused of being clumsy, stumbling over curbs, and uncharacteristically dropping things.

Acute inflammatory conditions commonly result in pain, muscle spasms, or splinting. Whiplash clients often complain that it feels like their head will fall off, increasing the intensity of the muscle guarding associated with inflammatory conditions. Scar tissue is the body’s response to inflammation, walling off the injured tissue. As the fibrosis of repair sets in, the scar tissue matures, shortens, and hardens. As people begin to move again, the scar tissue isn’t as elastic or flexible, and is torn as people attempt normal activities of daily living. This sets people up for repeated reinjury and chronic inflammation.23

How to Best Treat WAD

Acknowledge clients’ conditions. Explain how, even without visible signs of trauma, they can be experiencing symptoms beyond what they might have expected if damage to the car was minor or the collision occurred at low speeds.

Calm their nervous system. Nonrestorative sleep is detrimental
to healing.

Retrain their nervous system. The purpose of treatment should be not only to relieve pain but also to allow for proper proprioception.24 There are a host of resistive movement techniques, positional release techniques, and subtle movement techniques that will reset proprioception and invite alternative movement options.

Reduce inflammation. Fibrosis of repair complicates healing and increases the potential for chronic pain. Use ice, topical analgesics and anti-inflammatories, and manual lymph drainage techniques.

Utilize massage. Various types of massage, trigger-point therapy, and structural integration have been found to reduce pain, reduce cervicogenic headaches, reduce nervous system hypersensitivity, decrease electromyogram amplitude, increase range of motion, improve movement and postural stability, reduce muscle stiffness, and reduce anxiety in people with WAD and MND.25

Address TMJ. Not only are TMJ disorders common with whiplash injuries, treatment of the temporomandibular region has been found to significantly reduce the intensity of headaches and increase neck function.26 These improvements persist in the short term and long term.27

Focus on regaining function. Combine passive, soothing care with active movement techniques and exercise. Mobilization, manipulation, and soft-tissue techniques decrease pain and improve satisfaction. When musculoskeletal treatment strategies were combined with exercise, even greater improvements were achieved.28

Teach self-care. Education and referring effective products for self-care can help ensure healing continues between sessions. Manual therapies are more effective when combined with cervical pillow supports.29 Ice therapy is more effective when combined with topical menthol for relieving pain.30


Whiplash is not just a pain in the neck. Understanding the complexity of WAD and its long-term consequences can give clients peace of mind and therapists better command of successful treatment planning.

 A licensed massage practitioner since 1984, Diana L. Thompson has created a varied and interesting career out of massage: from specializing in presurgical and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.


1. R. Myran et al., “Headache and Musculoskeletal Complaints Among Subjects with Self Reported Whiplash Injury. The HUNT-2 study,” BMC Musculoskeletal Disorders 12, no. 1 (June 8, 2011): 129.

2. A. Berglund et al., “The Association Between Exposure to a Rear-End Collision and Future Health Complaints,” Journal of Clinical Epidemiology 54, no. 8 (August 2001): 851–6.

3.  M. Curatolo, L. Arendt-Nielsen, S. Petersen-Felix, “Central Hypersensitivity in Chronic Pain: Mechanisms and Clinical Implications,” Physical Medicine & Rehabilitation Clinics of North America 17, no. 2. (May 2006): 287–302.

4. R. Myran, “Headache and Musculoskeletal Complaints Among Subjects with Self Reported Whiplash Injury. The HUNT-2 study.”

5. A. Woodhouse, O. Stavdahl, O. Vasseljen. “Irregular Head Movement Patterns in Whiplash Patients During a Trajectory Task,” Experimental Brain Research 201, no. 2 (March 2010): 261–70; J.  Nijs, J. Van Oosterwijck, W. De Hertogh, “Rehabilitation of Chronic Whiplash: Treatment of Cervical Dysfunctions or Chronic Pain Syndrome?” Clinical Rheumatology 28, no. 3, (March 2009): 243–51; D. Scott, G. Jull, M. Sterling, “Widespread Sensory Hypersensitivity is a Feature of Chronic Whiplash-Associated Disorder but not Chronic Idiopathic Neck Pain,” The Clinical Journal of Pain 21, no. 2 (March–April 2005): 175–81.

6. US Department of Transportation National Highway Traffic Safety Administration Traffic Safety Facts, Research Note (August 2010).

7. J. Schofferma, N. Bogduk, P. Slosar, “Chronic Whiplash and Whiplash-Associated Disorders: An Evidence-Based Approach,” Journal of the American Academy of Orthopaedic Surgeons 15, no. 10 (October 2007): 596–606.

8. J.H. Coert, A.L. Dellon, “Peripheral Nerve Entrapment Caused by Motor Vehicle Crashes,” The Journal of Trauma 37, no. 2 (August 1994): 191–4.

9. Ibid.

10. H.B. Chen, K.H. Yang, Z.G. Wang, “Biomechanics of Whiplash Injury,” Chinese Journal of Traumology 12, no. 5 (October2009): 305–14.

11. Ibid.

12. Ibid.

13. G.P. Siegmund et al., “The Anatomy and Biomechanics of Acute and Chronic Whiplash Injury,” Traffic Injury Prevention 10, no. 2 (April 2009): 101–12.

14. J. Nijs, J. Van Oosterwijck, W. De Hertogh, “Rehabilitation of Chronic Whiplash: Treatment of Cervical Dysfunctions or Chronic Pain Syndrome?”

15. R. Garcia, J.A. Arrington, “The Relationship Between Cervical Whiplash and Temporomandibular Joint Injuries, An MRI Study,” Cranio 14, no. 3 (July 1996): 233–9.

16. L. Hartling, W. Pickett, R.J. Brison, “Derivation of a Clinical Decision Rule for Whiplash Associated Disorders Among Individuals Involved in Rear-End Collisions,” Accident Analysis & Prevention 34, no. 4 (July 2002): 531–9.

17. B. O’Neill, “Preventing Passenger Vehicle Occupant Injuries by Vehicle Design—A Historical Perspective from IIHS,” Traffic Injury Prevention 10, no. 2 (April 2009):  113–26.

18. B. Denb et al., “Kinematics of Human Cadaver Cervical Spine During Low Speed Rear-End Impacts,” Stapp Car Crash Journal 44 (November 2000): 171–88.

19. A. Berglund et al., “The Association Between Exposure to a Rear-End Collision and Future Health Complaints,” Journal of Clinical Epidemology 54, no. 8 (August 2001): 851–6.

20. Steve Holder, “Cognitive Impairment in Traumatic Brain Injury Cases,” Head and Brain Injuries, accessed July 2011, www.headbraininjuries.com/cognitive-impairment.

21. Ibid.

22. A. Woodhouse, O. Stavdahl, O. Vasseljen, “Irregular Head Movement Patterns in Whiplash Patients During a Trajectory Task.”

23. H. Jónsson Jr. et al.,“Findings and Outcome in Whiplash-Type Neck Distortions,” Spine 19, no. 24 (December 1994): 2,733–43.

24. C. Davis, “Chronic Pain/Dysfunction in Whiplash-Associated Disorders,” Journal of Manipulative and Physiological Therapeutics 24, no. 1 (January 2001): 44–51.

25. J.M. Sefton et al., “Physiological and Clinical Changes After Therapeutic Massage of the Neck and Shoulders,” Manual Therapy (May 11, 2011). [Epub ahead of print]; E. Kristjansson J. Treleaven, “Sensorimotor Function and Dizziness in Neck Pain: Implications for Assessment and Management,” Journal of Orthopaedic & Sports Physical Therapy 39, no. 5 (May 2009): 364–77.

26. V.K. Capellini, G.S. de Souza, C.R. de Faria, “Massage Therapy in the Management of Myogenic TMD: A Pilot Study,” Journal of Applied Oral Science 14, no. 1 (January 2006): 21–6.

27. H. von Piekartz, K. Lüdtke, “Effect of Treatment of Temporomandibular Disorders (TMD) in Patients with Cervicogenic Headache: A Single-Blind, Randomized Controlled Study,” Cranio 29, no. 1 (January 2011): 43–56.

28. J. D’Sylva et al., “Manual Therapy With or Without Physical Medicine Modalities for Neck Pain: A Systematic Review,” Manual Therapy 15, no. 5 (October 2010): 415–33. [Epub June 9, 2010]; T.M. Kay et al., “Exercises for Mechanical Neck Disorders,” Cochrane Database System Review 20, no. 3 (July 2005): CD004250.

29. A. Helewa et al., “Effect of Therapeutic Exercise and Sleeping Neck Support on Patients with Chronic Neck Pain: A Randomized Clinical Trial,” Journal of Rheumatology 34, no. 1 (January 2007): 151–8.

30. R. Topp et al., “The Effects of Combined Topical Menthol and Ice on Distal Blood Flow,” Proceedings of the 12th Annual Thera-Band Research Advisory Committee (Athens, Greece, July 19–21, 2010), 4.