April 14, 2000 (Atlanta) -- "Car crash + whiplash = cold cash," a Canadian law firm advertises. But money can't explain the 10% of whiplash patients who suffer long-lasting neck pain -- and neither can doctors.
Whiplash is a neck injury that most often happens to people riding in cars that are unexpectedly struck from behind by another car. Most of these injuries get better fast, but about one in 10 patients has lasting pain -- and half the time this pain is so severe that it makes a person unable to work or enjoy a normal lifestyle. Dueling editorials in the journal Archives of Neurology show that experts differ greatly in the way they understand this chronic whiplash syndrome -- and in the way they treat their patients.
"It is hard to accept that the symptoms of whiplash are the result of an international, translingual conspiracy," write Nikolai Bogduk, MD, PhD, and Robert Teasell, MD, in their commentary. These authors argue that there is something physically wrong with whiplash patients who feel severe neck or head pain more than a year after their injury.
Bogduk, a researcher at the University of Newcastle in Australia, has conducted several studies of chronic whiplash patients suggesting that at least half the time, the pain comes from specific nerves inside the neck. To find out whether a patient has this kind of pain, it is necessary to inject a painkiller into the joint to see if the pain goes away. If it does, the patient can choose to have the nerve permanently deadened. So far, this is the only medically proven treatment for chronic whiplash syndrome. Bogduk and Teasell admit that people with chronic neck pain have more psychological symptoms than other people, but they say this is the result -- not the cause -- of their pain.
The exact opposite is the case, argues an accompanying commentary by neurologist Henry Berry, MD, of the University of Toronto. Berry says that by considering only physical explanations, doctors fail to understand that chronic whiplash syndrome is a combination of many things -- nearly all of which involve a person's state of mind.
"There are many doctors who [think that] if a patient comes to them with a disorder, there must be something wrong with them," Berry tells WebMD. "They take every symptom literally. Whereas if you step back, you see that these symptoms can be caused by life stress, the illness 'role' as a way of adjusting to life, psychiatric disorders, or even [made up by the patient]. This makes [the doctor's job] more difficult -- you have to make some difficult judgments, and some of your patients become unhappy with you because you tell them nothing is wrong and they want to be ill," he says.
Both sides want to help their patients with chronic neck pain -- but their approaches are very different. While Bogduk and Teasell recommend the neck injection, Berry believes that extensive medical tests compound the problem. "[The diagnosis you get depends] on the specialist you send patients to," he says. "If you take these symptoms literally, you go on to investigations that further the problems."
Berry, senior neurologist at St. Michael's Hospital in Toronto, says it is important to tell patients who have recently suffered whiplash that their pain will soon go away. He believes that it is extremely important to keep a person from falling into the role of permanent patient, so he advises no more than two weeks of physical therapy and sends people back to work as soon as possible. "If a person is under a great deal of stress, he or she may realize subconsciously that the illness 'role' is better than their life," he warns.
Trauma expert Michael D. Freeman, PhD, thinks Berry is wrong. "The contention that whiplash is not [a physical disease] can only be made if you ignore the medical literature," he tells WebMD. "The idea that it is a psychological disturbance is a myth that has been perpetuated with absolutely no scientific basis at all."
Berry recently performed a study of demolition-derby drivers and found that none had chronic neck pain -- despite a lifetime average of 1,600 whiplash injuries. He also points out that, in court cases, far fewer plaintiffs than defendants report chronic pain.
Freeman dismisses the demolition-derby study as having nothing to do with the actual conditions under which car accidents occur. Similarly, he says that being struck from behind while totally unprepared is far different from being in the car that strikes another. He notes that he soon will publish a study showing that 45% of people with chronic neck pain were injured in a motor vehicle crash. "Some 6 million people are injured in U.S. car crashes every year -- 3 million of these are whiplash," he says. "Are you telling me all these people are crazy?" Freeman is assistant professor at the Oregon Health Sciences University School of Medicine.
Berry does not use the word crazy, but he says all this pain cannot be real. "It may be presented as severe pain, but often if you look at what these people can do in their lives you may find there is a disproportion," he says. "They are quite active and capable of doing many things except work."
- Whiplash is a neck injury that most often happens to drivers who are hit from behind, and 10% of these injuries cause lasting pain.
- Some doctors believe that whiplash is a physical condition attributed to specific nerves inside the neck joint.
- Others argue that whiplash is a combination of psychological factors and say doctors should try to prevent sufferers from becoming "chronic patients."