Whiplash

This page has been designed to provide you with the right information about whiplash-associated disorders and how to manage them from a physiotherapy point of view.

What are whiplash-associated disorders?

The term whiplash-associated disorder is a term used to describe injuries caused by a sudden acceleration-deceleration movement and is most commonly associated with road traffic incidents.

You may know the condition simply as ‘whiplash’ but this only relates to injury mechanism and not the symptoms that may be associated with it.

A close-up of a woman's lower face and neck.

What does an ‘acceleration-deceleration’ movement mean?

An acceleration-deceleration movement relates to any movement involving a rapid speeding up followed by a rapid slowing down of a body part. It is most commonly associated with injuries to the neck and typically will follow a road traffic incident, although falls and sporting injuries can cause similar issues.

For the purpose of this information page, the details will focus on whiplash-associated disorders associated with road traffic incidents (RCI).

I think I’ve got whiplash but how do I know?

Firstly, it’s important to know that your neck is unbelievably strong, robust and actually really quite difficult to damage. It doesn’t mean that it can’t get sore from time to time, but it does mean that it is capable of having an injury, such as an RCI and not being actually damaged (i.e. broken bones).

If you have had an injury to your neck, such as an RCI, and you are feeling symptoms such as soreness, stiffness or headaches since the injury, then you may have a whiplash-associated disorder.

What are the common symptoms of whiplash-associated disorders?

This is a really important question and it is useful for you to know what is normal for necks affected by whiplash-associated disorders. We’ve broken the answer down into things that are found most commonly:

Whiplash-associated disorders can cause pain but equally so, sometimes don’t cause any pain at all. In most cases when the neck is sore, the discomfort will stay around the neck, but sometimes may travel to the shoulder blade and even to the arm. This is called ‘referred pain’ which in other words means that the pain is travelling away from the neck. Pain when turning your head, looking down or simply holding your head up is common.

In some cases of whiplash-associated disorders, the neck may feel stiff or tight. This is likely to be linked to increased muscular work around the neck as it deals with the recovery after your injury.

Clicks, pops, clunks and grinds are very normal in all joints, including your spine, and in the vast majority of cases are nothing to worry about. People often find themselves worrying that they are ‘wearing their neck out’ because of the noises it makes. This is simply not the case and your neck, along with all of your joints, are strong, robust and designed to last you a lifetime. Noises are often gas bubbles popping in the joint or friction between the moving surfaces. Noises from the neck are normal and not to be worried about, just like rumbles from your tummy are normal and don’t mean anything is wrong, it’s just another noise the body tends to make.

The feeling that the head is ‘too heavy’ for your neck is often reported by people with neck pain. It is not a concerning symptom and is likely to be linked to muscular tiredness, as a painful neck will make the muscles around the neck region work differently and eventually they can get tired and grumpy.

Are there any other symptoms that can happen with a whiplash-associated disorder?

There are a number of other symptoms that are linked with whiplash-associated disorders but these tend to be less common:

Neck pain can typically travel to the shoulder blade and arm but can sometimes go upwards towards the head causing headaches. Often, this is linked to the increased muscular activity in the neck muscles which acts as a protective response whilst the neck starts its recovery.

The nerves that supply your arms with their ability to work and feel things come from your neck. If you have had an injury to your neck, then it is possible to irritate your nerves. Nerve irritation tends to cause pain, tingling (pins & needles) and/ or numbness. Nerves are not easily damaged but are very sensitive and don’t take kindly to being upset. An interesting example of this is when you hit your funny bone. Your funny bone is actually a nerve, not a bone at all and when you hit it, it’s often sore, tingly and might even burn all the way down to your fingers. Encouragingly, just like funny bone bashes, the symptoms of tingling with a whiplash-associated disorder often get better with time.

If you have suffered an injury, it is completely normal to experience emotional symptoms, as well as physical ones. As mentioned before, whiplash- associated disorders often follow a car accident and the emotional impact can sometimes be quite traumatic and not easy to get over. We will all react differently to the same thing but it is not uncommon to find that you feel anxious, worried or even suffer flashbacks or nightmares related to the accident. It is important to know that the emotional symptoms are as important as the physical symptoms and they may need their own special rehabilitation. As your physical symptoms improve, you will hopefully find that the emotional ones will follow suit, however, if you feel you need someone to discuss your concerns with then please contact our colleagues at Wellbeing or check out the support guides in our Health and Wellbeing page.

When your neck is sore you might feel a bit reluctant to move it. This is an entirely normal reaction to an injury. Most of the time, the worry about moving will settle as your symptoms settle, however, if you find yourself frightened or nervous that movement may hurt or damage your neck, then it is really important for you to know that movement is safe and crucial to helping your neck get better. Pain will often make people feel vulnerable and can be concerning, but as outlined throughout this whole information page, your neck is strong, robust and very resilient. Pain is normal with whiplash-associated disorders and the best medicine is normal, confident movement. Us physios like to say "motion is lotion!" therefore, any movement is better than none and will help you on your road to recovery.

Should I go to Accident and Emergency?

If you have had a road traffic incident and are experiencing neck pain or any other type of pains or distress following the incident that are causing you concern, you may want to talk with a healthcare professional about what action you should take. It is hoped that the information on this page may help you with this however, talking to your physio, GP or calling 111 is normally enough for most people.

If you have major concerns about your health, you should seek help from A&E or call 999.

How are whiplash-associated disorders diagnosed?

In most cases, whiplash-associated disorders can be diagnosed through the clinical features (what it looks like and how it behaves), your symptoms (what you tell us about your neck) and the clinical assessment (testing the movements etc.). An X-ray of the neck can be used to help exclude certain issues but they are not always required.

Why are X-rays/scans not always required?

In a lot of cases, the information we as healthcare professionals can get from asking you questions and testing the neck is enough to make a decision. X-rays are a very useful tool (and would always be ordered if needed) as they show you what your neck looks like on the inside, however, in some cases what your neck looks like on the inside doesn’t really marry up with what your problem might be.

There is growing evidence (experiments and clinical studies) that demonstrate what you see is not always what you get with X-rays and scans, and that a lot of the so-called ‘worn out’ or ‘abnormal’ findings are seen commonly in people with no pain, stiffness or symptoms.

In a large study of over 1200 people, Nakashima et al. (2015) demonstrated that most of the common ‘problems’ found in neck scans, including disk changes, are seen as much and sometimes more, in people WITHOUT any pain, stiffness or symptoms as those with symptoms.

What this means is that what you say about your neck issue, how you move and how you feel etc. are often more important than the results of an X-ray or scan.

Are there different types of whiplash-associated disorders?

Yes, and there are many factors that might influence the type of issue you may get.

Given that we as people are all different, it might not come as a surprise that we can all react differently to the same incident or injury.

Not every road traffic incident will result in whiplash-associated disorders. Lots of things can play a part in whether you develop issues after the accident or not. These include things like the speed and direction of the collision; whether you were expecting the impact (i.e. you saw it coming); whether you were wearing a seatbelt or if the airbags were deployed.

Interestingly, less obvious things may also have an influence on whether you develop issues or not such as how you were feeling on that day (i.e. happy and confident vs low in mood or stressed); whether you have had a previous neck issue or pre-existing health issues.

The grades of whiplash-associated disorders are as follows:

Grade 0:

No neck pain and no physical signs.

Grade 1:

Symptoms may include neck pain, stiffness or tenderness but these are difficult to reproduce with physical (moving and touching) assessment.

Grade 2:

a) Symptoms may include neck pain, stiffness or tenderness with reduced neck movements. Neck movements may be painful and may have sensory (feeling) changes.

b) Symptoms may include neck pain, stiffness or tenderness with reduced neck movements. Neck movements may be painful, may have sensory (feeling) changes and elevated emotional distress.

c) Symptoms may include neck pain, stiffness or tenderness with reduced neck movements. Neck movements may be painful, may have sensory (feeling) changes, elevated emotional distress and generally increased nervous system sensitivity.

Grade 3:

Symptoms may include neck pain, stiffness or tenderness with reduced neck movements. Neck movements may be painful, may have sensory (feeling) changes, elevated emotional distress, generally increased nervous system sensitivity and neurological signs (these include changes in sensation or feeling, muscle weakness and/ or reduced deep tendon reflexes).

Grade 4:

Symptoms may include all of the above and the patient shows a fracture or dislocation.

Adapted from: Sterling, M. (2004). A proposed new classification system for Whiplash associated disorders – implications for assessment and management. Musculoskeletal Science and Practice, 9(2) 60-70.

Does it matter what grade mine is?

The exact ‘type’ of whiplash-associated disorder you may be suffering with shouldn’t mean too much to you as it is more to help guide your physiotherapist/ GP on the most appropriate direction for treatment. As you may be able to gather, different ‘types’ of whiplash-associated disorders may benefit from different treatment approaches and as such, there are no quick and easy recipes for success with all neck issues. Regardless of the grade, some people will recover quickly and effectively and some may take more time and require more help.

What can I do to help myself?

Reassuringly, there are lots of things that you can do to help get your neck going and start your rehabilitation.

Taking time to read and digest the information above will hopefully help you understand that whiplash-associated disorders aren’t necessarily something that should be feared, that it’s safe to be sore and that you can do something about it. Understanding the problem is halfway to dealing with it.

It would be lovely if we could simply take pain relief or exercise our way out of all of the aches and pains that we face in our lifetimes wouldn’t it? For a number of issues, that might be all you need to do and you will end up feeling better, however it is often a useful thing to do to take some time to think about some of the reasons why things might be sore.

If you think of your pain as your neck trying to say that it is struggling to do what you want it to do or the way you want to do it, by looking at the things that make it sore, you may be able to consider what you can do to help yourself. For example, if you find that your neck is always worse on the days that you are on the computer for longest or the days you don’t have your breaks, then perhaps your neck is saying it’s struggling and you might find taking more breaks/ having your lunch away from the desk might help.

By looking at what’s making your neck sore and asking yourself ‘how can I do that differently?’, you can find that the answers come more easily than you would have thought. Making small changes or adapting things can have big results and this is often the best way to start your recovery.

You can find some guidance about ‘calming it down’ here: Calm it down

As mentioned before, pain regardless of where it is and where it has come from, can make you feel vulnerable, drained and sometimes a bit lost. There is always potential to be ‘better’, however, what better might mean to you might be different to the next person. Your body is amazing and can sort most issues out by itself but sometimes it needs some help. Taking time to look after yourself is important. Relaxation, meditation or simply taking ‘you time’ can be really useful in helping get yourself ready to start your rehabilitation or make your rehabilitation more effective.

Relaxing will mean different things to different people, therefore it is worth thinking what works best for you, however, you can find some ideas and useful app suggestions here: Wellbeing

Exercise, including strengthening exercise (working against something like a weight, gravity or exercise bands) is considered one of the key treatments for most aches and pains.

Exercise comes in many shapes and forms and there is no ‘best’ exercise. Often it is best to think of the most effective exercise as the one you enjoy and will actually do. Current recommendations on exercise and how often we should be looking to do it can be found here: Understanding Exercise

Exercise, even lifting weights or attending a gym, is safe for your neck and encouragingly, in a large review of the research on people with neck pain, de Zoete et al. (2019) found that exercise (of any type) helped to lower pain levels and improve disability.

We have included a series of exercises at the bottom of the page that will be able to help you move forwards with managing your neck complaint.

Some people will choose to manage their pain with pain relief, whilst some may choose to avoid medication. Applying something warm around your neck may also be useful in helping with some of the pain (do remember to wrap your hot water bottle in a towel before applying it to your skin to avoid burns).

What can physiotherapy do for me?

Physiotherapy for neck complaints including whiplash-associated disorders can be very effective. We offer a range of options to help you manage your complaint with exercise, education and lifestyle advice/coaching forming the main part of what we can offer you. We are able to offer other treatments including manual therapy and acupuncture if deemed appropriate, however these would only likely be offered alongside the exercise, education and lifestyle advice.

Is there anything I should look out for?

In most cases, neck symptoms associated with whiplash-associated disorders are easily recognised, but occasionally there are things that do not fit and should be highlighted to your doctor, nurse or physio.

Generally feeling unwell and/or a temperature alongside your neck pain

A history of trauma that started your neck pain

Pain or symptoms that travel into your face

Headaches that are different to your normal headaches

Changes in your vision, speech or hearing alongside your neck pain

The following symptoms would be considered rare with whiplash-associated disorders and if you develop any of the following you should seek medical attention urgently.

Difficulty coordinating your arms or legs

Pins and needles or numbness in your both your arms, or both your legs or all limbs

Changes in your bladder/ bowel or sexual function since the injury

Will it get better?

In a lot of cases, it is very much possible for you to improve the symptoms you have with your neck. Obviously, it is impossible to predict the timescale or the path your recovery will take but encouragingly, with normal confident movement, increased physical and emotional fitness and resilience (if needed), most people will find that their symptoms can change for the better.

How long will it take before I feel something?

This is a very difficult question, but it is best to think about how much time and effort you are going to throw at the challenge and how confident and motivated you are to do something about it. If you work hard and are consistent with what you do, often people will notice signs of positive response within weeks to months. If you are not committed to the challenge it will take longer or may not respond at all.

Frequently asked questions

Q: Should I use a collar or a support for my neck?

A: Collars and supports for neck pain are no longer recommended. It used to be that collars were issued by physios for neck issues, however we now understand that these can actually make things worse as keeping your neck still will not support normal movement - it will cause strength loss and may make you feel worried about moving your neck when the support comes off.

Q: Can acupuncture help?

A: Acupuncture is something that can help some people, however not everyone benefits from it. Acupuncture is best thought of as a type of pain relief and as such, it might help ease the pain temporarily but will probably do very little to address the reason why your neck is sore in the first place. Working on normal confident movement and the strength of your neck is likely to help most people.

Q: Could my posture be part of the issue?

A: Interestingly, this is not as clear as some people might have you believe. In a study by Gamkhar & Kahlaee (2018), no significant link between head and neck posture in pain could be found in people with and without neck pain, however muscle size was significantly smaller in people with neck pain. In other words, it doesn’t really matter what your posture is like but things like your strength, fitness and confidence in your neck and how well you manage things like stress seem to matter.

Q: I don’t have any weights at home, how am I supposed to do the exercises?

A: This doesn’t matter. Most, if not all, of the exercises below can be modified or adapted using heavy bags, bottles of water or even books.

Q: Are the exercises going to be sore?

A: If your neck is sore to begin with, then it is normal to expect that starting some exercises might be a bit sore to start with. As you get better and start to tolerate the exercises better, you should find that they are more comfortable, however it is worth knowing that strengthening exercises are meant to be hard work (and a bit sore), so if they’ve become too easy perhaps you need to increase the challenge.

Q: My neck is worse when I do a certain something (e.g. looking to the left), should I still do it?

A: The pain in your neck is not an indication of damage, therefore it is safe to move your neck normally. If something is really sore, it makes sense not to force it and work within a range that is comfortable, but it is safe to be sore.

Q: Are exercises the only things I can do?

A: Quite simply, no! The exercises will help get you moving and hopefully help with your strength, which are both important for helping neck pain. However, often looking at the things that your neck doesn’t like, such as sitting for long periods/ carrying shopping and making some changes/ adaptations to those things will help the exercises be more effective.

Q: Should I change my pillow?

A: If you are not having issues with your sleep then changing your pillow isn’t likely to help. If you are having issues, first think about what changes/ effort you're putting into controlling your neck during the day as this is likely to be most effective. If you want to change your pillow and think it will help, then choose the one that is most comfortable. There isn’t a ‘best’ pillow as we all have different needs and preferences.

Q: What happens if I do all this and it just doesn’t get better?

A: Firstly, ask yourself if you have really done everything you can to try and move your neck issue forwards. If the answer is no, consider re-reading the information above and seeking some guidance from your physio.

If you have really committed to your rehabilitation and still don’t find any benefit, then please bring this up with your physio who will be able to discuss your options.

Exercise tips:

For movement exercises, aim to complete the exercises little and often throughout the day within what is comfortable.

For strengthening, you may choose to start by simply completing the exercises until your neck gets tired for 3-4 sets with about a minute’s rest in between sets. If you want more structure, try completing 8-12 repetitions for 3-4 sets, with about a minute’s rest in between sets. Complete these exercises every other day.

Movement Exercises

Strengthening Exercises

Need more help? Refer yourself here.

References:

de Zoete R, M, J. , Armfield N, R., McAuley J, H., Chen, K. and Sterling, M. (2019). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. European Journal of Physiotherapy http://dx.doi.org/10.1136/bjsports-2020-102664 (accessed 26/01/2021).

Gamkhar, L. and Kahlaee. (2018). Is forward head posture relevant to cervical muscles and performance and neck pain? A case-control study. Brazilian Journal of Physical Therapy, 23(4) 346-354 doi: 10.1016/j.bjpt.2018.08.007. Epub 2018 Aug 22 (accessed 29/01/2021).

Nakashima, H., Yasutsugu, Y., Suda, K., Yamagata, M., Ueta, T. and Kato, F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine, 40(6):392-8. doi: 10.1097/BRS.0000000000000775 (accessed 26/01/2021).

Sterling, M. (2004). A proposed new classification system for Whiplash associated disorders – implications for assessment and management. Musculoskeletal Science and Practice, 9(2) 60-70.