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After neck injury or generalised pain problems, the disturbances in sensory aspects may occur in the arms and legs even though there are no symptoms in these areas. Local hyperalgesia in the neck, an increased pain response to normally painful stimuli, may be due to the local nerve systems being abnormally sensitised to incoming stimuli. But these more widespread reactions can be indicative of altered processing in the central nervous system. Locally increased pain reactions in the neck can be present in whiplash and general neck pain sufferers but the more widespread sensory upsets may help distinguish whiplash from less severe neck problems.

Patients suffering from whiplash associated disorder report increased levels of disability and neck pain and have more widespread pain on manual examination. There are typical changes which occur in the processes by which pain is processed in the central nervous system which are shared by both whiplash patients and those with nerve root lesions in the cervical spine. A pain condition called allodynia may also present, which is a pain reaction defined by being a painful response to a normally non-painful stimulus. Allodynia also gives a clue that central nervous systems are involved in the process.

At the time of the injury the abnormal pain processing mechanisms are set up in the nervous system and the same abnormalities have been shown to be present in patients with chronic whiplash pain. Whatever the severity of the whiplash injury, all sufferers seem to have some degree of pain overreaction to inputs, with this typically settling down in two or three months in less severe cases. Those patients who suffer from chronic neck symptoms and increased levels of pain will also likely have continuing mechanical overreaction which may persist rather than reduce with time. The levels of mental distress also affect pain thresholds.

Whiplash associated disorder is known to be combined with significant levels of psychological distress and patients with elevated amounts of disability and pain also suffer from higher levels of distress. However, psychological distress is not the cause of increased sensitivity to pain but both the sensitivity and the distress might be the result of the increased reactivity of the central nervous system. As well as this evidence, investigations have also indicated that an increased and abnormal reaction to cold can exist and that the circulatory reactions can also be altered.

As an overreaction to cold is part of the typical symptoms of injury to the peripheral nerves of the body this may indicate that nerve injury is present in some cases of whiplash injury. This cold overreaction is also found in neck nerve root injury, reinforcing the idea that the same underlying nerve abnormalities are found in both this condition and whiplash. In investigations of acute whiplash patients a significant percentage of neuropathic pain symptoms such as cold overreaction, burning neck pain and sudden bursts of electric shock pains have been found.

The jump from investigating the abnormalities in sensory abilities to the application of effective physiotherapy programmes is a large one. Physiotherapy or other manual therapy techniques can help to reduce hyperalgesia caused by local neck structure damage in the absence of other more severe abnormalities of the sensory systems. Prescribing an exercise routine can also have some effect in improvement of local coordination of muscles and reducing the tendency of nerves to overreact.

It takes much more careful judgment and planning to treat a patient who has the added symptoms of neuropathic pain, the allodynia, the widespread sensitivity and the cold overreaction. Stirring up the pain and other symptoms in treatment will only reinforce the abnormal neural processing and worsen the pain. Manipulative and manual techniques need to be much more gently applied and there is some evidence that physiotherapy can be useful in the overall management of whiplash disorder.

This approach works less well however if patients exhibit the cold overreaction symptoms. Those patients with neuropathic symptoms show significantly higher reports of disability and pain and a physiotherapy treatment approach is not clear, with only thirty percent of patients exhibiting pain improvement from medication.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Reading. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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