Question
I was rear ended 2 1/2 years ago while I was driving my car.  I sustained whiplash injuries inc. sore / stiff neck, immediate clenching of teeth, headaches, stiff shoulders.  These symptoms lasted 3-4 months, and faded after that, although I always continued to have a weak neck that would stiffen quickly if holding at an angle, looking up, or sitting on a couch / desk, etc.  At this time I did  not undego any long term treatment (physio, massage therapy, etc.).

A year later I began clenching my teeth chronically.  After afew months of this I got a mouthguard from my family dentist and afew months later saw a TMJ specialist and was diagnosed to having TMJ.  

While this was going on I began feeling a numbness and aching feeling in both my hands - this began one summer while driving during various long roadtrips.  I would awake at night with awful pain in my hands, and eventually it became a constant. the pain in my hands eventually moved up my forearms to my elbow and I began to feel shooting pains in my nerves (in my upper arms).  I went to my family doctor, and after poking and prodding at me for afew minutes he told me he believed I had Carpal Tunnel.

It is now a year after first feeling the pain / tingling in my hands.  It disappeared once for 2-3 months but has now been a constant pain / ache for about 4-5 months.  It gets worse and worse.  I have been going to physio, getting acupuncture, and stretching for 8 months now.  My physiotherapist is quite determined I DO NOT have CTS (I have been seeing her for the whole 8 months) but has never confirmed what she thinks is causing this.  

I recently began seeing a massage therapist.  She believes this is caused from an injury that my hands sustained when I was hit from behind (my hands were on the steering wheel).

HELP!!  Could this be caused from my accident?  Is this sort of injury common?

Answer
Dear Rayna,

The pain/dysfunction/symptoms you have are very common after rear impact vectored collisions and have been well documented in the clinical research and literature.  Tingling into the arms and hands as well as TMJ pain and dysfunction have been explained with detail in multiple journals and are due to the mechanism of injury that is specific to rear impact collisions.

Several authors have noted the high association of TMJ dysfunction and the whiplash trauma (1-11). Friedman et al. (12) have recently analyzed 300 patients with TMD (tempromandibular disorder) in which whiplash was the causative event. The most common complaints, in order, were jaw pain, neck pain, headaches, jaw fatigue, and severe TM joint clicking.  Several studies have painted a fairly grim picture of the outcome in trauma-induced TMD. It has been shown to respond to conservative therapy in only 36% of cases, as opposed to the 86% recovery seen in non-trauma or idiopathic cases (13,14). More recently, Romanelli et al. (15) found that 48% of trauma patients and 75% of non-trauma patients reported recovery from treatment. The trauma patients required significantly more care. The most recent and probably most reliable assessment uses the new TMJ Scale as an outcome
assessment (16). Comparing trauma to non-trauma groups of TMD patients they reported higher symptom levels in trauma patients, but better overall recovery in that group as well.

Now, Carpal Tunnel Syndrome(CTS) is commonly seen following crash trauma (17). The symptoms of CTS include the following: (1) Intermittent (nocturnal) paresthesia in the median innervated portion of the hand which includes the thumb and first two fingers (it may travel up the arm-early stage). (2) Persistent paresthesia and numbness of the thumb and first two fingers (intermediate stage). (3) Permanent impairment of sensory and motor function of the hand; atrophy of hand musculature near the thumb; pain (advanced stage).  You really need to be careful with this diagnosis though...most physicians diagnose it improperly leading to unnecessary surgeries and poor outcomes.  A nerve conduction velocity of the neck, upper arm, lower arm, and hand is the best diagnostic tool after clinical correlation, and even if you do have CTS, conservative care options are generally better than surgery.

On the other hand, the problems can easily be referred from structures of the neck, such as the brachial plexus or nerve roots, rather than the wrist.  This is also poorly understood by many physicians and therapists because it is not purely in a neurological distribution.  This pain is called sclerotogenous pain, and has also been documented in the clinical literature.  

Many years ago Kellgren (18) conducted his now-classic research into the nature of referred pain. He injected hypertonic saline into paraspinal and other soft
tissues and observed that the volunteers felt not only a local pain at the site of injection, which was to be expected, but also a pain radiating some distance away. Often these volunteers complained of deep pain or autonomic symptoms such as sweating, pallor (paleness), or palpitations. Kellgren mapped these referred patterns and found that there was a fair amount of consistency from one person to the next.Some time later, Inman and Saunders (19) conducted similar research, again injecting fluid into the paraspinal tissues and documenting the patterns and nature of the referred pain which resulted. Essentially the same study has been repeated by Feinstein et al. (20). In both instances they found that fairly consistent patterns of referred pain could be reproduced. Usually this referred pain began shortly after the injection and grew gradually. Most volunteers described it as gripping, aching, burning, heavy, or cramp-like. Again this pain can refer down the arms and into the hands.

Perhaps most interesting about this referred pain, is the observation that the levels of referral, while reproducible from patient to patient, do not seem to follow known classic dermatomal or myotomal patterns known to the medical community. In fact, the body maps created by Feinstein demonstrate that, very often, injection at one spinal level results in referral to areas innervated two to four spinal segments away. And often, referral is to not one, but several segment levels. This serves to confuse the issue all the more, and probably the physician as well. For example, an injection at C7 may result in referred pain in areas innervated by C5, C6, C7, C8 and T1.  For a more complete understanding of these referral patterns and illustrations, please check out the glossary of terms on my website under the word SCLEROTMES.

http://suncoasthealthcare.net/glossaryofterms/

Rayna, what I would suggest for you is to do some more research and arm yourself with information.  The Spine Research Institute of San Diego has a great website and also has a physician listing.  You can find it on the web at:  www.srisd.com   Additionally, I would suggest that you try a chiropractic physician for management of treatment options...we are the doctors that treat these injuries with the best results.  

In 1996, a retrospective Study on 28 chronic whiplash patients was reported in the journal Injury; 27(9). Their initial treatments included anti-inflammatories, soft collars, and physiotherapy. These patients were referred for Chiropractic adjustments at an average of 15.5 months (range 3-44 months) after their initial injury. Chiropractic treatment included "specific spinal manipulation, proprioceptive neuromuscular facilitation and cryotherapy. Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid." Following Chiropractic treatment, 93 percent of the patients had improved." The results of this retrospective study would suggest that benefits can occur in over 90 percent of patients undergoing chiropractic treatment for chronic 'whiplash' injury."

The Journal of Orthopaedic Medicine 21(1) in 1999 investigated if patients with chronic whiplash would benefit from chiropractic treatment. The 93 patients all underwent spinal manipulation performed by a chiropractic physician. Referral for chiropractic treatment was a mean of 1.2-7 months (0-82 months) after injury. Patients were in 3 groups according to severity of injury, and underwent a mean of 19.3 treatments (range 1-53) over a period of 4.1 months. Results: Group 1, (50 patients), 36 patients (72%) gained benefit from chiropractic spinal adjustments, 12 (24%) became asymptomatic, and 12 (24%) improved by 2 grades. Group 2, (32 patients), 30 patients (94%) responded positively to chiropractic manipulation with 12 (38%) becoming asymptomatic and 13 (43%) improving by two grades. [This is a remarkable response considering these patients had neurological involvement.] Group 3, (11 patients), with severe symptomatology, 3 (27%) improved following chiropractic treatment and 1 improved by two grades. The authors concluded that Chiropractic is the only proven effective treatment in chronic cases.  Again, I would suggest that you get checked by a chiropractor... this has been a problem for quite awhile, and it will only get worse over time.

Rayna, I know this information may be a bit dense, but I want you to have the facts, not all the fiction that is promulgated by the media, and insurance companies.  The sequela to whiplash injuries are real and can be debilitating.  Feel free to write back if I can be of any further assistance.

Respectfully,
Dr. J. Shawn leatherman
www.suncoasthealthcare.net

REFERENCES:
1. Weinberg S, Lapoint H: Cervical extension-flexion injury (whiplash) and internal derangement of the temporomandibular joint.  J Oral Maxillofac Surg 45:653-656, 1987.
2.  Livingston M: Whiplash injury: misconceptions and remedies. Aust Fam Phys 21(11):1642-1643, 1646-1647, 1992.
3.  Frankel VH: Temporomandibular pain syndrome following deceleration injury to the cervical spine.  Bull Hosp Joint Dis 26:47, 1969.
4.  Steigerwald D: Acceleration-deceleration injury as a precipitating cause of temporomandibular joint dysfunction.  ACA J Chiro 26(11):61-64, 1989.
5.  Lader E: Cervical trauma as a factor in the development of TMJ dysfunction and facial pain.  Craniomand Pract 1:85, 1983.
6.  Schneider K, Zernicke RF, Clark G: Modeling of jaw-head-neck dynamics during whiplash.  J Dent Res 68(9):1360-1365, 1989
7.  Croft AC: The cervical acceleration/deceleration syndrome. In Steigerwald DP, Croft AC (eds): Whiplash and Temporomandibular Joint Dysfunction: an Interdisciplinary Approach to Case Management.  Encinitas, Keiser Publishing Co., 1992
8.  Goldman JR: Soft Tissue Trauma.  In Kaplan AS, Assael LA (eds): Temporomandibular Disorders Diagnosis and Treatment.  Philadelphia, W.B. Saunders Co., 1991.
9.  Burgess J: Symptom characteristics in TMD patients reporting blunt trauma and/or whiplash injury. J Craniomandib Dis Fac Oral Pain 5:251-257, 1991.
10.  Epstein JB: Temporomandibular disorders, facial pain and headache following motor vehicle accidents. J Can Dent Assoc ? 58(6):488-495, 1992.
11.  Pressman BD, Shellock FG, Schames J, Schames M: MR imaging of temporomandibular joint abnormalities associated with cervical hyperextension/hyperflexion (whiplash) injuries. JMRI 2:569-574, 1992.
12.  Friedman MH, Weisberg J. The craniocervical connection: A retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders. Cranio-The Journal of Craniomandibular Practice 18:163-167, 2000.
13.  Brooke RI, Stenn PG, Mothersill KJ: The diagnosis and conservative treatment of myofascial pain dysfunction. Oral Surg 44:844-852, 1977.
14. Brooke RI, Stenn PG: Post-injury myofascial pain dysfunction syndrome: its etiology and prognosis. Oral Surg 45:846-850, 1978.
15.  Romanelli GG, Mock D, Tenenbaum HC: Characteristics and response to treatment of posttraumatic temporomandibular disorder--a retrospective study. Clin J Pain 8(1):6-17, 1992.
16.  1376) Matsumoto M, Fujimura Y, Suzuki N, Toyama Y, Shiga H. Cervical curvature in acute whiplash injuries: prospective comparative study with asymptomatic subjects. Injury 29:775-778, 1998.
17.  Coert JH, Dellon AL: Peripheral nerve entrapment caused by motor vehicle crashes. J Trauma 37(2):191-194, 1994.
18.  Kellgren JH: On distribution of pain arising from deep somatic structures with charts of segmental pain areas.  Clin Sci 4:35-46, 1939
19.  Inman VT, Saunders JBdeCM: Referred pain from skeletal structures.  J Nerv Ment Dis 99:660-667, 1944.
20.  Feinstein B, Langton JNK, Jameson RM, Schiller F: Experiments of pain referred from deep somatic tissues.  J Bone Joint Surg 36A(5):981-997, 1954