Whiplash and Chronic Neck Pain: Mechanisms & Evidence-Based Management

Why does the pain persist and how can it be treated?

Introduction

Whiplash, medically known as a cervical acceleration–deceleration (CAD) injury, most often occurs during motor vehicle collisions, when the neck is subjected to rapid extension–flexion movements. This can strain cervical musculature, ligaments, discs, and facet joints, sometimes leading to persistent symptoms grouped under the term whiplash-associated disorders (WAD) [1].

While many individuals recover within weeks, a significant proportion—15–50%—experience persistent pain and disability lasting months to years [2,3]. Epidemiological studies suggest that nearly half of patients with chronic neck pain attribute their symptoms to prior motor vehicle accidents, underscoring the strong link between whiplash and chronicity [4].

Whiplash Mechanism.

Hyperflexien and extension during whiplash injury.

Mechanisms Underlying Chronic Neck Pain After Whiplash

Muscles and joints injury : peripheral generators of pain.

Cervical facet joints are well-known contributors to chronic whiplash symptoms. Studies have shown that facet pain is involved in 74% of patients with chronic whiplash symptoms. These results were obtained using diagnostic anaesthetic blocks, a technique that involves injecting a local anaesthetic directly into the cervical joints to identify the exact source of pain in a placebo-controlled manner, in order to confirm that the pain is indeed coming from the targeted joints [5].

However, cervical muscle structures also play an essential role in the persistence of post-traumatic pain. Direct muscle damage, microtears and secondary fibrosis can lead to local sensitisation and chronic pain. Furthermore, numerous studies have demonstrated the presence of myofascial trigger points in the cervical muscles (particularly the upper trapezius, sternocleidomastoid and deep neck flexor muscles) in patients suffering from chronic whiplash symptoms [6]. These painful points contribute not only to local pain, but also to referred pain and restricted cervical mobility.

Imaging studies, particularly MRI and ultrasound, have also revealed structural and functional changes in the cervical muscles following acceleration-deceleration trauma: fatty infiltration, impaired neuromuscular control, and decreased muscle endurance and strength [7]. These changes may explain the tendency toward chronicity and difficulties in full recovery in some patients.

Central sensitisation, psychosocial factors and impact on daily life

Chronic symptoms after whiplash cannot be explained solely by peripheral lesions. Research has shown that sensory hypersensitivity appears very early after injury and is associated with poor recovery [6]. This phenomenon, known as central sensitisation, corresponds to an amplification of pain signals by the central nervous system, even in the absence of detectable tissue damage. It can cause persistent, exaggerated pain or pain triggered by normally painless stimuli [6].

Psychological and cognitive factors also play a major role in the progression of symptoms. A prospective study has shown that intense initial pain and a high level of catastrophising (the tendency to anticipate the worst and amplify the negative consequences of pain) are strongly associated with the development of post-traumatic headaches after whiplash, with catastrophising significantly increasing the risk (x15) [7]. These data highlight the importance of early assessment of pain beliefs and coping strategies in the acute phase.

Finally, whiplash has a considerable impact on patients' daily lives. A qualitative study of 349 patients showed that this condition alters body perception, disrupts daily life and influences the recovery process of chronic patients [8]. This illustrates the profound biopsychosocial impact of whiplash and highlights the need for appropriate therapeutic approaches.

Whiplash Associated Disorders (The Lancet: Chronic whiplash-associated disorders: to exercise or not; Volume 384, Issue 9938 P109-111July 12, 2014)

Treatment and management of chronic neck pain: evidence and recommendations

Manual therapies (osteopathy) and physical rehabilitation

Data from the OPTIMa (Ontario Protocol for Traffic Injury Management) protocol and other recommendations indicate that manual therapy (mobilisation/manipulation) is beneficial in acute and chronic grade I–II whiplash-associated neck pain [9].

Supervised muscle strengthening exercise programmes are also beneficial and recommended for patients.

On the other hand, passive modalities such as ultrasound, diathermy, hydrotherapy and certain acupuncture approaches have limited or no benefit and are not recommended as stand-alone interventions [9].

Rehabilitation and patient education based on pain neuroscience

Modern rehabilitation approaches focus on the central mechanisms of pain. A major randomised clinical trial in 2025 showed that an approach combining pain education, stress management and cognitive exercises, performed on a contingent basis, led to greater improvements in terms of disability, central sensitisation and kinesiophobia compared to usual care. The MPNA group also showed better cost-effectiveness and a higher probability of improvement after treatment[11].

Additional data on chronic non-specific neck pain confirm that the combination of pain education and exercise is more effective in reducing disability, catastrophising and fear of movement than exercise alone [12].

Interventional approaches

In patients with facet-related pain, medial branch blocks and radiofrequency neurotomy remain validated interventional strategies, often providing significant pain relief and functional improvement [5].

Clinical implications

• Early risk identification: severe initial pain and catastrophising are powerful predictors of poor prognosis; early detection allows for targeted intervention [7].

• Multimodal management: the optimal approach combines education, active rehabilitation, manual therapy and, if indicated, targeted interventions.

• Avoid low-value care: passive modalities without strong evidence should be limited in favour of active, patient-centred approaches [9].

• Consideration of central mechanisms: the integration of pain education, stress management and cognitive-behavioural principles helps to target central sensitisation and maladaptive beliefs [11,12].

• Patient-centred biopsychosocial approach: recognising and addressing patients' experiences is essential for overall recovery [8].

Conclusion

Chronic whiplash-associated neck pain is multifactorial, resulting from both peripheral mechanisms (e.g. facet pain) and central processes (e.g. sensitisation, psychological distress). Current evidence clearly favours active, individualised management. Early identification of at-risk patients and the implementation of multimodal management are essential.

Personally, I combine the following in my treatment:

• Manual therapy and osteopathy

• Therapeutic education: My degrees and training in neuroscience and pain management allows me to establish pain management strategies and rehabilitation focused on neurophysiological mechanisms, I am able to offer comprehensive and personalised treatment to each patient.

Références

1. Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother. 2014;60(1):5–12. PMID: 24503214.

2. Carroll LJ, Holm LW, Hogg-Johnson S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD). Spine (Phila Pa 1976). 2008;33(4 Suppl):S83–92. PMID: 18204389.

3. Walton DM, MacDermid JC, Giorgianni AA, et al. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(2):31–43. PMID: 23322093.

4. Freeman MD, Croft AC, Rossignol AM. Whiplash associated disorders: redefining whiplash and its management. Spine (Phila Pa 1976). 1998;23(9):1043–9. PMID: 9580931.

5. Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine (Phila Pa 1976). 1996;21(15):1737–45. PMID: 8855458.

6. Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain. 2003;104(3):509–17. PMID: 12927623.

7. Thorn P, Nicholson B, MacDonald L, et al. Higher Neck Pain Intensity and Pain Catastrophizing Partially Explain Persistent Posttraumatic Headache with Whiplash. Clin J Pain. 2024;40(6):349–55. PMID: 38465710.

8. Crestani M, Cook C, Ceccarelli E, et al. “I’m Not the Same as I Was Before”: A Qualitative Evidence Synthesis Exploring the Experiences and Perceptions of Patients Living With Whiplash-Associated Disorders. J Orthop Sports Phys Ther. 2025;55(9):1–19. PMID: 40879621.

9. Wong JJ, Shearer HM, Mior S, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? Spine J. 2016;16(12):1598–1630. PMID: 26707074.

10. Peters R, Hallegraeff J, Koes B, van Trijffel E. Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review. Phys Ther. 2025;105(2):pzae179. PMID: 39791243.

11. Malfliet A, Lenoir D, Murillo C, et al. Pain Science Education, Stress Management, and Cognition-Targeted Exercise Therapy in Chronic Whiplash Disorders: A Randomized Clinical Trial. JAMA Netw Open.2025;8(8):e2526674. PMID: 40794407.

12. Lluch Girbés E, et al. Pain neuroscience education and exercise for chronic neck pain: a randomized controlled trial. Int J Environ Res Public Health. 2021;18(16):8848. PMID: 34444734.

Charbel Jean Kortbawi DO, MSc.

Ostéopathe - Gestion de la douleur chronique - Sport

Diplôme Français d'ostéopathie

Master 2 Neurosciences du mouvement

Diplôme Universitaire Gestion de douleur chronique

Diplôme Universitaire Douleur et motricité humaine

Diplôme Universitaire Anatomie clinique et imagerie