Whiplash: Is it still an enigma?

I am writing in response to the series of articles you have on the subject of whiplash [2002;44(5):236-263 and 2002;44(6):296-321].

It is quite apparent that the conventional approach to this common and costly condition is both inadequate and unsatisfactory. The physician feels frustrated for not being more helpful in alleviating the pain and sufferings of his or her patients. The patient feels he or she is poorly served, not listened to or understood, or worse yet, being labeled a “crying baby” or even a “malingerer” when compensation is involved.

Physicians are familiar with ongoing nociception and inflammation and diagnosis are readily made with clinical examination and conventional imaging techniques. The same cannot be said for neuropathic pain unfortunately.

In the early phase of neuropathy, the clinical signs are often more subtle and significant structural and functional changes have yet to appear.

Fortunately, Dr C. Chan Gunn of Vancouver pioneered a system of physical examination that can help clinicians in detecting the early signs of neuropathy. This system of examination and physical signs are commonly used in the multidisciplinary pain center of the University of Washington and the Institute for the Study and Treatment of Pain in Vancouver, BC. This system is also incorporated in Bonica’s Text Book on Pain.

Neuropathic pain does not respond well to conventional medications, as most physicians who have treated this group of patients can attest. The best form of treatment is to employ a fine flexible solid needle and insert it into the contracted muscle bands, causing the contractures to resolve and the affected muscle to return to its normal length.

Incorporating this system of physical examination, a retrospective review of 43 patients suffering from whiplash-associated disorders and treated with Intramuscular Stimulation was completed and published in the Journal of Musculoskeletal Pain Volume 9, November 2, 2001. In this study, 79% of the patients treated improved. All patients were followed up for over 1 year—minimum 61 weeks and a maximum of 164 weeks (average 128 weeks). All the patients belong to Grade 2 or 3 except for one Grade 4 according to the Quebec Task Force Classification.

For patients who are still suffering from pain beyond the normally expected period of time, and with an absence of ongoing source of nociception and inflammation, it is paramount for the clinician to look for the subtle signs of neuropathy before the patients are being categorized as malingerers or their condition as psychological.

—Allan C.P. Lam, MD
iSTOP, The Institute for the Study and Treatment of Pain, Vancouver