No longer is whiplash a pain in the neck, but rather an enigma, a puzzling riddle that has grown beyond the simplistic popular model that states, “If it hurts and it’s in the neck, it must be whiplash.” As with any riddle, the challenge to solve it has been taken up by many, thus the enigma of whiplash cannot be reduced to one edition; here, we have two. In this first edition, we’ll start with incidence. The epidemiologist (Galasko) has attempted to tell us how many are whiplashed [9], but there is no standard. The incidence ranges from zero in Lithuania to 900 per 100 000 population in British Columbia, by far the most whiplashed jurisdiction in the world. The answer to this enigma may have something to do with how the money is distributed—for some, whiplash is a goose that lays a golden egg.

The starting point of any purported traumatic disorder is the mechanics—injury cannot occur without the application of some external force. The engineer (Siegmund) has nicely deciphered the active ingredient of a rear-ender that might apply adverse forces of injury to a car occupant’s neck [10]. Indeed, all sorts of motions are measurable, but what are the human tolerances? Unfortunately, humans are not like material structures, so the possible tolerances probably vary through a very large and mostly unknown range.

Once injury has occurred, what next? Can you see the results? Not easily. But, points out the emergency physician (Fleming), it is still worth imaging to exclude the serious neck injuries [11]. Recent studies on the role of X-rays for whiplash have found some practical guidelines that should help the primary practitioner sort out the potentially serious injury.

When whiplash has occurred, how bad can it be? Taylor has found a wide selection of physical traumas among seriously whiplashed subjects, but no one trauma location in the neck qualifies as the whiplash site.

Besides a pain in the neck, a host of new disorders seem to swirl about the riddle. Fibromyalgia (Ferrari) [12] and temporomandibular disorder (Goldstein) [13] are two of the current popular ones. Are they real? Of course they are, but what you make of them depends on how you define real—more enigma!

In the next edition, watch for a major expansion on the issue of reality, with more enigma in the shape of post-traumatic stress disorder, purports of brain damage, the social side of whiplash, chronic pain syndromes versus malingering, and how lawyers dissect medical witnesses. Eventually this double edition ends with a reassuring note: a practical guide to the management of whiplash.

—Murray Allen, MD

Acknowledgment

The Fraser Institute for its support in approaching the issue of whiplash generally, and for its effect upon social and economic policy.